Hand hygiene awareness and handwashing effectiveness in caregivers of surgical patients: a cross-sectional study

Abstract

Objective

To evaluate surgical patients’ caregivers’ hand hygiene knowledge and to examine the discrepancy between reported knowledge and actual hand cleanliness following caregiving activities.

Design

Cross-sectional study.

Setting

General surgery inpatient clinics of a tertiary university-affiliated hospital in Turkey.

Participants

Caregivers of patients hospitalised in general surgery inpatient clinics; a total of 128 caregivers participated.

Primary and secondary outcome measures

The primary outcome was caregivers’ hand hygiene knowledge score. The secondary outcome was observed hand cleanliness, assessed using fluorescent simulation gel and ultraviolet light across different hand regions.

Results

Among the 128 caregivers (65.6% women; mean age 45.7±14.8 years), hand hygiene knowledge was high (mean score: 98.9±3.9). However, observations under ultraviolet light revealed residual contamination, particularly at the wrist. Caregivers with clean wrists had significantly higher knowledge scores than those with contamination (p<0.05). Although caregivers reported frequent handwashing, only 43% reported receiving encouragement from healthcare staff. Inter-observer reliability was excellent, with Cohen’s kappa values ranging from 0.864 to 0.913.

Conclusions

Although caregivers of surgical patients demonstrated high hand hygiene knowledge, a gap between knowledge and observed practice was identified, particularly in less visible areas such as the wrists. These findings suggest that strategies beyond knowledge transfer, including visual training tools and increased engagement of healthcare professionals, may help improve practical hand hygiene behaviours and infection prevention.

STRENGTHS AND LIMITATIONS OF THIS STUDY.

• This study focused on caregivers of surgical patients, an under-researched group in infection prevention research.

• Hand hygiene performance was assessed using a direct observational method with fluorescent gel and ultraviolet light, providing objective visual evidence of residual contamination.

• Inter-rater reliability between observers was high, supporting the methodological rigour of the observational assessment.

• The cross-sectional design limits causal interpretation, and hand hygiene practices were assessed at a single time point within a specific observation period.

• Only the dominant hand was evaluated, and contamination was assessed using fluorescent gel rather than microbiological sampling, which may underestimate overall contamination and does not directly measure microbial load.

Introduction

Healthcare-associated infections (HAIs) are a major global health concern and a key indicator of patient safety. They are defined as infections acquired during healthcare delivery that were not present or incubating at the time of admission and that occur on or after the third day of hospitalisation.¹,³ HAIs are associated with prolonged hospital stays, increased morbidity and mortality, and substantial healthcare costs.⁴

Surgical site infections are among the most common types of HAIs and typically occur within 30–90 days after surgery. They are often caused by Staphylococcus aureus or other endogenous flora.^{5 6} Effective prevention largely depends on the removal of transient microorganisms, primarily through proper hand hygiene.^{7 8}

Although hand hygiene is recognised as the simplest and most effective preventive measure, global compliance among healthcare workers remains suboptimal, often ranging from 20% to 70%.⁹,¹¹ Recent studies indicate that technology-assisted reminders and incentives may improve adherence; however, sustaining these improvements remains challenging.¹² Intervention-based research has also emphasised the importance of context-specific and structural strategies to enhance compliance. For example, He et al reported that tailored ‘Novel Six Moments’ training for hospital cleaning staff significantly increased adherence,¹³ while Shapiro et al demonstrated that linking automatic door systems to touchless sanitiser dispensers improved hand hygiene performance among visitors in a paediatric intensive care unit.¹⁴ These findings highlight the value of environmental and behavioural approaches that complement traditional educational measures.

Importantly, transmission is not limited to healthcare professionals. Relatives and visitors may also contribute to cross-contamination, yet their hand hygiene practices have been relatively understudied. Observational studies suggest that relatives frequently fail to follow recommended hand hygiene practices, particularly before patient contact.^{14 15} The outbreak of SARS-CoV-2 further underscored the importance of hygiene measures in limiting pathogen transmission.¹⁶ Despite advances in surveillance and infection control policies, the risk of HAIs persists, highlighting the need for comprehensive preventive strategies.¹⁷

Although several studies have examined hand hygiene among healthcare workers,¹⁸,²¹ research focusing on caregivers of surgical patients remains limited. Caregivers may inadvertently contribute to pathogen transmission during routine care activities, yet evidence regarding their knowledge levels and actual hand cleanliness is scarce. Assessing these aspects may help identify risk areas, such as less visible regions of the hand that are frequently missed during handwashing and may inform targeted infection prevention strategies. Therefore, this study aimed to evaluate the hand hygiene knowledge and actual hand cleanliness of caregivers of surgical patients following caregiving activities in a tertiary hospital.

