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2019

Assessing Knowledge, Attitude and Practices of

Hand Hygiene Among University Students
Linda Afia Mbroh
Minnesota State University, Mankato

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Assessing Knowledge, Attitude and Practices of Hand Hygiene Among University Students

By

Linda Afia Mbroh

A Thesis Submitted in Partial Fulfillment of the

Requirements for the Degree of

Masters

In

Community Health Education

Minnesota State University, Mankato

Mankato, Minnesota

June 2019
 i

7/24/2019

Assessing Knowledge, Attitude and Practices of Hand Hygiene Among University Students

Linda Afia Mbroh

This thesis has been examined and approved by the following members of the student’s
committee.

________________________________
Dr Mary Kramer

________________________________
Dr Joseph Visker

________________________________
Dr Emily Forsyth
 ii

Abstract

Objective: Proper hand hygiene is the key to reducing occurrence of infectious diseases in

many different types of communities, including the healthcare settings, daycare centers, and

grade schools. College students have been found to inadequately wash their hands, which

increases their chances of contracting infectious diseases. The purpose of this research is to

assess the knowledge, attitude and practices of hand hygiene among students at a large

midwestern university.

Participants and Methods: Using a cross- sectional survey, and three self-reported

questionnaires, data were collected from 406 undergraduate students, ages 18 years of age

and above enrolled at Minnesota State University, Mankato.

Results: Findings indicate that although participants in this current study had high levels of

knowledge, attitude and practices of hand hygiene, there were gaps in their knowledge,

attitude and practices. Recommendations for future research and for health educators were

offered.
 iii

Acknowledgments

In all thy ways acknowledge Him, and He shall direct thy path (Proverbs 3:6)

I am highly grateful to God Almighty His direction and provision throughout my education at

Minnesota State University, Mankato. I would like to express my sincerest appreciation and

gratitude to Dr. Mary Kramer, my advisor, mentor, and a wonderful tutor, whose shared

knowledge, encouragement and support carried me throughout my research. My sincere

appreciation is extended to Dr. Joseph Visker for his knowledge sharing and expertise,

mentorship and thought-provoking questions, which were invaluable in the completion of my

thesis. I would also like to acknowledge and thank Dr. Emily Forsyth for her expert assistance,

keen eye for detail and very insightful comment that has really contributed to the production

of this masterpiece.

Finally, I must express my heartfelt and profound gratitude to my dearest husband, Anthony,

for his constant love, on-going support, encouragement and prayers. Thank you for always

believing in me and keeping me sane. I am truly honored and love you dearly.

“Give thanks unto the Lord, for he is good; for his mercy endureth forever” (1 Chronicles

16:34)
 iv

Table of Contents

Chapter I: Introduction ............................................................................................................... 1

Statement of the Problem ....................................................................................................... 2

Purpose Statement .................................................................................................................. 3
Research Questions ................................................................................................................ 3
Limitations ............................................................................................................................. 3
Delimitations .......................................................................................................................... 4
Assumptions ........................................................................................................................... 4
Definition of Terms ................................................................................................................ 4
Chapter II: Literature Review .................................................................................................... 6

Introduction ............................................................................................................................ 6
Infectious Diseases................................................................................................................. 6
Transmission of Pathogens by Hands .................................................................................... 7
The Burden of Infections on University Students.................................................................. 8
Hand Hygiene ........................................................................................................................ 9
Importance of Hand Hygiene in Disease Prevention ........................................................... 10
Importance of Hand Hygiene in Disease Prevention among University Students .............. 10
Hand Hygiene Behavior among Students in College Settings............................................. 11
Health Behavior Theory of Hand Hygiene .......................................................................... 12
Summary .............................................................................................................................. 13
Chapter III: Methodology ........................................................................................................ 15

Introduction .......................................................................................................................... 15
Research Questions .............................................................................................................. 15
Research Design................................................................................................................... 15
Sample Selection and Data Collection Procedures .............................................................. 16
Instrumentation .................................................................................................................... 17
Data Analysis ....................................................................................................................... 18
Chapter IV: Results .................................................................................................................. 20

Introduction .......................................................................................................................... 20
Demographics of the Sample ............................................................................................... 20
Assessment of Research Questions ...................................................................................... 21
 v

Summary .............................................................................................................................. 28
Chapter V: Interpretation of Findings ...................................................................................... 29

Introduction .......................................................................................................................... 29
Interpretation and Discussion of the Research Questions.................................................... 29
Conclusions .......................................................................................................................... 32
Recommendations for Health Educators ............................................................................. 32
Recommendations for Future Research ............................................................................... 33
References ................................................................................................................................ 35

Appendices ............................................................................................................................... 44

Appendix A : Permission to Use Survey Instrument ........................................................... 44

Appendix B: Print Copy of Informed Consent .................................................................... 45
Appendix C: Institutional Review Board Letter of Approval .............................................. 46
Literature Review Matrix ..................................................................................................... 47

List of Tables
Table 1 Table of specification ........................................................................................... 19

Table 2 Description of Participants Demographics (N = 397).......................................... 20

Table 3 Percentage of correct and incorrect answers on the knowledge questions .......... 22

Table 4 Descriptive statistics for total attitude scores of individual questionnaire items (n

= 397) and Summated attitude score ........................................................................................ 23

Table 5 Frequency of response for self -reported Hand Hygiene practice among the study

participants .............................................................................................................................. 25

Table 6 Study participants’ Knowledge and Attitude levels of Hand Hygiene. ............... 28
 1

Chapter I: Introduction

Infectious diseases are caused by pathogenic microorganisms, such as bacteria,

viruses, parasites or fungi and the diseases can be spread, directly or indirectly, from one

person to another (World Health Organization [WHO], 2018). Among these modes of

transmission, person-to-person contact via the hands is a common mode of transmission of

bacterial infection (Aiello et al., 2012; Barker, Stevens, & Bloom, 2001). Serious disease-

causing pathogens commonly found in school settings includes Streptococcus pyogenes,

Streptococcus pneumoniae, Staphylococcus epidermidis, and Community-Associated

Methicillin-Resistant Staphylococcus (Scott & Vanick, 2007; White, Kolble, Carlson, &

Lipson, 2005).

According to the WHO (2009a), hand hygiene is defined as a behavior of cleaning the

hands with soap and water and by hand-rubbing using hand sanitizer without water.

Handwashing is an inexpensive and effective way to prevent infection and control disease

(Borghi, Guinness, Ouedraogo, & Curtis, 2002). Research is clear that proper hygiene is the

key to reducing occurrence of infectious diseases in many different types of communities,

including the healthcare settings, daycare centers, and grade schools (Aiello, Coulborn,

Perez, & Larson, 2008). Poor hand hygiene was significantly linked to higher incidence of

infectious diseases, medical visits and absence from classes or work (Prater et al., 2016).

Absenteeism related to communicable disease also affects educational institutions (White et

al., 2003) such as re-teaching absent students (Minnesota Department of Health, 2016).

People who are not regular hand washers have been shown to have an increased incidence of

viral illness that can lead to inevitable bed rest (Drankiewicz & Dundes, 2003; Moe,

Christmas, Echols, & Miller, 2001).

In 2002, it was established that a high level of proper hand hygiene may make the
 2

difference between a successful recovery and a health care–associated infection, which

account for 1.7 million infections and 99,000 associated deaths each year in American

hospitals alone (Center for Disease Control and Prevention [CDC], 2002). Closed

environments and low levels of handwashing contribute to disease transmission on college

campuses which is similar to that in hospitals. (Guinan, McGuckin-Guinan & Sevareid,

1997).

Statement of the Problem

Promotion of improved hand hygiene has been recognized as a cornerstone of

infectious disease control and an important public health measure (Tao, Cheng, Lu, Hu, &

Chen, 2013). While innumerable studies posit that proper hand hygiene is the key to reduce

occurrence of infectious diseases in different types of communities, college students have

been found to inadequately wash their hands, which increases their chances of contracting

infectious diseases (Aiello et al., 2008). Improper hand hygiene is an important contributing

factor to contracting infectious diseases among college students (Prater et al., 2016).

The CDC (2018) and the WHO (2009a) have published simple-to-follow

handwashing guidelines. However, incorrect handwashing practices and low compliance are

prevalent even among health care workers (Walker et al., 2014). Whether the college students

have adequate knowledge on the effect of hand hygiene practices against infectious diseases

is an interesting question that needs to be assessed. Approximately 2.4 million deaths can be

prevented annually by good hygiene practices, reliable sanitation, and drinking clean water

(Rabbi & Dey, 2013).

A meta-analysis on 30 hand hygiene studies found that improvements in

handwashing reduced the incidence of upper respiratory tract infections by 21% and

gastrointestinal illnesses by 31% (Aiello, 2008). It is also indicated that handwashing with
 3

soap could reduce the risk of diarrheal diseases by 42%–47%, and handwashing promotion

has been projected to save millions of lives (Curtis & Cairncross, 2003).

Purpose Statement

The purpose of this research is to assess the knowledge, attitude and practices of hand

hygiene among students at a large midwestern university.

Need for study

Although extensive research has been conducted to investigate the hand hygiene

knowledge, beliefs, and practices of health care providers (WHO, 2009a) and daycare centers

and elementary schools, (Guinan et al., 2002; Hammond et al., 2000 and St Sauver et al.,

1998), there are very few previous studies addressing hand hygiene practice on college

campuses (Anderson et al., 2008). This study would be very useful in identifying gaps in

knowledge, poor attitudes and substandard practices to enhance the development of

appropriate strategies to promote hand hygiene for college students in the future.

Research Questions

1. What are the levels of knowledge of hand hygiene among university students?

2. What are the attitudes regarding hand hygiene among university students?

3. What are the self-reported hand hygiene practices among university students?

Limitations

1. Participation of students will be determined, in part, by consent of instructors of

selected classes to permit the survey questionnaire to be distributed in their class(es).

2. This study is a cross-sectional study; therefore, the findings would reflect a single

point of time which may provide differing results if another timeframe had been

chosen.
 4

Delimitations

1. The study was delimited to college students at a single university which does not

represent all university students across the country.

2. To be included in the study, participants had to be enrolled in a class for Spring 2019

semester, be at least eighteen years of age and the survey questionnaire was

completed during class time.

Assumptions

1. Participants can read and understand the survey questions.

2. Participants will answer survey questions honestly and factually.

Definition of Terms

Hand hygiene – Hand hygiene is considered a behavior of cleaning the hands that includes

handwashing with soap and water and hand-rubbing using hand sanitizer without water

(WHO, 2009a).

Handwashing – handwashing is “washing hands with plain or antimicrobial soap and water

(WHO, 2009b).

Infectious diseases - Infectious diseases are diseases caused by pathogenic microorganisms,

such as bacteria, viruses, parasites or fungi and can be spread, directly, from one person to

another through contact (WHO, 2018).

Hand hygiene knowledge – is defined as having adequate understanding about hand hygiene

(Jemal, 2018).

High/Good knowledge level of hand hygiene - earning score of >75% and above on the

knowledge questions indicating having sufficient amount of knowledge.

Moderate level of hand hygiene - earning score of (50%-75%) on the knowledge questions.

Low levels of hand hygiene - earning score of < 50% and above on the knowledge questions.
 5

Hand hygiene attitude - defined as the individual’s positive or negative evaluation of hand

hygiene.

Levels of attitude of hand hygiene - earning score within a particular range on the attitude

scale.

Hand hygiene practices – is defined as an act of performing hand hygiene according to a set

standard (Jemal, 2018).

 6

Chapter II: Literature Review

Introduction

The main purpose of this study is to assess knowledge, attitudes, and practices of

hand hygiene among students at a large midwestern university. This chapter reviews

infectious diseases, transmission of pathogens via hand contact, the burden of infections on

university students, the importance of hand hygiene in disease prevention, importance of

hand hygiene in disease prevention among university students, a review of studies indicating

hand hygiene behavior of college students hand hygiene behavior theory.

Infectious Diseases

Infectious diseases are caused by pathogenic microorganisms, such as bacteria,

viruses, parasites or fungi and the diseases can be spread, directly or indirectly, from one

person to another (WHO, 2018). Person-to-person contact via the hands is a common mode

of bacterial infection (Aiello et al., 2012; Barker et al., 2001). In 1938, Price established that

bacteria recovered from the hands could be divided into two categories, namely resident flora

and transient flora.

Resident flora. Resident flora consists of microorganisms residing under the

superficial cells of the stratum corneum and can also be found on the surface of the skin

(Wilson, 2005). Resident flora refers to colonizing microorganisms not readily removed

through the mechanical friction associated with hand washing. The resident flora on the

hands are composed of a large number of microbial species, including the gram-positive

Micrococcaceae (Staphylococcus epidermidis, S. hominis, and S. captitis), Corynebacterium

and Propionibacterium (Propionibacterium acnes and P. granulosum. (Katz, 2004). In

general, resident flora is less likely to be associated with infections, but may cause infections

in sterile body cavities, the eyes, or on non-intact skin (Lark et al., 2001).
 7

Transient flora. Transient flora consists of colonizing microorganisms that are

present on hands due to contamination. They are more likely to cause illness and are of

greater concern. Transient flora are often acquired through direct contact with patients or

contaminated environmental surfaces and are more amenable to removal by routine hand

hygiene (WHO, 2009a). Hand hygiene is therefore significantly intended at reducing the

amount of transient flora on hands. (Katz, 2004 ).

Pathogens commonly found in school setting include Streptococcus pyogenes,

Streptococcus pneumoniae, Staphylococcus epidermidis, and Community-Associated

Methicillin-Resistant Staphylococcus (Scott & Vanick, 2007; White et al., 2005). Infections

preventable by improved hand hygiene include gastrointestinal infections (Aiello et al., 2008;

Ejemot-Nwadiaro et al., 2008) respiratory infections (Aiello, 2008; Rabie & Curtis, 2006)

trachoma (Emerson, Cairncross, Bailey & Mabey, 2000) and possibly worm infections

(Franziska et al., 2013).