Methods

Study design and setting

This cross-sectional study was conducted in the general surgery inpatient clinics of a tertiary care hospital in Turkey between November and December 2024. The study was reported in accordance with the Strengthening the Reporting of Observational Studies in Epidemiology guidelines. Data collection was carried out as part of a structured educational activity conducted by final-year undergraduate nursing students within the scope.

Participants

The study included 128 caregivers of hospitalised surgical patients who provided written informed consent to participate. The inclusion criteria were as follows: (1) being a first-degree relative actively involved in caregiving activities (eg, feeding and hygiene), (2) being 18 years of age or older and (3) having provided care for at least 72 hours after the patient’s hospitalisation. Caregivers who met the inclusion criteria and were present in the ward during the data collection period were invited to participate in the study using a convenience sampling approach.

A power analysis was conducted to determine the required sample size. The significance level was set at α=0.05, and the effect size (d) was set at 0.5 according to Cohen’s classification,²² indicating a medium effect size. Based on these parameters, the minimum sample size required to achieve a statistical power of 0.95(1−β) was calculated as 54 participants. The analysis was performed using G*Power software (V.3.1.9.4).

Data collection tools

Data were collected using the Caregiver Sociodemographic Characteristics Form, Practices and Beliefs of Caregivers Regarding Hand Hygiene Form, Hand Hygiene Knowledge Level Form and Evaluation of Handwashing Effectiveness Using Fluorescent Simulation Gel and UV LED Light.

The Caregiver Sociodemographic Characteristics and Hand Hygiene Practices Form was developed by the researchers based on a review of the relevant literature.⁵,¹⁰²³ The form collected descriptive information about caregivers, including age, gender, relationship to the patient, educational level, employment status and the number of hours spent providing care daily. It also assessed caregivers’ hand hygiene practices and beliefs, including handwashing frequency, perceived hand cleanliness, morning handwashing habits, products used for hand hygiene, encouragement from healthcare professionals, beliefs regarding the role of handwashing in infection prevention and perceptions of nurses’ attention to patient hand hygiene.

The Hand Hygiene Knowledge Level Form is a structured instrument designed to assess caregivers’ knowledge of proper hand hygiene practices. The form consists of 10 true/false questions, with a total possible score of 100 points, and was developed based on the recommendations of the Centers for Disease Control and Prevention regarding hand hygiene for patients in healthcare settings.²⁴ It evaluates participants’ understanding of key hand hygiene principles, including the timing, technique and rationale for handwashing and hand disinfection.

Evaluation of Handwashing Effectiveness Using Fluorescent Simulation Gel and UV LED Light was used to visually assess handwashing effectiveness. The fluorescent simulation gel contains particles comparable in size to microorganisms and allows visual identification of areas that remain contaminated after handwashing. When exposed to ultraviolet (UV) light, residual particles fluoresce, enabling assessment of hand cleanliness across different regions of the hand. This method has been widely used as an educational and assessment tool for hand hygiene performance. The procedure and illustrative examples of the fluorescent gel assessment are provided in online supplemental figure S1.

Procedure

Data collection was conducted as a purely observational procedure. Caregivers of inpatients in the general surgery ward who met the inclusion criteria were provided with both verbal and written information about the study, and written informed consent was obtained from all participants. No educational or behavioural intervention was implemented before or during the data collection process.

Data were collected after routine morning care procedures, between 10:00 and 12:00. This time interval was selected to ensure that caregivers had actively participated in patient care activities and to allow for a standardised observation period across participants. The potential influence of this timing on hand contamination levels is acknowledged as a limitation of the study.

Participants who agreed to participate first completed the Caregiver Sociodemographic Characteristics Form in the patient’s room, which required approximately 10–15 min. Subsequently, each caregiver applied 2 mL of fluorescent simulation gel to their hands and allowed it to dry for approximately 15–20 s. As reported in the literature, the dominant hand is more likely to be contaminated than the non-dominant hand; therefore, only the dominant hand was evaluated. For participants who reported being ambidextrous, the right hand was assessed.