Transmission of Pathogens by Hands

Human populations are continually infected with common pathogens that cause

respiratory and digestive discomfort (Ejemot-Nwadiaro, Ehiri, Arikpo, Meremikwu, &

Critchley, 2015). Germs like Salmonella, E. coli O157, and norovirus that cause diarrhea, can

also spread respiratory infections like adenovirus and hand-foot-mouth disease (CDC,

2018b).

The hands are used more than any other part of the body, from handshaking, to

doorknob use, and coughing (Curtis & Cairncross, 2003). There are 229,000 germs per

square inch on frequently used faucet handles, 21,000 germs per square inch on work desks

and 1,500 on each square centimeter of hands (Minnesota Department of Health, 2017).

Microorganisms are readily transmitted either directly through contact or indirectly by

inanimate objects serving as vectors, and contaminated hands are implicated in this process
 8

(CDC, 2018b). When the organisms are pathogenic, the spread of community-acquired

infections among students is inevitable (White, Shinder, Shinder, & Dyer, 2001).

The Burden of Infections on University Students

A causal relationship has been established between hand hygiene and rates of

infectious illness (Aiello & Larson, 2002). Similar to hospitals, schools have close, crowded

environments that increase the risk of microbial cross-contamination and transmission

(White, Shinder, Shinder, & Dyer, 2001). Low handwashing compliance has been linked to

the rapid spread of Norwalk-like viruses (Moe, 2001). A serial cohort study denoted that

colds and influenza-like illness are common among university students and these illnesses are

associated with substantial morbidity including school and work absenteeism, impaired

school performance, and significant health care utilization (Nichol, D'Heilly, & Ehlinger,

2005).

The level of upper respiratory infection on college campuses impacts class attendance

and academic performance, and burdens college health centers (White et al., 2003). School

absenteeism has been shown to increase due to illness during influenza season (Neuzil,

Hohlbein, & Zhu, 2002). Annually in the United States, an estimated 70 to 164 million school

days are lost due to infectious diseases (Vessey, Sherwood, Warn, & Clark, 2007). Low hand

hygiene compliance among college students has contributed to outbreaks of upper respiratory

illness (White et al., 2005), group B Streptococcus colonization (Bliss et al., 2002), and

Norwalk-like viruses, the leading cause of acute epidemic gastroenteritis in the United States

(Glass, et al., 2000; Moe et al., 2001).

In spite of the fact that the morbidity and mortality associated with some infectious

diseases such as respiratory and gastrointestinal illnesses among university students are

relatively low, these infections may still contribute to absenteeism and sickness presenteeism.

This can eventually affect academic performance and efficiency and can also be associated
 9

with outbreaks of viral gastroenteritis, upper respiratory tract infections, and group B

streptococcal colonization in this setting (Miko et al., 2012). High frequency of illness can

limit a student’s academic success in school and create excess burden for teachers to make up

for lost academic time. (Vessey, Sherwood, Warn, & Clark, 2007).

Hand Hygiene

Hand hygiene is considered a behavior that includes handwashing with soap and

water and/or hand-rubbing using hand sanitizer without water (WHO, 2009a). Washing hands

with soap and water removes pathogens mechanically and may also chemically kill

contaminating and colonizing flora. It has long been known that practicing hand hygiene,

either washing the hands with water and soap or using alcohol-based hand rub is the most

effective way of preventing the spread of infectious diseases (Anderson et al., 2008). Hand

hygiene is simple, easily implemented and an effective practice that can reduce the risk of

infection (Zakeri, Ahmadi, Rafeemanesh, & Saleh, 2017) and also recognized to be a

convenient and cost-effective means of preventing communicable diseases (Tao, Cheng, Lu,

Hu, & Chen, 2013).

Public health authorities recommend a thorough washing and scrubbing of the hands

before meals, during meal preparations and after using the toilet (Nadakavukaren, 2011).

Washing should last for at least twenty seconds, using soap and water, drying hands with a

paper towel; and turning off the faucet with a paper towel to avoid hand-to-surface contact

(CDC, 2018b). The practice of washing hands with water only or with soap may be

influenced by both knowledge of best practice and availability of water and soap (Curtis et

al., 2011). In addition to this, handwashing may require infrastructural, cultural, and

behavioral changes, which take time to develop, as well as substantial resources such as

trained personnel, community organization and provision of water supply and soap (Luby,
 10

2001). Hand sanitizers are an appropriate alternative to handwashing for hand cleansing and

may offer additional benefits in the school setting (Vessey, 2007).

Importance of Hand Hygiene in Disease Prevention

In healthcare settings, hand hygiene is globally recognized as the leading measure to

prevent cross-transmission of microorganisms, reduce the incidence of health care associated

infections and prevent the spread of antimicrobial resistant pathogens (Boyce & Pittet, 2002).

It is also an economical method for reducing healthcare associated infections (Pittet et al.,

2006). Hand hygiene is considered an important intervention measure for pandemic public

health threats, such as severe acute respiratory syndrome and avian influenza (Lau, Tsui, Lau,

& Yang, 2004; Muller & McGeer, 2006; Rothman et al., 2006). Infections preventable by

improved hand hygiene include gastrointestinal infections (Aiello et al., 2008; Ejemot-

Nwadiaro et al, 2008) respiratory infections (Aiello et al., 2008; Rabie & Curtis, 2006)

trachoma (Emerson et al., 2000) and possibly worm infections (Franziska et al., 2013).

Several studies have demonstrated that hand hygiene interventions using alcohol gel

sanitizers can reduce the rates of infection and absenteeism (Guinan, McGuckin, & Ali, 2002;

White et al., 2003).

A meta-analysis on 30 hand hygiene studies found that improvements in handwashing

reduced the incidence of upper respiratory tract infections by 21% and gastrointestinal

illnesses by 31% (Aiello et al., 2008). It has been shown that handwashing with soap could

reduce the risk of diarrheal diseases by 42%–47%, and handwashing promotion could save

millions of lives (Curtis & Cairncross, 2003).

Importance of Hand Hygiene in Disease Prevention among University Students

To improve public health, it is very important to understand the role of infectious

disease in our society by developing and practicing preventative efforts against infectious
 11

diseases. Handwashing prevents the direct transfer of infectious pathogens on the hands from

reaching a portal of entry and the indirect transfer through food preparation and fomite

transmission pathways (Katz, 2004 ). Several studies posit that proper hygiene is the key to

reduce occurrence of infectious diseases in different types of communities (Aiello et al.,

2008). Improper hand hygiene is an important contributing factor to contracting infectious

diseases among college students (Prater et al., 2016). Approximately 2.4 million deaths can

be prevented annually by good hygiene practices, reliable sanitation, and drinking clean

water (Rabbi & Dey, 2013).

Appropriate hand hygiene practices such as handwashing and hand sanitization can

possibly result in the reduction of the spread of infection and the resulting lost days of

school/work because of absenteeism (White et al., 2003). One way of reducing illness-

related absenteeism is to promote good hand hygiene practices as proper hand hygiene is a

well-known preventive measure for many infectious diseases (Heymann , 2008).

These studies indicate that hand hygiene plays an important role in reducing illness

and absenteeism in schools. Student education is an important function of an infection control

program just as in healthcare settings, which would be an important factor in limiting the

spread of disease in colleges.

Hand Hygiene Behavior among Students in College Settings

Understanding how the individual role in infection prevention is important in the

overall health of our community. College students have been found to inadequately wash

their hands, which would seemingly increase their chances in contracting infectious diseases

(Aiello et al., 2008). In addition, it was revealed that 63% of female college students washed

their hands after using the bathroom, but only 38% used soap and water (Drankiewicz &

Dundes, 2003). In an alternative study, 58.3% of college students washed their hands or used

a hand sanitizer after using the bathroom (Anderson et al., 2008). People presented with the
 12

benefits and consequences of hand hygiene are more likely to wash their hands (Guinan,

McGuckin, & Ali, 2002).

Handwashing is viewed as a social norm, and hand hygiene may contribute to social

acceptance thus people are more likely to wash their hands after using the restroom when

others are present (Monk-Turner et al., 2005). Although proper hand hygiene is a well-

established norm, maintaining good hand hygiene is considered a major challenge in

infection control (Pittet, 2001). The CDC (2018) and the WHO (2009a), have issued a

simple-to-follow handwashing guideline. However, incorrect handwashing practices and low

compliance are prevalent (Walker et al., 2014) even among health care workers. Whether

university students have adequate knowledge on the effect of hand hygiene practices against

infectious diseases is an interesting question that needs to be assessed. Henceforth, attitude

and practices on hand hygiene needs to be assessed as well.

Health Behavior Theory of Hand Hygiene

Most assessments of hand hygiene have measured knowledge (cognitive domain) and

practices (behavioral domain). A theoretical model in which to frame an assessment of

knowledge, attitude and practices is the Theory of Planned Behavior.

The Theory of Planned Behavior (TPB) predicts an individual's intention to engage in

a behavior at a specific time and place. It posits that individual behavior is driven by behavior

intentions, where behavior intentions are a function of three determinants: an individual’s

attitude toward behavior, subjective norms, and perceived behavioral control (Ajzen, 1991).

According to this theory, the immediate cause of a planned behavior as in a case of hand

hygiene is intention to perform the behavior, which, in turn, is shaped by personal attitude

(feelings or affective regard for the behavior), perceived behavioral control (a person’s

perception of the ease or difficulty in performing the target behavior), and subjective norms
 13

(a person’s perception of the social pressure to perform or not perform the behavior) (Ajzen,

1988).

Thus, intention is assumed to be the most immediate factor to determine a behavior.

Attitude toward a given behavior is determined by beliefs about the consequences of the

behavior and the evaluation of these (Ajzen, 1988). Identification of individual cognitive

factors associated with intention to perform hand hygiene may help build successful

promotion strategies.

Summary

Pathogens that cause respiratory and digestive discomfort continually infect human

populations (Ejemot-Nwadiaro et al., 2015). Schools, like hospitals, have close, crowded

environments that increase the risk of microbial cross-contamination and transmission

(White, Shinder, Shinder, & Dyer, 2001). Poor adherence to hand hygiene practices has been

described among students in the university setting (Boyce & Pittet, 2002).

Improved hand hygiene provides a simple and cost-effective means for preventing the

spread of infection in this population (Aiello & Larson, 2002; Aiello et al., 2008). Hand

hygiene can also prevent about 30% of diarrhea-related sicknesses and about 20% of

respiratory infections like colds (Ejemot et al., 2008; Rabie & Curtis, 2006). Reducing the

number of these infections by washing hands frequently helps prevent the overuse of

antibiotics—the single most important factor leading to antibiotic resistance around the world

(CDC, 2018a).

Whether the university students have adequate knowledge on the effect of hand

hygiene practices against infectious diseases is an interesting question that is unknown and

hence needs to be assessed. Even more critical is the need to discover their attitude and

practices on hand hygiene so as to identify the gaps in knowledge, attitudes and practices of
 14

hand hygiene. The purpose to this study therefore seeks to assess the knowledge, attitude and

practices of hand hygiene among college students.

 15

Chapter III: Methodology

Introduction

The purpose of this research was to assess the knowledge, attitude and practices of

hand hygiene among students at a large, midwestern university. In this chapter, the research

questions are reviewed, and the research design developed to answer the questions presented.

The population and sample, instrumentation and a detailed description of the data collection

process are provided. The data analysis procedures are also described in this chapter.

Research Questions

This study addressed the following research questions regarding sampled students, ages 18

and above.

1. What are the levels of knowledge of hand hygiene among university students?

2. What are the attitude levels of hand hygiene among university students?

3.What are the self-reported hand hygiene practices of university students?

Research Design

A cross-sectional study was conducted among students at a large, midwestern

university. This design was chosen because it enables the collection of quantitative data on

multiple variables at a single point in time (Bryman, 2012).

Advantages of using cross-sectional study design enables the study of multiple

outcomes which can be studied with ease while facilitating the description of population

characteristics and identifying associations among variables. The use of this design is

considerably inexpensive and less time consuming because there is no loss to be followed-up

on. Prevalence of outcome of interest can be estimated because samples are usually taken

from the whole population. Additionally, due to the assessible outcomes and factors, this
 16

study design becomes convenient for public health planning. The primary limitation of a

cross sectional design is the inability to establish causal inference and the situation may

provide differing results if another timeframe had been chosen (Levin, 2006).

Sample Selection and Data Collection Procedures

The estimated population of students at the target University was 15,000. Using a

table for determining sample size from a given population (Krejcie & Morgan, 1970), a

sample size of 365 participants was selected for the study. This study included a convenience

sample of undergraduate students, ages 18 years of age and above, who were enrolled at

Minnesota State University, Mankato, spring semester, 2019. Selection of classes was

obtained from the university’s website by choosing classes with large enrollment size. The

data collection took place during the month of April 2019. The student researcher contacted

Professors/Instructors from various courses at Minnesota State University, Mankato by email

dialogue for permission to distribute surveys in their respective classes.

A selection of courses was obtained from the university website. Courses containing

large numbers of students with a high probability of containing students from diverse

backgrounds were selected. The various courses included First Aid and CPR, Alcohol and

Drug Studies, Design and Architecture, Introduction to Sociology and Elements of

Geography.

The research was conducted in person at Minnesota State University, Mankato by

collecting data from participants attending selected classes, during class time, throughout the

university. Participants were asked to complete a traditional paper-pencil survey instrument.

The inclusion criterion for participants would be students enrolled in the spring

academic year and participation would be completely voluntary. The research was conducted

in person at the target university by distributing survey to participants attending selected

 17

classes, during class time. The nature and purpose of the study will be explained to the

participants. The participants will then be asked to complete a paper-based survey instrument.

Instrumentation

Three self-reported questionnaires, adapted from previously published studies were

utilized for this study (Ergin et al., 2011; Rosen, Zucker, Brody, Engelhard, & Manor, 2009;

CDC, 2016) to assess the knowledge, attitude and self-reported practices regarding hand

hygiene. Permission to use instruments was obtained through personal communication with

the author via email (Appendix A). The institutional review board approved the research

prior to implementation of the study. (Appendix C).

The hand hygiene questionnaire instrument consisted of three scales: knowledge,

attitude and self-reported practice regarding hand hygiene. A demographic section was added

to the questionnaire to elicit information on participants’ age, gender, race, level of education

completed and questions on if participants have had formal training on hand hygiene.

Hand hygiene knowledge scale

The first scale, hand hygiene knowledge was assessed using 10 questions which

includes “True” or “False” questions on general hygiene knowledge. A scoring system was

used where one point was given for each correct response to knowledge and 0 was given for

an incorrect answer. A total score was calculated on the knowledge items called KSCORE.

The higher the value of the variable KSCORE the more knowledge a student had in relation

to hand hygiene. A score of more than 75% was considered good, 50-74% moderate and less

than 50% poor. The cut off values to determine good, moderate and poor levels will be

adapted from previously published study (Kudavidanage, Gunasekara, & Hapuarachch,

2011).
 18

Hand hygiene Attitude scale

Attitudes toward hand hygiene was assessed using a seven-point semantic differential

scale using seven different descriptors about participants feeling of practicing hand hygiene.

The individual items measured the degree of inconvenience, irritation, frustration and

practicality involved in practicing hand hygiene at the appropriate times, as well as whether

hand hygiene is considered optional or beneficial. Attitude was calculated by adding the

summated items: the higher the score, the better the attitudes toward hand hygiene. A score of

more than 75% was considered good, 50-74% moderate and less than 50% poor. The cut off

values to determine good, moderate and poor levels will be adapted from previously

published study (Kudavidanage, Gunasekara, & Hapuarachch, 2011).

Self-reported hand hygiene practices scale

Self-reported hand hygiene practices were measured using 30 questions where

respondents were asked to choose from four options- always, sometimes, never and not

applicable. In the evaluation of self-reported practices of hand hygiene, ‘always’ response

received 3 points, “sometimes” received 2 points, “never” received 1 point and “not

applicable received 0 point for all questions.

Content Validity and Reliability

The adapted questionnaire was not pretested and did not go through the validation

process at target University. The source instrument was be prepared in English to ensure

readability.

Data Analysis

Data analysis was done using the Statistical Package for Social Sciences (SPSS)

version 25 to analyze the study data. Participant’s responses to individual items along with

participants’ summated totals for all scales were analyzed using descriptive statistics.
 19

Table 1
Table of specification

Research Question Survey items or methods Level of Data (Nominal, Analysis needed to assess
(RQ) used to assess RQ’S Ordinal, Interval/Ratio) * RQ
What are the levels of - Individual items on - Nominal data Descriptive Statistics
knowledge of hand questionnaire Part B, (individual survey including
hygiene among questions 1-10. items) frequencies, percentages,
sampled students at a - Total summated - Interval- (total and measures of central
large, midwestern scores of summated score) tendency and dispersion.
university? questionnaire Part B,
questions 1-10.
What are the attitude - Individual items on - Ordinal data Descriptive Statistics
levels of hand hygiene the attitude scale, (individual survey including
among sampled Part C, items 1-7. items) frequencies, percentages,
students at a large, - Total summated - Interval- (total and measures of central
midwestern scores of the attitude summated score) tendency and dispersion.
university? scale, Part C, items
1-7.
What are the self- - Individual items on - Ordinal data Descriptive Statistics
reported practices of the behavior (individual survey including
hand hygiene among questionnaire Part D, items) Frequencies and
sampled students at a questions 1- 30. percentages.
large, midwestern
university?

Note. * Indicates level of data for survey items or methods, not RQ’s

Summary

A cross-sectional study was conducted among students at a large, midwestern

university. A self-reported questionnaire was administered to a convenience sample of

university students in Minnesota to assess their hand hygiene knowledge, attitude and

practices. Data was analyzed using descriptive statistics.

 20

Chapter IV: Results

Introduction

The purpose of this research was to assess the knowledge, attitude and practices of

hand hygiene among students at a large, midwestern university. In this chapter, the results of

the study will be discussed.

Demographics of the Sample

A total of 406 surveys were collected from potential participants and 397 surveys (97.7%)

were included in the data analysis. The remainder of the surveys (2.21%; n=9) were

discarded due to incomplete/missing data.

The sample was predominantly female (56.4%) and White or Caucasian (81.9%) with 38.0%

of participants having completed one semester of university or less. While the age

distribution of the sample was diverse, the predominant age was nineteen years of age

(37.0%) and 50.9% of students have also received a formal training on hand hygiene. Please

refer to Table 2 for additional demographic data.

Table 2
Description of Participants Demographics (N = 397)
Item N N% N%
Age
18 years of age 60.0 15.1
19 years of age 147 37.0
20 years of age 90.0 2.7
21 years of age 47 11.8
22+ years of age 53 13.4
Sex
Male 173 43.6
Female 224 56.4
 21

Table 2 (Continued)
Description of Participants Demographics (N = 397)

Item N N%
Highest level of education
One Semester of College/University or less 151 38.0
One Year of College/University 92 23.2
Two Years of College/University 79 19.9
Three Years of College/University 50 12.6
Four or More Years of College/University 25 6.3
Race
White or Caucasian 325 81.9
Black or African American 30 7.6
American Indian, Native American, or Alaskan 5 1.3
Asian 23 5.8
Pacific Islander 1 0.3
Other 13 3.3
Have you received any formal training in hand hygiene before?
Yes 50.9
No 202 49.1
195

Assessment of Research Questions

What are the levels of knowledge of hand hygiene among sampled students at a

large, Midwestern university? Scores on the hand hygiene questions ranged from zero to

ten with a mean score of participants’ KSCORE of (M = 8.59, SD = 1.33). The percentages

of correct and incorrect answers with regards to hand hygiene knowledge are displayed in

Table 3. The table (3) shows that a significant number (80.9%) of participants provided

correct answers to the questions on hand hygiene. The question that had the least number of

correct answers (55.7%) was “Hot water should be used for handwashing” and “Hand

hygiene practices prevent an individual from getting infection” question had the highest

number of correct answers (99.7%). Table (6) shows that the majority of the participants

(80.9%) had a good level of knowledge of hand hygiene.

 22

Table 3
Percentage of correct and incorrect answers on the knowledge questions

Knowledge Question Correct n (%) Incorrect n

1. Cold water should be used for 370 (93.2) 27 (6.8)

handwashing

2. Medium hot water should be used for 294 (74.1) 103 (25.9)
handwashing

3. Hot water should be used for hand 221 (55.7) 176 (44.3)
washing

4. There is no need to remove watches and 309 (77.8) 88 22.2)

bracelets when washing hands

5. There is no need to remove rings when 352 (81.9) 72 (18.1)

washing hands

6. There is no need to wash wrists 377 (95.0) 19 (4.8)

7. Hands need to be washed at least 15 373 (94.0) 24 (6.0)

seconds

8. Hands need to be dried after washing 369 (92.9) 23 (5.8)

9. Hand hygiene practices prevent an 373 (94.0) 1 (0.3)

individual getting infection

10. Hand washing is part of personal hygiene 396 (99.7) 1 (0.3)

Hand hygiene knowledge mean score Mean (M) SD

8.59 1.33

What are the levels of attitude of hand hygiene among sampled at a large,

Midwestern university? Attitudes toward hand hygiene was assessed using a seven-point

semantic differential scale using seven different descriptors about participants feeling of

practicing hand hygiene. The individual items measured the degree of inconvenience,

irritation, frustration and practicality involved in practicing hand hygiene at the appropriate

times, as well as whether hand hygiene is considered optional or beneficial. Attitude scores
 23

were calculated by adding the summated items called ASCORE: the higher the score, the

better the attitudes toward hand hygiene.

Scores on the hand hygiene attitude ranged from sixteen to forty-nine with a mean

(±SD) score of participants’ ASCORE of (M = 41.89, SD = 7.55). An examination of the

summated data revealed that 17.6% of the participants had a highest score of forty-nine (49).

In contrast, 0.3% of participants had a low score of sixteen (16). Overall, attitudes toward

hand hygiene were positive among the study participants. The attitude levels (table 6) was

found to be good (more than 75%) in 80.6% of the participants, moderate (50%-75%) in

17.1% and poor (<50%) in only 2.3% of the total participants. The most positive attitude

occurred for the statement: I feel practicing hand hygiene is ‘Beneficial … Harmful’ (mean =

6.43, SD = 1.39). The lowest grade was assigned to irritability of practicing hand hygiene

(mean = 5.92, SD = 1.64). The detailed results are depicted in table 4.

Table 4
Descriptive statistics for total attitude scores of individual questionnaire items (n = 397) and
Summated attitude score

Attitude description Mean SD

I feel practicing hand hygiene is:
Inconvenient … convenient 5.97 3.55
Not frustrating … frustrating 5.92 1.69
Not practical … practical 6.19 1.30
Troubling …reassuring 5.81 1.64
Irritating … soothing 5.39 1.64
Optional … necessary 6.19 1.35
Harmful …Beneficial 6.43 1.39
Hand hygiene attitude mean score 41.89 7.55
Descriptive statistics for ASCORE

Score Frequency Percent

16.00 1 0.3
18.00 1 0.3
19.00 1 0.3
20.00 1 0.3
21.00 1 0.3
23.00 1 0.3
 24

24.00 2 0.5
25.00 4 1.0
26.00 2 0.5
27.00 4 1.0
28.00 8 2.0
29.00 5 1.3
30.00 3 0.8
31.00 3 0.8
32.00 4 1.0
33.00 12 3.0
34.00 8 2.0
35.00 10 2.5
36.00 5 1.3
37.00 11 2.8
38.00 21 5.3
39.00 11 2.8
40.00 19 4.8
41.00 18 4.5
42.00 23 5.8
43.00 31 7.8
44.00 18 4.5
45.00 23 5.8
46.00 20 5.0
47.00 25 6.3
48.00 30 7.6
49.00 70 17.6
Total 397 100

What are the self-reported practices of hand hygiene among sampled students at

a large, Midwestern university?

Table 5 depicts that, the majority of respondents (89.7%) of the study participants

reported that they wash their hands after handling animal waste and (87.4%) after using the

restroom. The majority (69.0) of the respondents answered “never” to washing their hands

before using the restroom and (61%) after combing their hair.
 25

Table 5
Frequency of response for self -reported Hand Hygiene practice among the study
participants

Hand hygiene behavior Always n Sometimes Never Not Applicable

(%) n (%) n (%) n (%)
1. I wash my hands before 90 (22.7) 287 (72.3) 19 (4.8) 0 (0)
meals

2. I wash my hands after 58 (14.6) 271 (68.3) 68 (17.1) 0 (0)

meals

3. I wash my hands before 21 (5.3) 98 (24.7) 274 (69.0) 4 (1.0)

using the restroom

4. I wash my hands after 347 (87.4) 43 (10.8) 6 (1.5) 1 (0.3)

using the restroom

5. I wash my hands when I 69 (17.4) 228 (57.4) 97 (24.4) 3 (0.8)

come home.

6. I wash my hands after 20 (5.0) 190 (47.9) 178 (44.8) 9 (2.3)

handshaking.

7. I wash my hands before 68 (17.1) 155 (39.0) 168 (42.3) 6 (1.5)

going to bed

8. I wash my hands after 129 (32.5) 182 (45.8) 79 (19.9) 7 (1.8)

using public
transportation

9. I wash my hands after 89 (22.4) 140 (35.3) 164 (41.3) 2 (0.5)

waking up in the morning

10. I wash my hands after 142 (35.8) 221 (55.7) 32 (8.1) 2 (0.5)
touching animals

11. I wash my hands after 356 (89.7) 22 (5.5) 6 (1.5) 13 (3.3)

handling animal waste

12. I wash my hands after 188 (47.4) 152 (38.3) 41 (10.3) 16 (4.0)
handling animal food

13. I wash my hands only if 148 (37.3) 134 (33.8) 68 (17.1) 46 (11.6)
they are soiled
 26

Table 6 (Continued)
Frequency of response for self -reported Hand Hygiene practice among the study
participants

Hand hygiene behavior Always n Sometimes Never Not Applicable

(%) n (%) n (%) n (%)

14. I wash my hands before 330 (83.1) 55 (13.9) 9 (2.3) 3 (0.8)

preparing meals

15. I wash my hands after 89 (22.4) 195 (49.1) 113 (28.5) 0 (0)
money exchange

16. I wash my hands after 185 (46.6) 187 (47.1) 25 (6.3) 0 (0)
blowing my nose

17. I wash my hands after 146 (36.8) 218 (54.9) 33 (8.3) 0 (0)
sneezing

18. I wash my hands after 126 (31.7) 232 (58.4) 38 (9.6) 0 (0)
coughing

19. I wash my hands after 297 (74.8) 95 (23.9) 5 (1.3) 0 (0.0)

touching garbage

20. I wash my hands before 190 (47.9) 139 (35.0) 61 (15.4) 7 (1.8)
touching sick people

21. I wash my hands after 317 (79.8) 67 (16.9) 8 (2) 4 (1)

touching sick people.