After drying, the dominant hand was examined under UV light by two independent observers. Prior to data collection, both observers received standardised training on the assessment protocol, including the identification of clean and contaminated areas under UV light and the application of the scoring system. Calibration was conducted using sample images and pilot assessments to ensure consistency. The observers performed the assessments independently and were blinded to each other’s ratings.

Hand cleanliness was evaluated across seven anatomical regions: fingertips, palm, anterior wrist, posterior wrist, nails, dorsal hand and interdigital spaces. Each region was scored as 1 (clean) or 2 (contaminated). Inter-observer agreement was evaluated using Cohen’s kappa coefficient.

After completion of the observational assessment, caregivers were provided with an informational hand hygiene brochure illustrating the correct handwashing steps. This brochure was distributed after data collection and did not constitute an intervention within the study design. A flow diagram describing participant recruitment and inclusion in the study is presented in figure 1.

Figure 1. Flow diagram—study procedure.

Data analysis

The data collected in this study were analysed using SPSS. Descriptive statistics, including mean, SD, minimum and maximum values, were calculated for continuous variables, while categorical variables were analysed using frequency and percentage distributions. The caregivers’ mean scores for hand hygiene knowledge and behaviour were determined, and an independent samples t-test was used to examine the relationship between hand hygiene practices and knowledge levels. Cohen’s kappa test was also used to assess inter-observer reliability.

Patient and public involvement

Patients and the public were not involved in the design, conduct, reporting or dissemination plans of this research. Caregivers of surgical patients participated only as study participants during the data collection process.

Results

Characteristics of caregivers and hand hygiene practices

A total of 128 caregivers of surgical patients participated in the study. Among them, 65.6% (n=84) were women and 34.4% (n=44) were men, with a mean age of 45.66±14.78 years (range: 18–77 years) (table 1). All caregivers (100%) reported washing their hands in the morning, with 97.7% using soap and water and 2.3% using hand sanitiser. While 43% of caregivers reported receiving encouragement from healthcare staff to maintain hand hygiene, 57% indicated that they had not received such guidance. Most caregivers (84%) believed that nurses’ hand hygiene plays a critical role in preventing infection, and 82.8% acknowledged the importance of hand hygiene for patients themselves. On average, caregivers reported washing their hands 11.17±6.24 times per day and rated their perceived level of hand cleanliness as 5.28±2.12 on a 10-point scale (table 1).

Table 1. Characteristics of caregivers and hand hygiene practices.

Characteristics	n	%	$X\overline{X}$±SD	Min.	Max.
Gender
Female	84	65.6
Male	44	34.4
Years	128	100	45.66±14.78	18.00	77.00
Morning handwashing status
Yes	100	100
No	0	0
Handwashing method
Soap and water	125	97.7
Disinfectant	3	2.3
Encouraged by a healthcare professional to wash/clean your hands at specific times
Yes	55	43.0
No	73	57.0
Nurses’ own hand hygiene plays an important role in preventing infection
Yes	105	84.0
No	23	18.0
Recognition of patient hand hygiene by nurses as a key component of infection prevention
Yes	106	82.8
No	22	17.2
Daily handwashing frequency	128	100	11.17±6.24	3.00	50.00
Perceived level of hand cleanliness	128	100	5.28±2.12	0.00	10.00

Max, maximum; Min, minimum.

Hand hygiene knowledge of caregivers

The mean total hand hygiene knowledge score among participants was 98.98±3.93, with scores ranging from 80 to 100. The high mean score and narrow score distribution indicate a ceiling effect, suggesting limited variability in knowledge levels within the study sample. Participants achieved full marks (10.00±0.00) on several core items, including statements such as ‘Hands can spread germs.’, ‘It is important to wash hands before food preparation or consumption.’ and ‘It is important to wash your hands after using the toilet, wiping your nose or coughing.’ (table 2). This restricted variability should be considered when interpreting associations between knowledge scores and observed hand hygiene performance.

Table 2. Hand hygiene knowledge of caregivers.