22. I wash my hands after 31 (7.8) 115 (29.0) 242 (61.0) 9 (2.3)
combing my hair

23. I wash my hands after 202 (50.9) 136 (34.4) 58 (14.6) 1 (0.3)
cleaning my home

24. I wash my hands after 234 (58.9) 103 (25.9) 60 (15.1) 0 (0)
washing dishes

25. I wash my hands after 53 (13.4) 132 (33.2) 211 (53.1) 1 (0.3)
doing laundry

26. I wash my hands before 326 (82.1) 59 (14.9) 10 (2.5) 2 (0.5)

preparing food
 27

Table 7 (Continued)
Frequency of response for self -reported Hand Hygiene practice among the study
participants

Hand hygiene behavior Always n Sometimes Never Not Applicable

(%) n (%) n (%) n (%)

27. I wash my hands after 255 (64.2) 120 (30.2) 18 (4.5) 4 (1.0)
preparing food

28. I wash my hands after 299 (75.3) 25 (6.3) 9 (2.3) 64 (16.1)

changing diapers

29. I wash my hands after 167 (42.1) 150 (37.8) 34 (8.6) 46 (11.6)
handling babies

Classification of levels of knowledge and attitude

Table 6 shows participants’ levels of knowledge and attitude of hand hygiene. A score

of more than 75% was considered good level, indicating participants had sufficient amount of

knowledge on hand hygiene, 50-74% moderate and less than 50% poor or low level of hand

hygiene knowledge.

Scores on the hand hygiene attitude ranged from sixteen to forty-nine. High levels of

attitude ranged from scores between (37 - 49), which represented (75%) of the total score,

moderate level of attitude ranged between (25 - 36) representing (50-74%) of the total score

and low of poor attitude levels ranged from scores between (16-24) which also represented

less than 50% of the total score.

The table (6) depicts that the majority of the participants (80.9%) had a high level of

knowledge of hand hygiene, when the attitude levels was also found high in 80.6% and low

in only 2.3%.
 28

Table 8
Study participants’ Knowledge and Attitude levels of Hand Hygiene.

Levels of knowledge of hand hygiene Number Percentage (%)

High (>75%) 321 80.9

Moderate (50%-75%) 72 18.2

Low (<50%) 2 0.5

Levels of attitude of hand hygiene

High (37 - 49) 320 80.6

Moderate (25 – 36) 68 17.1

Low (16 -24) 9 2.3

Summary

Data was collected from three self-reported questionnaires using convenience

sampling method to assess the levels of hand hygiene knowledge, attitude and practices

among university students at a large, midwestern university. Data was analyzed using

descriptive statistics. The analysis of the variables assisted in answering the levels of

knowledge, attitude and practices of hand hygiene among the sampled university students.

Overall, the results of the survey show reasonably good responses towards knowledge,

attitude and practices of hand hygiene. The distribution of answers with regards to hand

hygiene knowledge, attitude and practices are displayed in Table 3, Table 4 and Table 5.
 29

Chapter V: Interpretation of Findings

Introduction

This research focused on assessing the knowledge, attitude and practices of hand

hygiene among students at a large, midwestern university. This chapter includes an

interpretation and discussion of the research findings, conclusions, and recommendations for

future research.

Interpretation and Discussion of the Research Questions

Data for this study was collected using a supervised format through a traditional

paper-pencil survey instrument. Using a convenience sample of undergraduate courses, 406

participants completed the survey. The survey included demographic items, and items

assessing levels of knowledge, attitude and practices of hand hygiene.

Knowledge on hand hygiene. The overall knowledge of hand hygiene was high

which was a positive finding. Table 3 shows that respondents have good knowledge on basic

hand hygiene where more than 80.9% answered 8 out of 10 questions correctly. This was

perhaps due to their usual understanding on personal and hand hygiene, obtained from formal

and informal learning processes. This could be considered to be a positive influence to

students at large, mid-western university. Table 6 revealed that that only 0.5% of participants

(2 out of 397) had low knowledge level regarding hand hygiene and 18.2% of participants

had moderate levels of knowledge of hand hygiene.

Although participants in this current study had high knowledge of hand hygiene and

achieved a satisfactory score on the knowledge questionnaire, the results showed deficits in

their knowledge, most notably in the area of the water temperature that should be used for

hand washing. Most of them did not know that the temperature of the water was an important
 30

factor for hand hygiene which was found in a similar study conducted to evaluate students

social hand hygiene knowledge in a university setting (Ergin et al., 2011).

Nevertheless, it is important to address the gaps of knowledge with regard to the

temperature of water that should be used for hand washing. Apart from the issue of skin

tolerance and level of comfort, water temperature does not appear to be a critical factor for

microbial removal from hands being washed. In contrast, in a study comparing water

temperatures of 4 °C, 20 °C and 40 °C, warmer temperatures have been shown to be very

significantly associated with skin irritation (Berardesca et al., 1995). The use of very hot

water for handwashing should therefore be avoided as it increases the likelihood of skin

damage (WHO, 2009b). In addition to this, warm water makes antiseptics and soap work

more effectively, while very hot water removes more of the protective fatty acids from the

skin. Therefore, washing with hot water should be avoided (WHO, 2009b).

In this current study, 74.1% of participants answered correctly that medium hot water

should be used for handwashing and 55.7% percent of participants answered correctly that

hot water should not be used for handwashing. However, 44.3% answered incorrectly to the

hot water being used to wash hands as documented in the WHO evidence-based guideline on

Hand Hygiene (WHO, 2009b) which articulates that, use of very hot water for handwashing

should therefore be avoided as it increases the likelihood of skin damage. Knowledge

questions on water temperature used in hand hygiene should be more layman-friendly, for

example using terms like warm water and very hot water. Deficits in knowledge have the

potential to create barriers to hand hygiene, such as skin breakdown, thus reducing the

motivation to perform hand hygiene.

Attitude towards hand hygiene. The findings of this survey indicated that the

participants’ level of attitude toward hand hygiene was high (more than 75%) in 80.6%,

moderate (50%-75%) in 17.1% and low (<50%) in 2.3% of the total participants. This
 31

indicates that attitudes toward handwashing were positive among the study participants. In

six out of seven items relating to feelings regarding practicing hand hygiene, attitudes were

more positive with a total mean score of 41.89 ± 7.55.The most positive attitude was for the

question: I feel practicing hand hygiene is: Harmful … Beneficial (M = 6.43, SD = 1.39). The

question with the least positive attitude was assigned to: I feel practicing hand hygiene is:

Irritating … soothing (M = 5.39, SD = 1.64).

Areas where the level of attitude was low cannot be underestimated. While attitude levels

relating to hand hygiene have not been previously investigated in the population of university

students, they have been explored in the healthcare workers and health student’s population.

Interestingly, one published study of attitudes toward hand hygiene among nurses, similarly

reported positive attitudes. (Kingston, Slevin, O’Connell, & Dunne, 2017).

Hand hygiene practices. CDC recommends when one should wash hands regardless

of the location; before, during, and after preparing food; before eating food; before and after

caring for someone who is sick, before and after treating a cut or wound; after using the

toilet; after changing diapers or cleaning up a child who has used the toilet; after blowing

your nose, coughing, or sneezing; after touching an animal, animal feed, or animal waste;

after handling pet food or pet treats and after touching garbage (CDC, 2018b).

In this current study, self - reported practices were highest after handling animal

waste (89.7%) and after using the restroom (87.4%). The next highest hand hygiene practices

reported were before preparing meals (83.1%) and after touching sick people (79.8%).

Practices were lowest before using the restroom and after combing my hair. In comparison to

other studies, describing the self-reported hand hygiene practices showed that most of the

participants wash their hands after using restrooms (Uner, Sevencan, Basaran, Balci, &

Bilaloglu, 2009) which was similar to the findings of this study. In a similar study where

participants were asked similar questions on hand hygiene. Most of the participants wash
 32

their hands after using restrooms, however ‘washing hands before meals’ scored less (Larson,

Bryan, Adler, & Blane, 1997).

Conclusions

Hand hygiene is essential to the health of the school community. This study assessed

the levels of knowledge, attitude and practices of hand hygiene among university students.

Overall, the study showed that levels of knowledge, attitude and practices of hand hygiene

among university students were high. Although the results of this study indicated that

participants had high levels of knowledge, attitude and practices of hand hygiene, the

information provided in this study regarding current hand hygiene knowledge, attitudes and

practices among university students will help identify the gaps in knowledge, poor attitudes

and substandard practices. This will also be valuable to the design and implementation of the

hand hygiene intervention.

Recommendations for Health Educators

Improper hand hygiene is an important contributing factor to contracting infectious

diseases among college students (Prater et al., 2016). The Save Lives: Clean Your Hands

campaign launched by the WHO in 2009 has provided extensive multimodal hand hygiene

improvement strategies which have been implemented by local and national health care

agencies. Although extensive research has been conducted to investigate the hand hygiene

knowledge, beliefs, and practices of health care providers (WHO, 2009a) and daycare centers

and elementary schools, (Guinan et al., 2002; Hammond et al., 2000 and St Sauver et al.,

1998), there are very few previous studies addressing hand hygiene practice on college

campuses (Anderson et al., 2008). This current research and the results of previous studies

suggest there are a number of areas that require attention. One important area is addressing
 33

the gaps in knowledge, poor attitudes and substandard practices to enhance the development

of appropriate strategies to promote hand hygiene for college students in the future.

Existing guides to implementing hand hygiene improvement strategies, such as those

published by the WHO (2009b) can serve as an invaluable framework when planning hand

hygiene education on college campuses. Key interventions for the implementation of hand

hygiene strategies may include frequent training sessions and education; evaluation and

performance feedback to encourage students to follow correct hand hygiene practices; and

reminders on campuses. These interventions would help identify gaps in knowledge and

practice and also help to ensure that students develop habits consistent with what is required

to curb the incidence contracting infectious diseases.

It is proposed that future interventions should target university campuses and focus

more on the important aspects of hand hygiene; how, when and where to practice hand

hygiene. This could be part of the university’s curriculum for all freshmen, where students

can be educated on the importance of hand hygiene, when to practice hand hygiene and focus

on how hand washing or the use of sanitizer is done. The use of educational materials such as

posters and brochures which will help provide information on hand hygiene.

The study also highlights that it is important to target training on hand hygiene among

general students not just medical or nursing students. Imparting knowledge to all students

would result in better understanding on hand hygiene, with which information would be

conveyed to their families, either directly or indirectly.

Recommendations for Future Research

Most assessments of hand hygiene have measured knowledge (cognitive domain) and

general practices (behavioral domain) rather than affective factors (values, beliefs,

perceptions, motivation). Identification of individual cognitive factors associated with

intention to perform hand hygiene is needed to help build successful promotion strategies.
 34

Henceforth, the present study evaluated the knowledge, attitude and the practices of the hand

hygiene among university students at large, mid-western university. For future research,

additional aspects of constructs which would be relevant in promoting hygiene could be

explored. Many studies about preventive health behavior are based on the principles of the

Health Belief Model (Rosenstock, 1974). In this case, constructs of the health belief model

could be explored among university students to promote hand hygiene.

The present study was a cross-sectional study. The limited amount of research in

investigating students’ level of knowledge, attitude and practices of hand hygiene, and the

inability to generalize the results of this or similar research to different populations,

necessitates further study using research designs that enable generalization.

 35

References

Aiello, A. E., & Larson, E. L. (2002). What is the evidence for a causal link between hygiene

and infection? Lancet Infectious Diseases, 2, 103-10. doi:10.1016/S1473-

3099(02)00184-6.

Aiello, A. E., Coulborn, R. M., Perez, V., & Larson, E. L. (2008). Effect of hand hygiene on

infectious disease risk in the community setting: A Meta-Analysis. American Public

Health Association, 98, 1372–1381. doi: 10.2105/AJPH.2007.124610

Aiello, A. E., Perez, V., Coulborn, R. M., Davis, B. M., Uddin, M., & Monto, A. S. (2012).

Facemasks, hand hygiene, and influenza among young adults: a randomized

intervention trial. PLoS ONE, 7(1), e29744. doi: 10.1086/650396

Ajzen, I. (1988). Attitudes, personality, and behavior: A Review of Its Applications to

Health-Related Behaviors. Buckingham, United Kingdom: Open University Press.

Ajzen, I. (1991). The theory of planned behavior. Organizational Behavior and Human

Decision Processes, 50(2), 179-211. doi: https://doi.org/10.1016/0749-

5978(91)90020-T

Anderson, J. L., Warren, C. A., Perez, E., Louis, R. I., Phillips, S., Wheeler, J., & Cole, M.

(2008). Gender and ethnic differences in hand hygiene practices among college

students. American Journal of Infection Control, 36, 361-368. doi:

https://doi.org/10.1016/j.ajic.2007.09.007

Barker, J., Stevens, D., & Bloom, S. F. (2001). Spread and prevention of some common viral

infections in community facilities and domestic homes. Journal of Applied

Microbiology, 91, 7-21. doi: https://doi.org/10.1046/j.1365-2672.2001.01364.x

Berardesca, E., Vignoli, G. P., Distante, F., Brizzi, P., & Rabbiosi, G. (1995). Effects of

water temperature on surfactant-induced skin irritation. Contact Dermatitis, 32(2), 83-

7 doi: https://doi.org/10.1111/j.1600-0536.1995.tb00751.x
 36

Bliss, S. J., Manning, S. D., Tallman, P., Baker, C. J., Pearlman, M. D., Marrs , C. F., &

Foxman, B. (2002). Group B Streptococcus colonization in male and nonpregnant

female university students: a cross-sectional prevalence study. Clinical Infecious

Diseases, 34, 184-90. doi: 10.1086/338258

Borghi, J., Guinness, L., Ouedraogo, J., & Curtis, V. (2002). Is hygiene promotion cost-

effective? A case study in Burkina Faso. Tropical Medicine and International Health,

7(11), 960–969. doi: https://doi.org/10.1046/j.1365-3156.2002.00954.x

Boyce, J. M., & Pittet, D. (2002). Guideline for hand hygiene in health-care settings.

Recommendations of the healthcare infection control practices advisory committee

and the HICPAC/SHEA/APIC/IDSA hand hygiene task force. Society for Healthcare

Epidemiology of America/Association. Morbidity and Mortality Weekly Report, 51,

1–45.

Bryman, A. (2012). Social research methods (2nd ed.). New York, NY: Oxford University

Press. doi: https://doi.org/10.4324/9781315529011

Centers For Disease Control And Prevention. (2018b, September 17). Hand washing: Clean

hands save lives. Retrieved from https://www.cdc.gov/handwashing/why-

handwashing.html.

Centers for Disease Control and Prevention. (2018a, October 18). Retrieved from Wash Your

Hands: https://www.cdc.gov/handwashing/why-handwashing.html.

Curtis , V., & Cairncross, S. (2003). Effect of washing hands with soap on diarrhoea risk in

the community: A systematic review. Lancet Infectious Diseases, 3, 275–81.

Curtis, V., Schmidt, W., Luby, S., Florez, R., Touré, O., & Biran, A. (2011). Hygiene: New

hopes, new horizons. Lancet Infectious Diseases, 11(4), 312–21. doi: 10.1016/S1473-

3099(10)70224-3
 37

Drankiewicz, D., & Dundes, L. (2003). Handwashing among female college students.

American Journal of Infection Control, 31, 67-71. doi: 10.1067/mic.2003.6 ·

Ejemot-Nwadiaro, R. I., Ehiri, J. E., Arikpo, D., Meremikwu, M. M., & Critchley, J. A.

(2015). Handwashing promotion for preventing diarrhoea. Cochrane Database of

Systematic Reviews, 9, CD004265. doi: 10.1002/14651858.CD004265.pub3

Ejemot-Nwadiaro RI, R. I., Ehiri, J. E., Arikpo, D., Meremikwu, M. M., & Critchley, J. A.

(2008). Handwashing for preventing diarrhoea. Cochrane Database of Systematic

Reviews, 1, CD004265. doi: 10.1002/14651858.CD004265.pub3.

Emerson, P. M., Cairncross, S., Bailey, R. L., & Mabey, D. C. (2000). A review of the

evidence for the “F” and “E” components of the Safe strategy for trachoma control.

Tropical Medicine & International Health, 5, 515–27.

Ergin, A., Bostanc, M., Önal, O., Bozkurt, A. I., & Ergin, N. (2011). Evaluation of students’

social hand washing knowledge, practices, and skills in a university setting. Central

European Journal Public Health, 19 (4), 222–227. doi: 10.1007/s12199-015-0470-6

Franziska, B. A., Gray, D. J., Williams, G. M., Raso, G., Li, Y.-S., Yuan, L., McManus, D. P.

(2013). Health-Education package to prevent worm infections in Chinese school

children. The New England Journal of Medicine, 368, 1603–12. doi:

10.1056/NEJMoa1204885

Glass, R. I., Noel, J., Ando, T., Fankhauser, R., Belliot , G., Mounts, A., Monroe, S. S.

(2000). The epidemiology of enteric caliciviruses from humans: A reassessment using

new diagnostics. Journal of Infecious Diseases, 181(2), S254-61. doi:

https://doi.org/10.1086/315588

Guinan, M. E., McGuckin-Guinan, M., & Sevareid, A. (1997). Who washes hands after using

the bathroom. American Journal of Infectious Control, 25, 424-425. doi:

https://doi.org/10.1016/S0196-6553(97)90092-4
 38

Guinan, M., McGuckin, M., & Ali, Y. (2002). The effect of a comprehensive handwashing

program on absenteeism in elementary schools. American Journal of Infectious

Control, 30, 217-20. doi: 10.1067/mic.2002.120366 ·

Hammond, B., Ali, Y., Fendle, E., Dolana, M., & Donovan, S. (2000). Effect of hand

sanitizer use on elementary school absenteeism. American Journal of Infectious

Control, 28, 340-6. doi:10.1067/mic.2000.107276

Heymann, D. L. (2008). Control of communicable diseases manual. (19th ed). Washington

(DC): American Public health association. doi: https://doi.org/10.1086/605668

Katz, J. D. (2004 ). Handwashing and hand disinfection: more than your mother taught you.

Anesthesiology Clinics of North America, 22, 457–471. doi:

10.1016/j.atc.2004.04.002

Krejcie, R. V., & Morgan, D. W. (1970). Determining sample size for research activities.

Educational and psychological measurement 30, 607-610. doi:

https://doi.org/10.1177/001316447003000308

Kudavidanage, B. P., Gunasekara, T. D., & Hapuarachch, S. (2011). Knowledge, attitudes

and practices on hand hygiene among ICU staff in Anuradhapura Teaching Hospital.

Anuradhapura Medical Journal, 1, 29-40. doi: http://doi.org/10.4038/amj.v5i1.5781

Lau, J. T., Tsui, H., Lau, M., & Yang, X. (2004). SARS transmission, risk factors, and

prevention in Hong Kong. Emerging Infecious Disease journal, 10:587–592. doi:

10.3201/eid1004.030628

Larson, E. L., Bryan, J. L., Adler, L. M., & Blane, C. (1997). A multifaceted approach to

changing handwashing behavior. American Journal of Infectious Control, 25(1), 3-10

Lark, R. L., VanderHyde, K., Deeb, M., Dietrich, S., Massey, J. P., Chenoweth, C. (2001).

An outbreak of coagulase-negative staphylococcal surgical-site infections following

 39

aortic valve replacement. Infection Control and Hospital Epidemiology, 22:618–623.

DOI: 10.1086/501832

Levin, K. A. (2006). Study design III: Cross-sectional studies. Evidence Based Dental. 7(1),

24-5. doi: 10.1038/sj.ebd.6400375

Luby, S. (2001). The role of handwashing in improving hygiene and health in low-income

countries. American Journal of Infection Control, 29(4), 239–40. doi:

10.1067/mic.2001.115678

Miko, B., Cohen, B., Conway, L., Gilman, A., Seward, S. L., & Larson, E. (2012).

Determinants of personal and household hygiene among college students in New

York City, 2011. American Journal of Infection Control, 40, 940-5. doi:

10.1016/j.ajic.2011.12.015

Minnesota Department of Health. (2017, April 19). Retrieved from Germs Are Tough:

https://www.health.state.mn.us/people/handhygiene/why/tough.html

Moe, C. L., Christmas, W. A., Echols, L. J., & Miller., S. E. (2001). Outbreaks of acute

gastroenteritis associated with Norwalk-like viruses in campus settings. Journal of

American College Health, 50, 57-66. doi: 10.1080/07448480109596008

Monk-Turner, E., Edwards , D., Broadstone, J., Hummel, R., Lewis, S., & Wilson, D. (2005).

Another look at handwashing behavior. Scientific Journal Publishers Limited, 629-

634. doi: https://doi.org/10.2224/sbp.2005.33.7.629

Muller, M. P., & McGeer, A. (2006). Febrile respiratory illness in the intensive care unit

setting: an infection control perspective. Current Opinion in Critical Care, 12, 37–42.

Nadakavukaren, A. (2011). Food quality. Our global environment: A health perspective.

Waveland Press, Incorporated.

Neuzil, K. M., Hohlbein, C., & Zhu, Y. (2002). Illness among schoolchildren during

influenza season effect on school absenteeism, parental absenteeism from work, and
 40

secondary illness in families. Archives of Pediatrics and Adolescent Medicine,

156(10), 986-991.

Nichol, K. L., D'Heilly, S., & Ehlinger, E. (2005). Colds and Influenza-Like Illnesses in

University Students: Impact on Health, Academic and Work Performance, and Health

Care Use. Clinical Infectious Diseases, Vol. 40, 1263-1270. doi:

https://doi.org/10.1086/429237

Pittet, D. (2001). Improving adherence to hand hygiene practice: A multidisciplinary

approach. Emerging Infectious Diseases, 7, 234-40. doi: 10.3201/eid0702.010217

Pittet, D., Allegranzi, B., Sax, H., Dharan, S., Pessoa-Silva, C. L., Donaldson, L., & Boyce, J.

M. (2006). Evidence-based model for hand transmission during patient care and the

role of improved practices. Lancet Infectious. Disease, 6, 641–642. doi:

10.1016/S1473-3099(06)70600-4

Prater, K. J., Fortuna, C. A., Janis , M. L., Brandeberry, M. S., Stone, A. R., & Lu, X. (2016).

Poor hand hygiene by college students linked to more occurrences of infectious

diseases, medical visits, and absence from classes. American Journal of Infection

Control, 44, 66-70.

Price, P. B. (1938). The bacteriology of normal skin: A new quantitative test applied to a

study of the bacterial flora and the disinfectant action of mechanical cleansing.

Journal of Infectious Diseases, 63, 301–318. doi:

https://doi.org/10.1093/infdis/63.3.301

Rabbi, S. E., & Dey, N. C. (2013). Exploring the gap between handwashing knowledge and

practices in Bangladesh: A cross-sectional comparative study. BioMed Central Public

Health, 13, 89. doi: 10.1186/1471-2458-13-89

 41

Rabie, T., & Curtis, V. (2006). Handwashing and risk of respiratory infections: a quantitative

systematic review. Tropical Medicine and International Health, 11: 269–78. doi:

10.1111/j.1365-3156.2006.01568.x

Rothman, R. E., Irvin, C. B., Moran, G. J., Saue, L., Bradshaw, Y. S., Fry, R. B., Hirshon, J.

M. (2006). Respiratory hygiene in the emergency department. Annals of Emergency

Medicine, 48, 570–582. doi: 10.1016/j.jen.2007.01.013

Scott, E., & Vanick, K. (2007). A survey of hand hygiene practices on a residential college

campus. American Journal of Infection Control, 35, 694-6. doi:

10.1016/j.ajic.2007.01.009

Tao, S. Y., Cheng, Y. L., Lu, Y., Hu , H. Y., & Chen, D. F. (2013). Handwashing behaviour

among Chinese adults: a cross-sectional study in five provinces. Public Health, 127,

620-628. doi: 10.1016/j.puhe.2013.03.005

Taylor, J. K., Basco, R., Zaied, A., & Ward, C. (2010). Hand hygiene knowledge of college

students. Clinical Laboratory Science, 23(2), 89-93.

Uner, S., Sevencan, F., Basaran, E., Balci, C., & Bilaloglu, B. (2009). Determining of

persons’ knowledge and attitudes on social hand washing who were admitted to a

primary health care center. TAF Preventive Medicine Bulletin, 8(3), 207-16.

Vessey, J. A., Sherwood, J. J., Warn, D., & Clark, D. (2007). Comparing handwashing to

hand sanitizers in reducing elementary school students' absenteeism. Pediatric

Nursing, 33(4), 368-36872.

Walker, J. L., Sistrunk, W. W., Higginbotham, M. A., Burks, K., Halford, L., & Goddard, L.

(2014). Hospital hand hygiene compliance improves with increased monitoring and

immediate feedback. American Journal of Infection Control, 42, 1074-8. doi:

10.1016/j.ajic.2014.06.018
 42

Wilson, M. (2005). Microbial inhabitants of humans: their ecology and role in health and

disease. New York, NY. Cambridge University Press.

White, C. G., Shinder, F. S., Shinder, A. L., & Dyer, D. L. (2001). Reduction of illness

absenteeism in elementary schools using an alcohol-free instant hand sanitizer.

Journal of School Nursing, 17, 258-65. doi:10.1177/10598405010170050401

White, C., Kolble, R., Carlson, R., & Lipson, N. (2005). The impact of a health campaign on

hand hygiene and upper respiratory illness among college students living in residence

halls. Journal of American College Health, Volume 53, 175-81. doi:

10.3200/JACH.53.4.175-181

White, C., Kolble, R., Carlson, R., Lipson, N., Dolan, M., Ali, Y., & Cline, M. (2003). The

effect of hand hygiene on illness rate among students in university residence halls.

American Journal of Infection Control, 31, 364-70. doi:10.1016/S0196-

6553(03)00041-5

World Health Organisation (2009a). Guidelines on Hand Hygiene in Health Care: First

Global Patient Safety Challenge Clean Care Is Safer Care. Geneva: World Health

Organization; 1, Definition of terms. Retrieved from:

https://www.ncbi.nlm.nih.gov/books/NBK144046/

World Health Organization. (2009b). Save lives, clean your hands. Retrieved from Guide to

implementation of the WHO multimodal hand hygiene improvement strategy:

http://www.who.int/gpsc/5may/Guide_to_Implementation.pdf

World Health Organization. (2018). Retrieved from

http://www.who.int/topics/infectious_diseases/en/ World Health Organization.

(2009b). Save lives, clean your hands. Retrieved from Guide to implementation of the

WHO multimodal hand hygiene improvement strategy:

http://www.who.int/gpsc/5may/Guide_to_Implementation.pdf
 43

Zakeri, H., Ahmadi, F., Rafeemanesh, E., & Saleh, L. A. (2017). The knowledge of hand

hygiene among the healthcare workers of two teaching hospitals in Mashhad.

Electronic Physician, 9(8), 5159-5165. doi: 10.19082/5159

 44

Appendices

Appendix A : Permission to Use Survey Instrument

 45

Appendix B: Print Copy of Informed Consent

ANONYMOUS SURVEY CONSENT {Assessment of Hand hygiene Knowledge, Attitude and

Practices Among University Students}.

You are requested to participate in research supervised by Dr. Mary Kramer on the assessment
of Hand hygiene knowledge, attitude and practices among university students. This survey
should take about 5 to 10 minutes to complete. The goal of this survey is to understand
university students Hand hygiene knowledge, attitude and practices and you will be asked to
answer questions about that topic. If you have any questions about the research, please
contact Dr. Mary Kramer at (507) 389-1422 or [email protected].
Participation is voluntary. You have the option not to respond to any of the questions. You
may stop taking the survey at any time. The decision whether or not to participate will not affect
your relationship with Minnesota State University, Mankato, and refusal to participate will
involve no penalty or loss of benefits. If you have any questions about participants' rights and
for research-related injuries, please contact the Administrator of the Institutional Review
Board, at (507) 389-1242.
Responses will be anonymous.
The risks of participating are no more than are experienced in daily life.
There are no direct benefits for participating. The information from this study will help health
professionals help build successful promotion and intervention strategies of hand hygiene
among university students. This may intend help reduce the risk infection. Submitting the
completed survey will indicate your informed consent to participate and indicate your
assurance that you are at least 18 years of age.
Please print a copy of this page for your future reference.