Knowledge	$X\overline{X}$±SD	Min.	Max.
Hands can spread germs	10.00±0.00	0.00	10.00
It is important to use alcohol-based hand sanitiser as it eliminates most of the pathogens responsible for causing illness	10.00±0.00	0.00	10.00
It is important to wash hands before food preparation or consumption	10.00±0.00	0.00	10.00
It is important to wash your hands before touching your eyes, nose or mouth to prevent the spread of germs	10.00±0.00	0.00	10.00
It is important to wash hands both before and after changing wound dressings or bandages	10.00±0.00	0.00	10.00
It is important to wash your hands after using the toilet, wiping your nose or coughing	10.00±0.00	0.00	10.00
Hands should be rubbed for a minimum of 15 s when washing with soap and water	10.00±0.00	0.00	10.00
If possible, hands should be dried using a paper towel	10.00±0.00	0.00	10.00
Patients should be requested to wash their hands prior to any contact with a healthcare professional	9.53±2.12	0.00	10.00
The use of gloves alone does not adequately prevent infection transmission	9.45±2.25	0.00	10.00
Total hand hygiene knowledge score	9.98±3.93	80.00	100.00

Total hand hygiene knowledge score range: 0–100; higher scores indicate greater knowledge.

Max, maximum; Min, minimum.

Hand hygiene observation and inter-rater reliability

Observations of hand cleanliness using UV light and fluorescent gel revealed varying levels of contamination across different areas of the hands. Inter-rater agreement was high, with Cohen’s kappa values ranging from 0.864 to 0.913, indicating excellent reliability (table 3).

Table 3. Hand hygiene observation and inter-rater reliability.

Area of the hand	Observer 1	Observer 2		Cohen’s kappa
		Clean	Contaminate
Dorsal hand	Clean	79	1
	Contaminate	6	42	0.881
Palm hand	Clean	61	1
	Contaminate	6	60	0.891
Posterior wrist	Clean	64	4
	Contaminate	3	59	0.891
Anterior wrist	Clean	64	3
	Contaminate	3	58	0.906
Fingertips	Clean	41	3
	Contaminate	2	82	0.913
Interdigital spaces	Clean	42	2
	Contaminate	6	78	0.864
Nails	Clean	38	3
	Contaminate	4	83	0.875

Hand cleanliness was evaluated using fluorescent gel and ultraviolet light. Statistical test: inter-rater agreement was assessed using Cohen’s kappa coefficient. Kappa values >0.80 indicate excellent agreement.

Relationship between hand hygiene and hygiene knowledge

Statistically significant differences in hand hygiene knowledge scores were observed between the ‘clean’ and ‘contaminated’ groups for the posterior wrist (99.69±2.46 vs 98.22±4.96, p<0.001) and anterior wrist (99.40±3.42 vs 98.52±4.42, p=0.016). However, the absolute differences in mean knowledge scores between groups were small. Given the presence of a ceiling effect in the knowledge measure, these statistically significant findings should be interpreted with caution, as they may not reflect clinically meaningful differences. No significant differences were found in other hand regions (table 4).

Table 4. Relationship between hand hygiene and hygiene knowledge.

	Clean		Contaminate		Test statistics
	n	$X\overline{X}$±SD	n	$X\overline{X}$±SD
Dorsal hand	80	99.12±3.62	48	98.75±4.43	t=0.520; p=0.303
Palm hand	62	99.19±3.28	66	98.78±4.47	t=0.581; p=0.231
Posterior wrist	66	99.69±2.46	62	98.22±4.96	t=2.143; p=0.000
Anterior wrist	67	99.40±3.42	61	98.52±4.42	t=1.264; p=0.016
Fingertips	44	99.31±2.54	84	98.80±4.50	t=0.693; p=0.143
Interdigital spaces	44	99.31±2.54	84	98.80±4.50	t=0.693; p=0.143
Nails	41	99.26±2.63	87	98.85±4.42	t=0.559; p=0.231

Statistical test: independent-samples t-test was used to compare mean knowledge scores between clean and contaminated hand regions.

Bold values indicate statistically significant differences (p<0.05) between groups.