MSU IRBNet ID# 1413877

Date of MSU IRB approval: April 2, 2019

Do you agree to participate?

Yes No
 46

Appendix C: Institutional Review Board Letter of Approval

Literature Review Matrix

Authors, title, journal Type Purpose Methodology Results Conclusions

(Type of data collection and
Instrumentation)
Price, P. B. (1938). The bacteriology Journal An in-depth information on NA NA NA
of normal skin: a new quantitative Article the types of skin bacteria
test applied to a study of the bacterial
flora and the disinfectant action of
mechanical cleansing. Journal of
Infectious Diseases, 63:301–318.
Krejcie, R. V., & Morgan, D. W. Journal Determining sample size for NA NA NA

(1970). Determining sample size Article research activities

for research activities.

Educational and psychological
measurement 30, 607-610.
Ajzen, I. (1988). Attitudes, Book NA NA NA NA

Personality, and Behavior: A

Review of Its Applications to
Health-Related Behaviors.
Buckingham, United Kingdom:
Open University Press.
 48

Guinan, M. E., McGuckin-Guinan, Journal Reports on the compliance Observation of students’ Adults and health care Schools, like hospitals, have
M., & Sevareid, A. (1997). Who Article rate, duration, and handwashing in bathrooms workers have a compliance significant predisposing
washes hands after using the handwashing techniques rate of only 50% with this factors for the transmission
bathroom? American Journal of used by middle and high basic control measure. of bacteria and infections
Infectious Control, 25:424-425. school students after using among students, such as a
the bathroom. close environment, many
inanimate objects serving as
vehicles of transmission, and
insufficient compliance with
handwashing.
Ajzen, I. (1991). The theory of Journal To show that the theory of Predictive validity of the theory of The underlying foundation of It is at the level of beliefs
planned behavior. Organizational Article planned behavior provides a planned behavior is shown by the beliefs provides the detailed that we can learn about the
Behavior and Human Decision useful conceptual multiple correlations. descriptions needed to gain unique factors that induce
Processes, 50(2), 179-211 framework for dealing with substantive information one person to engage in the
the complexities of human about a behavior’s behavior of interest and to
social behavior. determinants. It is at the prompt another to follow a
level of beliefs that we can different course of action.
learn about the unique
factors that induce one
person
 49

Emerson, P. M., Cairncross, S., Journal The article describes the Systematic review The reasons why latrines and Simple messages about the
Bailey, R. L., & Mabey, D. C. Article process by which the clean faces are protective importance of good hygiene,
(2000). A review of the evidence for evidence base for trachoma need to be clarified and the the role of flies and how to
the “F” and “E” components of the control using the SAFE recent evidence that Musca identify trachoma could be
Safe strategy for trachoma control. strategy has been developed sorbens is a likely vector incorporated in the science,
Tropical Medicine & International and why there is a good needs to be verified and home economics and civics
Health, 5:515–27. expectation that it will be sustainable methods to curricula of both primary and
effective control it must be developed. secondary schools.
Glass, R. I., Noel, J., Ando, T., Journal To trace the growing Review of articles The identification of single The results will be to rapidly
Fankhauser, R., Belliot, G., Mounts, Article awareness of the role of strains of Norwalk-like virus fill in the current diagnostic
A., Monroe, S. S. (2000). The calicivirus that parallels the that have caused multistate gap in our understanding of
epidemiology of enteric caliciviruses advances in our diagnostic outbreaks of AGE in the the unknown agents of acute
from humans: a reassessment using methods. United States or global out- gastro-enteritis and the
new diagnostics. Journal of Infecious breaks linked to recognition of the primary
Diseases, 181(Suppl 2) S254-61. contaminated foods has role that Norwalk-like virus
demonstrated the value of play in food and waterborne
molecular epidemiology to disease, thus per- mitting a
link diverse patients to a reallocation of efforts and
single common exposure and resources to address this
to trace single food items urgent need.
back to a common source
that is suitable for control.
 50

Hammond, B., Ali, Y., Fendle, E., Journal To assess the effectiveness The overall reduction in Elementary school
Dolana, M., & Donovan, S. (2000). Article of the use of an alcohol gel absenteeism due to infection absenteeism due to
Effect of hand sanitizer use on hand sanitizer in the in the schools included in
infection is significantly
elementary school absenteeism. classroom to help decrease this study was 19.8% for
reduced when an alcohol
American Journal of Infectious the illness-related absentee schools that used an alcohol
gel hand sanitizer is used
Control, 28:340-6. rate for elementary school gel hand sanitizer compared
in the classroom as
students. with the control schools (P
<.05). Data from the school part of a hand hygiene
system with the largest program.
teacher population (n = 246)
showed that teacher
absenteeism decreased
10.1% (trend) in the schools
where sanitizer was used.
 51

Lark, R. L., VanderHyde, K., Deeb, Journal To determine the cause of a Retrospective case-control study. Seven patients developed A surgical resident was
M., Dietrich, S., Massey, J. P., Article coagulase-negative The cohort of 64 patients infection (10.9% vs 1.1% significantly associated
Chenoweth, C. (2001). An outbreak staphylococcal outbreak and undergoing Freestyle valve during the preceding 8
with infection. However,
of coagulase-negative staphylococcal to identify risk factors for replacement from September 1998 months), including two with
the cause of this outbreak
surgical-site infections following surgical-site infections to December 1998. mediastinitis and five with
was likely multifactorial.
aortic valve replacement. Infection among patients following endocarditis. There were no
Control and Hospital Epidemiology, Medtronic Freestyle statistically significant Changes occurring
22:618–623. bioprosthesis implantation. differences between cases during the investigation
and controls with respect to included institution of
age, gender, weight, vancomycin as routine
underlying illness,
prophylaxis and
preoperative hospital stay,
modification of surgical
duration of surgery, time on
technique, which
bypass, central venous
catheter duration, National contributed to the
Nosocomial Infection resolution of the
Surveillance risk index, New outbreak.
York Heart Association
class, albumin, or antibiotic
prophylaxis. This S
epidermidis strain, however,
was not isolated from
operating room staff.
 52

Luby, S. (2001). The role of Journal Reviews the results of Systematic review Handwashing with soap, a The challenge is to develop
handwashing in improving hygiene Article interventions promoting low-cost intervention for and evaluate cost-effective,
and health in low-income countries. handwashing in which persons are generally sustain- able methods to
American Journal of Infection communities with a high willing to pay, reduces the promote handwashing in the
Control, 29(4):239–40. incidence of diarrhea and incidence of one of the commu- nities most affected
examines the roles of public largest killers of young by diarrhea.
health institutions and soap children worldwide.
manufacurers in extending
the benefits of handwashing
to these communities.
Barker, J., Stevens, D., & Bloom, S. Journal To examine the dispersal, NA There is growing evidence Raising awareness about the
F. (2001). Spread and prevention of Article persistence and control of that person‐to‐person importance of key
some common viral infections in some common viruses in the transmission via the hands procedures, such as through
community facilities and domestic domestic home and in and contaminated fomites handwashing and surface
homes. Journal of Applied community facilities. plays a key role in the spread hygiene (particularly hand
Microbiology, 91, 7-21. of viral infections and food contact surfaces),
will have a considerable
impact in the control and
prevention of infectious
organisms.

Moe, C. L., Christmas, W. A., Journal To describe the Investigation of two campus The outbreaks exhibited Increased vigilance should
Echols, L. J., & Miller., S. E. (2001). Article investigation of two campus outbreaks of gastroenteritis several inter- esting be practiced. especially when
Outbreaks of acute gastroenteritis outbreaks of gastroenteritis associated with NLVs: one at a similarities. Both began students return to the campus
associated with Norwalk-like viruses associated with NLVs and medium-sized private university abruptly soon after students from a holiday break,
in campus settings. Journal of use these examples to (termed the university) and one at a returned to campus from a because students who travel
American College Health, 50:57-66. review the characteristics of small private college (the college). holiday; in both, molecular during a holiday may
NLV outbreaks, describe epi- demiologic investigation become infected with NLVs,
how to identify these detected the same strain of bring them back to campus,
 53

outbreaks, offer case- virus in many cases and and spread the viruses
management strategies, indicated that the exposure through the campus
define risk factors for trans- had occurred on campus. In community.
mission, and suggest control both outbreaks, illness
measures appropriate for spread rapidly through- out
college campuses. the campus population and to
the staff and surrounding
community.
Pittet, D. (2001). Improving Journal This article reviews barriers NA NA NA
adherence to hand hygiene practice: a Article to appropriate hand hygiene
multidisciplinary approach. and risk factors for non-
Emergency Infectious Disease, compliance and proposes
7:234-40. strategies for promoting
hand hygiene.

White, C. G., Shinder, F. S., Shinder, Journal To assess whether an Prior to the study, students were Students using the active Students, schools, and the
A. L., & Dyer, D. L. (2001). Article alcohol-free, instant hand educated about proper product were 33% less likely community can benefit from
Reduction of illness absenteeism in sanitizer containing handwashing technique, the to have been absent because improved health and
elementary schools using an alcohol- surfactants, allantoin, and importance of handwashing to of illness when compared increased attendance that
free instant hand sanitizer. J Sch benzalkonium chloride prevent transmission of germs, and with the placebo group. good hand hygiene provides.
Nurs, 17:258-65. could reduce illness the relationship between germs and
absenteeism and serve as an illnesses. Children (ages 5–12)
effective alternative when were assigned to the active or
regular soap and water placebo hand-sanitizer product and
handwashing was not instructed to use the product at
readily available. scheduled times during the day and
as needed after coughing or
sneezing. Data on illness
absenteeism were tracked.
 54

Aiello, A. E., & Larson, E. L. (2002). Journal To examine and assess the The Medline database was The results from this review Studies suggest that personal
What is the evidence for a causal link Article epidemiological evidence searched from January 1980 to demonstrate that there is a and environmental hygiene
between hygiene and infection? for a causal relation between June 2001 and studies were continued, measurable, reduces the spread of
Lancet Infectious Diseases, 2:103-10. hygiene practices and included if the outcome(s) was positive effect of personal infection.
infections. infection or symptoms of infection, and community hygiene on
and if the independent variable(s) infections
was one or more hygiene measures.
Bliss, S. J., Manning, S. D., Tallman, Journal To describe the prevalence GBS isolation in urine specimens Colonization with group B More studies are needed to
P., Baker, C. J., Pearlman, M. D., Article of colonization with group obtained from participants. Streptococcus species occurs verify these findings.
Marrs, C. F., & Foxman, B. (2002). B Streptococcus (GBS) at a high frequency among
Group B Streptococcus colonization species in a random sample healthy students, and there
in male and nonpregnant female of otherwise healthy male was a suggestion that it is
university students: a cross-sectional and nonpregnant female associated with having
prevalence study. Clinical Infecious college students. engaged in sexual activity,
Diseases, 34:184-90. tampon use, milk
consumption, and
handwashing done ≤4 times
per day.
Borghi, J., Guinness, L., Ouedraogo, Journal To estimate the incremental The programme effects were The annual cost of the Hygiene promotion reduces
J., & Curtis, V. (2002). Is hygiene Article cost‐effectiveness of a large‐ derived from an intervention study programme represents the occurrence of childhood
promotion cost-effective? A case scale urban hygiene that estimated the impact on 0.001% of the national health diarrhoea in Burkina Faso at
study in Burkina Faso. Tropical promotion programme in handwashing with soap after budget for Burkina Faso. The less than 1% of the Ministry
Medicine and International Health, terms of reducing the handling child stools through a direct annual cost of of Health budget and less
7(11), 960–969. incidence of childhood time-series method of observing implementing the than 2% of the household
diarrhoeal disease in, 37,319 mothers. Using data from programme at the household budget and could be widely
Burkina Faso. the literature, the associated level represents 1.3% of replicated at lower cost.
reductions in childhood morbidity annual household income.
and mortality were estimated. The
direct medical savings and indirect
savings of caregiver time and lost
productivity associated with child
death were estimated from
 55

interviews with households and

health workers. The cost and
outcome data were combined to
provide an estimate of the cost per
mother who starts handwashing
with soap as a result of the
programme and the cost per case of
childhood diarrhoea averted.
Boyce, J. M., & Pittet, D. (2002). Journal Provides health-care Reviews studies published since NA NA
Guideline for hand hygiene in health- Article workers (HCWs) with a the 1985 CDC guideline and the
care settings. Recommendations of review of data regarding 1995 APIC guideline
the healthcare infection control handwashing and hand
practices advisory committee and the antisepsis in health-care
hicpac/shea/apic/idsa hand hygiene settings. In addition, it
task force. Morbidity and Mortality provides specific
Weekly Report (MMWR), 51:1–45. recommendations to
promote improved hand-
hygiene practices and
reduce transmission of
pathogenic microorganisms
to patients and personnel in
health-care settings.
Guinan, M., McGuckin, M., & Ali, Journal To determine the Each test classroom had a control Absenteeism data were The data strongly suggest
Y. (2002). The effect of a Article effectiveness of a classroom, and only the test collected for 3 months. The that a hand hygiene program
comprehensive handwashing program comprehensive classroom received the intervention number of absences was that combines education and
on absenteeism in elementary handwashing program on (education program and hand 50.6% lower in the test use of a hand sanitizer in the
schools. Am J Infect Control, 30:217- absenteeism in elementary sanitizer). group (P <.001). classroom can lower
20. grades. absenteeism and be cost-
effective.
 56

Neuzil, K. M., Hohlbein, C., & Zhu, Journal To quantify the effect of Prospective survey study of all Total illness episodes, febrile Influenza season has
Y. (2002). Illness Among Article influenza season on illness children enrolled in the school illness episodes, analgesic significant adverse effects on
Schoolchildren During Influenza episodes, school were eligible for the study. use, school absenteeism, the quality of life of school-
Season Effect on School absenteeism, medication parental industrial aged children and their
Absenteeism, Parental Absenteeism use, parental absenteeism absenteeism, and secondary families.
from Work, and Secondary Illness in from work, and the illness among family
Families. Arch Pediatric Adolescence occurrence of secondary members were significantly
Medicine, 156(10):986-991. illness in families among a higher during influenza
cohort of children enrolled season compared with the
in an elementary school non-influenza winter season.
during the 2000-2001
influenza season.