Discussion

This study examined hand hygiene knowledge and actual hand cleanliness among caregivers of surgical patients in a tertiary hospital. Although caregivers demonstrated high levels of hand hygiene knowledge, observed hand cleanliness varied across anatomical regions. In particular, the wrist areas showed frequent residual contamination, indicating a discrepancy between reported knowledge levels and observed hand hygiene performance rather than a direct effect of knowledge on practice. This finding is consistent with previous studies reporting that higher knowledge levels are not necessarily accompanied by optimal hand hygiene behaviour.^{9 15}

The presence of statistically significant differences in knowledge scores between caregivers with clean and contaminated wrists suggests an association between knowledge level and hand cleanliness in specific regions; however, this relationship was not consistent across all hand areas. The wrists are commonly neglected during handwashing, which may partly explain the observed contamination.¹² Given the cross-sectional design, these findings should be interpreted as associative rather than causal. Observational assessment may help identify hand regions where hygiene performance is suboptimal and where additional attention during handwashing may be warranted.

The use of fluorescent gel and UV light provided an objective method for assessing hand cleanliness and demonstrated excellent inter-observer reliability, supporting the methodological rigour of the observational approach.²⁵ While visual assessment tools are often discussed as educational strategies, in this study they were used solely to document observed hand hygiene performance and discrepancies between self-reported and observed practices. Direct observation remains a valuable assessment method, although it has known limitations such as observer bias.²⁶,²⁸

Despite high knowledge scores, most caregivers reported receiving limited encouragement or reinforcement from healthcare professionals regarding hand hygiene. Within the context of this observational study, this finding reflects an observed pattern rather than evidence of an effect on hand hygiene behaviour. Caregivers constitute an important group within the patient care environment, and their hand hygiene practices may be associated with infection risk when they are involved in daily care activities.^{1 4 29 30} However, broader inferences regarding infection control outcomes should be made cautiously due to the study’s cross-sectional design.

The increased global attention to hand hygiene following the SARS-CoV-2 pandemic provides a contextual background for interpreting the high knowledge scores observed in this study. Although pandemic-related behaviours were not assessed, this context may be associated with increased general awareness of hand hygiene principles, without necessarily ensuring correct technique.¹⁷,²⁰²⁹

Overall, the findings indicate that caregivers of surgical patients possess adequate hand hygiene knowledge but do not consistently demonstrate optimal hand cleanliness, particularly in less visible areas such as the wrists. The results underscore the importance of combining self-reported measures with observational assessments to better understand gaps between knowledge and practice. Future longitudinal or interventional studies are needed to determine whether specific educational or institutional strategies can improve hand hygiene performance, given the observational and cross-sectional nature of the present study.³¹,³³

Limitations

This study has several limitations. Only the dominant hand of each caregiver was assessed, and ambidextrous participants had only their right hand evaluated, which may have overlooked contamination on the non-dominant hand. Assessing only the dominant hand may have led to an underestimation of overall hand contamination, as hygiene perfo$X\overline{X}$rmance may differ between hands.

The cross-sectional design provides a snapshot of hand hygiene practices and does not allow conclusions regarding causality or changes over time. In addition, self-reported practices and beliefs may have been influenced by social desirability bias, potentially leading to an overestimation of caregivers’ adherence to hand hygiene recommendations.

Data collection was conducted after routine morning care within a specific time window (10:00–12:00), which may have influenced hand contamination levels and limits the generalisability of the findings to other times of the day. Furthermore, data collection was carried out within the context of a student-led volunteer course activity, which may have influenced caregiver behaviour due to increased awareness or the presence of observers, introducing a potential source of observational bias.

Finally, although the fluorescent gel and UV light method is effective for visual assessment of hand hygiene technique, it does not directly measure microbial contamination. Despite these limitations, the study provides valuable descriptive evidence of the discrepancy between hand hygiene knowledge and observed hand cleanliness among caregivers of surgical patients.

Conclusion

Caregivers of surgical patients demonstrated a high level of hand hygiene knowledge; however, observed hand cleanliness, particularly in specific regions of the hand, was suboptimal. The findings suggest an association between knowledge and hand hygiene performance rather than a causal relationship. Observational assessments may help identify areas where hand hygiene technique is incomplete. Including caregivers in infection prevention initiatives may represent a supportive strategy to improve hand hygiene practices in surgical inpatient settings. Further longitudinal or interventional studies are needed to determine the effectiveness of such approaches.

Data availability statement

Data are available upon reasonable request.