Drankiewicz, D., & Dundes, L. Journal To determine handwashing An observational study was Most students (63%) washed The use of simple hygiene
(2003). Handwashing among female Article compliance of female designed to assess handwashing their hands, 38% used soap, practices, like handwashing,
college students. American Journal college students after using practices including the use of soap, 32% washed with soap for 5 can prevent infections and
Infection Control, 31:67-71. the bathroom. and the duration of the wash or more seconds, but only should be promoted to
among female college students 2% washed their hands with encourage the 98% of female
after they exited a bathroom stall. soap for 10 or more seconds. college students who do not
Substantial bacterial colony conform to the CDC-
counts were found on a recommended handwashing
female bathroom sink faucet regimen after going to the
and toilet seat confirming the bathroom. These results
need for programs to should be confirmed in a
increase handwashing larger study that includes
compliance. both male and female college
students.
 57

Curtis, V., & Cairncross, S. (2003). Journal To determine the impact of A meta-analysis of data sources Washing hands with soap More and better-designed
Effect of washing hands with soap on Article washing hands with soap on (previous studies) linking can reduce the risk of trials are needed to measure
diarrhoea risk in the community: a the risk of diarrhoeal handwashing with diarrhoeal diarrhoeal diseases by 42- the impact of washing hands
systematic review. Lancet Infectious diseases in the community. diseases. 47% and interventions to on diarrhoea and acute
Diseases, 3: 275–81. promote handwashing might respiratory infections in
save a million lives. developing countries.
White, C., Kolble, R., Carlson, R., Journal To assess the effectiveness The health attitude, knowledge, The overall increase in hand- Hand-hygiene practices were
Lipson, N., Dolan, M., Ali, Y., & Article of both a hand-hygiene and behavior survey assessed hygiene behavior and improved with increased
Cline, M. (2003). The effect of hand message campaign and the handwashing practices; smoking reduction in symptoms, frequency of handwashing
hygiene on illness rate among use of an alcohol gel hand frequency; exercise behaviors; and illness rates, and absenteeism through increasing
students in university residence halls. sanitizer in decreasing the diet, water-consumption, and between the product group awareness of the importance
Ameican Journal Infectious Control, incidence of upper- sleeping practices. The social- and control group was of hand hygiene, and the use
31:364-70. respiratory illness among support survey addressed social- statistically significant. of alcohol gel hand sanitizer
students living in university support structures for health in university dormitories.
residence halls. practices within the college This resulted in fewer upper
environment. respiratory–illness
symptoms, lower illness
rates, and lower absenteeism.
Katz, J. D. (2004). Handwashing and Article Discusses the rationale and NA NA Handwashing is considered
hand disinfection: more than your practical application of the single most important
mother taught you. Anesthesiology current protocols for hand intervention for prevention
Clinics North America, 22:457–471. hygiene as they specifically of nosocomial infections in
apply to the practice of patients and health care
anesthesiology. workers

Discusses the consequences

of poor compliance with
handwashing practices for
patient and health care
provider safety.
 58

Lau, J. T., Tsui, H., Lau, M., & Yang, Journal To delineate the distribution Analyzed information obtained Multivariate analysis of this Community-acquired
X. (2004). SARS transmission, risk Article of different sources of from 1,192 patients with probable case-control study showed infection did not make up
factors, and prevention in Hong transmission of the SARS severe acute respiratory syndrome that having visited mainland most transmissions, and
Kong. Emerging Infecious Disease cases in Hong Kong and to (SARS) reported in Hong Kong China, hospitals, or the public health measures have
journal, 10:587–592. identify the undefined through interview. Amoy Gardens were risk contributed substantially to
source group. factors (odds ratio [OR] 1.95 the control of the SARS
to 7.63). In addition, frequent epidemic.
mask use in public venues,
frequent hand washing, and
disinfecting the living
quarters were significant
protective factors (OR 0.36
to 0.58)
Monk-Turner, E., Edwards, D., Journal Noted how handwashing Observational study. Observed the Women are more likely to It will be interesting to track
Broadstone, J., Hummel, R., Lewis, Article behavior varied by race, handwashing behavior of people wash their hands compared handwashing behavior over
S., & Wilson, D. (2005). Another gender, and having an (by race and gender) in the public to men. tune to see the effectiveness
look at handwashing behavior. observer present. restrooms of a large regional There was no significance in of current public hygiene
Scientific Journal Publishers Limited, university. race, gender or observational campaigns.
629-634. status and the the likelihood
of washing one's hands for
the minimum CDC period.
Nichol, K. L., D'Heilly, S., & Journal To assess the impact of A cohort study of college students These URIs caused 6023 Colds and ILIs were
Ehlinger, E. (2005). Colds and Article upper respiratory infections at the University of Minnesota, bed-days, 4263 missed common and associated with
Influenza-Like Illnesses in University (colds and influenza-like Twin Cities campus (Minneapolis- school days, 3175 missed substantial morbidity in
Students: Impact on Health, illnesses [ILIs]) on the St. Paul). work days, and 45,219 days university students.
Academic and Work Performance, health, academic and work Data were collected by use of of illness. ILIs versus colds Enhanced efforts to prevent
and Health Care Use. Clinical performance, and health Internet-based questionnaires. had a much greater impact and control URIs, especially
Infectious Diseases, Vol. 40: 1263- care use of university on all parameters. influenza vaccination, could
1270. students. improve the health and well-
being of the 17 million
college and university
students in this country.
 59

White, C., Kolble, R., Carlson, R., & Journal To determine whether a An experimental-control design Findings indicate that Conducting a health
Lipson, N. (2005). The Impact of a Article message campaign about study in 4 campus residence halls. students who were exposed promotion campaign in
Health Campaign on Hand Hygiene hand hygiene and the Pre- and post-surveys examined to the message campaign and residence halls may therefore
and Upper Respiratory Illness Among availability of gel hand participants' knowledge, attitudes, provided with gel hand help prevent colds and flu
College Students Living in Residence sanitizer could decrease cold and perceived behaviors related to sanitizer increased their and decrease absenteeism on
Halls. Journal of American College and flu illness and school a healthy lifestyle, the impact of knowledge about the university campuses.
Health, Volume 53:175-81. and work absenteeism. hand hygiene on wellness, and potential health benefits of
basic demographic information. handwashing and sanitizer
Weekly surveys inquired about use. These students also
URI symptoms and daily hand experienced fewer cold and
hygiene, smoking, and exercise flu illnesses during the study
regimens. than those in the control
group and missed fewer class
or work engagements
because of colds or flu.
Wilson, M. (2005). Microbial Book The book summarizes a NA NA NA
inhabitants of humans: their ecology body of scattered
and role in health and disease. New information on the
York, NY. Cambridge University significance of commensal
Press. microorganisms in humans.
Muller, M. P., & McGeer, A. (2006). Journal Examined studies published Examination of literature on Most respiratory pathogens Healthcare worker awareness
Febrile respiratory illness in the Article since the severe acute infection control strategies can be transmitted by more of clinical syndromes
intensive care unit setting: an respiratory syndrome designed to prevent the than one route. associated with respiratory
infection control perspective. Current outbreak that elucidate the transmission of respiratory pathogens that require
Opinion in Critical Care, 12:37–42. mode of transmission of pathogens in the ICU. airborne precautions,
respiratory pathogens and combined with the use of
the optimal means of standard precautions for all
interrupting their patients, and contact/droplet
transmission, focusing on precautions for patients with
transmission in the intensive undifferentiated febrile
care unit. respiratory illness should be
effective in interrupting the
 60

transmission of respiratory
pathogens within the
intensive care unit.

Levin KA. Study design III: Cross- Journal To describe cross-sectional NA NA NA

sectional studies. Evid Based Dent. Article studies, their uses,
(2006). 7(1):24-5 advantages and limitations.

Pittet, D., Allegranzi, B., Sax, H., Journal To review the evidence Systematic review Increased hand hygiene Results indicate that
Dharan, S., Pessoa-Silva, C. L., Article supporting steps and compliance is associated improved hand hygiene
Donaldson, L., & Boyce, J. M. propose a dynamic model with reduced cross- practices reduce the risk of
(2006). Evidence-based model for for hand hygiene research transmission and infection transmission of pathogens.
hand transmission during patient care and education strategies, rates.
and the role of improved practices. together with corresponding
Lancet Infectious. Disease, 6:641– indications for hand hygiene
642. during patient care.
Rabie, T., & Curtis, V. (2006). Journal To determine the effect of Review of published articles if All eight eligible studies Handwashing is associated
Handwashing and risk of respiratory Article handwashing on the risk of they reported the impact of an reported that handwashing with lowered respiratory
infections: a quantitative systematic respiratory infection. intervention to promote hand lowered risks of respiratory infection. However, studies
review. Tropical Medicine and cleansing on respiratory infection, with risk were of poor quality, none
International Health, 11: 269–78. infections. reductions ranging from 6% related to developing
to 44% Pooling the results of countries, and only one to
only the seven homogenous severe disease.
studies gave a relative risk of
1.19 (95% CI 1.12%–
1.26%), implying that hand
cleansing can cut the risk of
respiratory infection by 16%
(95% CI 11–21%).
 61

Rothman, R. E., Irvin, C. B., Moran, Journal The article presents a Systematic review The synopsis should help Education of key individuals,
G. J., Saue, L., Bradshaw, Y. S., Fry, Article summary of the most clinicians and administrators along with rapid
R. B., Hirshon, J. M. (2006). current information understand, develop, and dissemination of accurate
Respiratory hygiene in the emergency available in the literature implement appropriate information, is necessary to
department. Annals of Emergency about respiratory hygiene in policies and procedures to support these policies and
Medicine, 48:570–582. the emergency department, address respiratory hygiene will be instrumental in
including administrative, in the emergency ensuring effective
patient, and legal issues. department. implementation.
Wherever possible, specific
recommendations and
references to practical
information from the
Centers for Disease Control
and Prevention are
provided.
Scott , E., & Vanick, K. (2007). A Journal To determine the level of A confidential, self-administered Nine hundred and ninety- We recommend the
survey of hand hygiene practices on Article knowledge about hand on-line survey was delivered via four participants completed importance of creating an
a residential college campus. hygiene and to elicit e-mail campus-wide using an the survey. Of these, 49% awareness of proper hand
America Journal of Infection information on the barriers Internet-based survey tool were undergraduates, 30% hygiene practices as they
Control, 35:694-6. to good hand hygiene (Zoomerang) performed during were graduates, and 34% relate to the everyday context
practices on campus. April–May 2006. lived in residence halls on of a college campus. In
campus. Residential addition, we believe there is
students were significantly a need for hand hygiene
less likely to wash their education targeted at
hands for a range of students. Finally, we strongly
activities. recommend that college
authorities provide soap and
a means of hand drying in all
residential bathrooms.
 62

Vessey, J. A., Sherwood, J. J., Warn, Journal To compare the efficacy of A randomized cross-over design No significant differences in Hand sanitizers are an
D., & Clark, D. (2007). Comparing Article an alcohol-based hand was used with 18 classrooms of absenteeism rates were appropriate alternative to
handwashing to hand sanitizers in sanitizer to standard 2nd and 3rd grade students (n = demonstrated. A follow-up handwashing for hand
reducing elementary school students' handwashing in reducing 383) from 4 elementary schools. focus group comprised of cleansing and may offer
absenteeism. Pediatric Nursing, 33.4 : illness and subsequent Half of the classes from each teachers and school nurses additional benefits in the
p368+. absenteeism in school-age school used an anti-microbial gel indicated that hand sanitizers school setting.
children. hand sanitizer while the other half were preferred over soap and
used soap and water for regular water.
hand hygiene for 2 months, then,
the students switched cleaning
methods for the following 2
months. No significant
differences in absenteeism rates
were demonstrated. A follow-up
focus group comprised of teachers
and school nurses indicated that
hand sanitizers were preferred
over soap and water.
Aiello, A. E., Coulborn, R. M., Perez, Journal To quantify the effect of Meta-analyses to generate pooled Improvements in hand Hand hygiene is clearly
V., & Larson, E. L. (2008). Effect of Article hand-hygiene interventions rate ratios across interventions by hygiene resulted in effective against
Hand Hygiene on Infectious Disease on rates of gastrointestinal searching electronic databases for reductions in gastrointestinal gastrointestinal and, to a
Risk in the Community Setting: A and respiratory illnesses and hand-hygiene trials published illness of 31% and lesser extent, respiratory
Meta-Analysis. American Public to identify interventions that from January 1960 through May reductions in respiratory infections. Studies
Health Association, 98:1372–1381. provide the greatest 2007. illness of 21%. The most examining hygiene practices
efficacy. beneficial intervention was during respiratory illness and
hand-hygiene education with interventions targeting
use of nonantibacterial soap aerosol transmission are
needed.
Anderson, J. L., Warren, C. A., Journal To evaluate gender and Observational study of hand Hand hygiene practices were Handwashing is the most
Perez, E., Louis, R. I., Phillips, S., Article race/ethnic differences in hygiene practices better in academic buildings effective way of preventing
Wheeler, J., & Cole, M. (2008). hand hygiene practices than in the student recreation the spread of infectious
Gender and ethnic differences in among college students. center. Visual prompts diseases, and our findings
 63

hand hygiene practices among improved handwashing have implications for the
college students. American Journal of behavior only among design of effective hand
Infection Control 36, 361-368. students in the “other” ethnic hygiene education programs
category, but not by gender. in college students.
Ejemot-Nwadiaro RI, R. I., Ehiri, J. Journal To evaluate the effects of Systematic review Interventions promoting Handwashing can reduce
E., Arikpo, D., Meremikwu, M. M., Article interventions to promote handwashing resulted in a diarrhoea episodes by about
& Critchley, J. A. (2008). handwashing on diarrhoeal 29% reduction in diarrhoea 30%. This significant
Handwashing for preventing episodes in children and episodes in institutions in reduction is comparable to
diarrhoea. Cochrane Database of adults. high-income countries and a the effect of providing clean
Systematic Reviews, 1:CD004265. 31% reduction in such water in low-income areas
episodes in communities in
low- or middle-income
countries.
Heymann D. L. (2008). Control of Book The book addresses NA NA NA
communicable diseases manual. 19th concerns about the impact
ed. Washington (DC): American of communicable diseases
Public health association. around the globe as
communicable diseases,
new and unknown, continue
to thrive, kill, maim and
surprise the masses.

Heymann, D. L. (2008). Control of Book The 19th edition is an NA NA NA

communicable diseases manual. 19th update to a milestone
ed. Washington (DC): American reference work that ensures
Public health association. the relevance and usefulness
to every public health
professional around the
world. New disease
 64

variants have been included

and some chapters have
been fundamentally
reworked.
World Health Organisation. (2009). Website Provides information on NA NA NA
Retrieved from WHO Guidelines on Hand Hygiene in Health
Hand Hygiene in Health Care: First Care
Global Patient Safety Challenge
Clean Care Is Safer Care.
https://www.ncbi.nlm.nih.gov/books/
NBK144046/#parti_ch1.s2
Taylor, J. K., Basco, R., Zaied, A., & Journal To evaluate hygiene habits The study was divided into an Females and science majors Proper hand hygiene could
Ward, C. (2010). Hand hygiene Article of students with fields of observational stage, a quiz to scored significantly higher
potentially decrease the
knowledge of college students. study, gender, and ascertain student's knowledge of on the survey than males and
non-science majors, and that spread of this virus.
Clinical Laboratory Science, 23(2), understanding of hygiene at hygiene and the spread of
those observed not washing
89-93 a university in Alabama. pathogens, and a survey of self- Promoting hygiene is an
their hands reported being
reported illness rates. sick more often than those important tool for keeping
observed washing their
the population healthy.
hands.
Curtis, V., Schmidt, W., Luby, S., Journal This review gathers the facts A systematic review of articles Hygiene can be promoted Full and active involvement
Florez, R., Touré, O., & Biran, A. Article about the importance of from Medline from 1970 to 2009. successfully through of the health sector in getting
(2011). Hygiene: new hopes, new hygiene for public health conventional health safe hygiene to all homes,
channels, water and schools, and institutions will
horizons. Lancet Infectious Diseases, and explore the scale of the
sanitation initiatives, bring major gains to public
11(4):312–21. problem. schools, and by commercial health.
companies.
Kudavidanage, B. P., Gunasekara, T. Journal To assess the knowledge, By the use of self-administered The study showed that The study highlights the
D., & Hapuarachch, S. (2011). Article attitudes, practices and questionnaire. majority of respondents urgent need for introducing
Knowledge, attitudes and practices satisfaction of facilities (72.5%) had moderate measures to increase the
knowledge of hand hygiene. knowledge, attitudes,
on hand hygiene among ICU staff in available to health care
When the attitudes were practices and facilities
Anuradhapura Teaching Hospital. workers in the intensive care assessed for each individual available for hand hygiene in
units with regard to hand respondent 47% had good the lCUs in Anuradhapura
 65

Anuradhapura Medical Journal, 1: hygiene in the attitudes whereas a majority Teaching Hospital, which
29-40. Anuradhapura Teaching (62.5%l was seen to have may play a very important
hospital poor hand hygiene practices. role in increasing hand
The level of satisfaction hygiene compliance among
among the health care the ICU staff and reducing
workers regarding the cross transmission of
facilities available for hand infections among the ICU
hygiene was poor (55%). patlents.
Nadakavukaren, A. (2011). Food Book The book explores the NA NA NA
quality. Our global environment: A crucial interdependence
health perspective. Waveland Press, between humans and their
Inc. environment, revealing
overview of the major
environmental issues facing
society in the twenty-first
century.
Aiello, A. E., Perez, V., Coulborn, R. Journal To examine if the use of A cluster-randomized intervention Face masks and hand These non-pharmaceutical
M., Davis, B. M., Uddin, M., & Article face masks and hand trial was designed involving hygiene combined may measures should be
Monto, A. S. (2012). Facemasks, hygiene reduced rates of 1,178 young adults living in 37 reduce the rate of ILI and recommended in crowded
Hand Hygiene, and Influenza among influenza-like illness (ILI) residence houses in 5 university confirmed influenza in settings at the start of an
Young Adults: A Randomized and laboratory-confirmed residence halls during the 2007– community settings. influenza pandemic.
Intervention Trial. PLoS ONE, 7(1): influenza in the natural 2008 influenza season.
e29744. setting.
Bryman, A. (2012). Social research Book The book also explores the NA NA NA
methods (2nd ed.). New York, NY: nature of social research and
Oxford University Press. provides students with
practical advice on doing
research.
Miko, B. A., Cohen, B., Conway, L., Journal To describe students’ The use of a questionnaire to There was no significant The hygiene habits of
Gilman, A., Seward, S. L., & Larson, Article knowledge, practices, and assess demographics, personal relationship between college students may be
E. (2012). Determinants of personal beliefs about hygiene and and household hygiene behaviors, reported behaviors and self- motivated by perceptions of
and household hygiene among determine whether there is beliefs and knowledge about reported health status. socially acceptable behavior
college students in New York City, an association between hygiene, and general health status.
 66

2011. American Journal of Infection reported behaviors and rather than scientific
Control, 40:940-5. frequency of illness. knowledge.
Franziska, B. A., Gray, D. J., Journal To determine the effect of A single-blind, unmatched, The health-education The health-education
Williams, G. M., Raso, G., Li, Y.-S., Article an educational package at cluster-randomized intervention package increased students' package increased students'
Yuan, L., McManus, D. P. (2013). rural schools in Linxiang trial involving 1718 children, 9 to knowledge about soil- knowledge about soil-
Health-Education Package to Prevent City District, Hunan 10 years of age, in 38 schools transmitted helminths and transmitted helminths and
Worm Infections in Chinese province, China, where over the course of 1 school year. led to a change in behavior led to a change in behavior
Schoolchildren. The New England these worms are prevalent. Schools were randomly assigned and a reduced incidence of and a reduced incidence of
Journal of Medicine, 368: 1603–12. The intervention aimed to to the health-education package. infection within 1 school infection within 1 school
increase knowledge about year. year.
soil-transmitted helminths, Infection rates, knowledge about
induce behavioral change, soil-transmitted helminths (as
and reduce the rate of assessed with the use of a
infection. questionnaire), and handwashing
behavior were assessed before
and after the intervention.

Rabbi, S. E., & Dey, N. C. (2013). Journal The study compared A cross-sectional comparative A gap between perception Gap between knowledge and
Exploring the gap between Article handwashing knowledge study between baseline (2006), and practice of proper practice still persists in
handwashing knowledge and and practices in BRAC’s midline (2009) and end-line handwashing practices with handwashing practices. Long
practices in Bangladesh: a cross- water; sanitation and (2011) surveys in 50 sub-districts soap was identified in the term and extensive initiatives
sectional comparative study. Biomed hygiene (WASH) from the first phase of the study areas. can aware people about the
Central Public Health, 13:89. programme areas over time. programme. effectiveness of hand
Data were collected from washing.
households through face-to-face
interview using a pre-tested
questionnaire.
Tao, S. Y., Cheng, Y. L., Lu, Y., Hu, Journal To describe the patterns of Data on handwashing behavior, Urban area, high level of Adherence to an appropriate
H. Y., & Chen, D. F. (2013). Article handwashing behavior knowledge of hand hygiene and education level, high level of handwashing method and
Handwashing behaviour among among Chinese adults and sociodemographic factors were knowledge about diseases, duration of handwashing are
Chinese adults: a cross-sectional assess their associations female gender and older age critical problems among
 67

study in five provinces. Public with sociodemographic collected through self- were protective factors for Chinese adults. Area
Health, 127:620-628. factors and knowledge of administrated questionnaires. good hand hygiene; of these, difference, level of education
hand hygiene. area was found to be and level of knowledge of
associated most strongly hand hygiene were most
with handwashing behavior. strongly associated with
handwashing behavior and
should be targeted in future
health education.

Walker, J. L., Sistrunk, W. W., Journal Evaluation of the The HHMP consisted of 4 key Findings suggest that
Higginbotham, M. A., Burks, K., Article effectiveness of a new hand components: extensive education, continuous monitoring by
Halford, L., & Goddard, L. (2014). hygiene monitoring program conspicuous and visible monitors, salient observers and
Hospital hand hygiene compliance (HHMP) and measured the immediate feedback concerning immediate feedback are
improves with increased monitoring sustainability of this compliance to health care critical to the success of hand
and immediate feedback. American effectiveness over a 1-year workers, and real-time data hygiene programs.
Journal Infection Control, 42:1074-8. period. dissemination to leadership. The
HHMP was implemented in 2
hospital care units. Two different,
but similar, departments served as
controls, and hand hygiene
compliance was monitored via the
“secret shopper” technique. All 4
departments were followed for 12
months.
Ejemot-Nwadiaro, R. I., Ehiri, J. E., Journal Assessed the effects Individually randomized There was increase in Handwashing promotion
Arikpo, D., Meremikwu, M. M., & Article of handwashing promotion controlled trials (RCTs) and handwashing frequency, probably reduces diarrhoea
Critchley, J. A. (2015). Handwashing interventions on diarrhoeal cluster-RCTs that compared the seven times per day in the episodes in both child day-
promotion for preventing diarrhoea. episodes in children and effects of handwashing intervention group versus care centers in high-income
Cochrane Database of Systematic adults. interventions on diarrhoea three times in the control in countries and among
Reviews, Issue 9. Art. No.: episodes in children and adults this hospital trial (one trial, communities living in
CD004265. with no intervention. 148 participants, moderate LMICs by about 30%.
quality evidence). However, less is known
 68

It was found that no trials about how to help people

evaluating or reporting the maintain handwashing habits
effects of handwashing in the longer term.
promotions on diarrhoea-
related deaths, all-cause-
under five mortality, or
costs.
Prater, K. J., Fortuna, C. A., Janis, M. Journal Investigated the hand Microbial samples were collected Hands of 57.7% volunteers It is critical to promote
L., Brandeberry, M. S., Stone, A. R., article hygiene statuses of college 3 times from each of the 220 valid were colonized by an education on proper
& Lu, X. (2016). Poor hand hygiene students and their volunteers before washing their uncountable number of handwashing in colleges, in
by college students linked to more occurrences in relation to hands, after washing with their microbial colonies, grade schools, and
occurrences of infectious diseases, infectious diseases, medical own procedures, and after which were significantly at home to improve health
medical visits, and absence from visits, and absence from washing with a procedure linked to more occurrences and learning outcomes.
classes. American Journal of classes or work. recommended to infectious diseases
Infection Control, 44:66-70. by the Centers for Disease medical visits and arguably
It also examined the effects Control and Prevention (CDC). more absence from classes or
of education on work. The handwashing
handwashing technique to Survey questionnaire procedure provided
improve hand hygiene. including questions on their by the CDC significantly
health conditions, medical visits, improved hand hygiene.
and absence from classes or work.
Minnesota Department of Health. Website Where do Germs Hide? NA NA NA
(2017, April 19). Retrieved from
Where do Germs Hide?
http://www.health.state.mn.us/handhy
giene/why/hide.html
Zakeri, H., Ahmadi, F., Journal To assess effectiveness of A descriptive cross-sectional There was a significant The study showed the
Rafeemanesh, E., & Saleh, L. A. article structured teaching or survey to assess the knowledge of improvement in knowledge important of training
(2017). The knowledge of hand training sessions on hand hygiene. They used pre-test after training as seen after sessions on awareness of
hygiene among the healthcare awareness of hand structured questionnaire, followed comparison of results of hand hygiene. These training
workers of two teaching hospitals in hygiene. (Not stated in by an intervention (training post-test questionnaire from sessions should be conducted
article). regarding various aspects of hand its pre-test counter-part. The more frequently and there
 69

Mashhad. Electronic Physician, hygiene) and a posttest post-test knowledge should be a curriculum by
Volume: 9, Issue: 8: 5159-5165. questionnaire. assessment became excellent MCI that every student of
(55%) as compared to pre- medical, nursing and
test (5%) in patient's paramedical college will
relatives. There was a participate in transferring
significant difference in the knowledge of hand hygiene
knowledge of residents, to all HCW's and if possible
nurses and nursing students knowledge should be
as compared to caregivers in transmitted to community by
the pre-test hand hygiene celebrating hand hygiene
questionnaire week every year starting
from world Hand hygiene
day.
Centers for Disease Control and Website Why Wash Your Hands? NA NA NA
Prevention. (2018b, September 17).
Hand washing: Clean hands save
lives. Retrieved from:
https://www.cdc.gov/handwashing/w
hy-handwashing.html.
Centers for Disease Control and Website Wash Your Hands Often to NA NA NA
Prevention. (2018a, October 18). Stay Healthy
Retrieved from Wash Your Hands:
https://www.cdc.gov/features/handwa
shing/
World Health Organization. (2018). Website Infectious diseases NA NA NA
Retrieved from
http://www.who.int/topics/infectious_
diseases/en/