Abstract
Background
Hand hygiene (HH) regimens significantly prevent the spread of healthcare-associated infections and multidrug-resistant organisms. Practising correct HH is crucial in achieving the target of near-zero infections. Globally, HH compliance rates among healthcare workers (HCWs) remain suboptimal. This study aimed to evaluate HCWs’ hand hygiene knowledge, perception and self-reported practice and their correlations in a tertiary care hospital in Qatar.
Methods
A cross-sectional study was conducted at Al Ahli Hospital, an Australian Council on Healthcare Standards International (ACHSI) accredited tertiary care hospital, from December 2023 to February 2024. The final analytical sample comprised 434 licensed HCWs (physicians, nurses and allied health professionals) responses. A validated self-administered questionnaire from the World Health Organisation and the Centers for Disease Control resource was used. Descriptive and inferential statistics were used for analysis.
Results
The mean and standard deviation scores of knowledge, perception, and self-reported practice were 24.9 ± 2.83, 25.5 ± 2.69, and 18 ± 2.99 respectively. 65% of HCWs demonstrated a high level of knowledge. Between 57% and 90% of HCWs perceived HH as highly important, whereas 59 to 86% of HCWs self-reported that they performed HH more than 95% of the time in a day. Pearson’s correlation analysis showed significant positive correlations between HH knowledge and self-reported practice (r = 0.215, P < 0.001). Chi-square test and one-way ANOVA analysis shown statistically significant differences (p < 0.05) across professional groups for selected knowledge, perception and self-reported practice items. These findings revealed that nurses were moderately compliant, which potentially reflects patient contact and nature. Post-hoc Bonferroni analyses showed statistically significant mean group differences (p < 0.05) confirming that nurses performed better than physicians and allied health professionals. Major barriers to HH practice included being too busy, lacking time, skin irritation and prioritisation of patient needs.
Conclusion
HCWs possess strong knowledge and positive perception toward HH, and notable gaps persist between their understanding and their self-reported practices. These findings highlight the need for periodical monitoring and specialised HH modular training integrated with behavioural interventions. A collaborative approach involving all stakeholders is essential to implement strategic initiatives to eliminate the identified barriers and improve HH compliance, contributing to improved patient safety.
Keywords: Hand hygiene, Healthcare workers, Knowledge, Perception, Self-reported practice, Infection prevention, Compliance
Background
The World Health Organisation (WHO) estimates that more than one million healthcare-associated infections (HAIs) and multidrug-resistant organisms (MDROs) occur annually worldwide, resulting in tens of thousands of deaths and billions of dollars in healthcare costs [1]. One in every thirty-one hospitalised patients is affected by HAIs, with Clostridioides difficile (C. diff) alone accounting for 12.1% of cases due to its spore-based resistance and high mortality rate [2]. These infections pose a major global health challenge contributing to the economic burden of healthcare systems through recurrent admission and prolonged hospital stays [3]. Hand hygiene (HH) is widely recognised as the most effective preventive measure, capable of reducing half of HAIs and preventing the spread of MDROs [4, 5]. The Centers for Disease Control and Prevention (CDC) [6] emphasises that HH methods must be tailored to specific pathogens, such as C.diff and norovirus, underscoring their importance in reducing the risk of transmission of infection and its impact on patient safety.
Despite the implementation of the WHO’s multimodal strategies, achieving the targeted national and international benchmark standard of the HH compliance rate faces persistent challenges in both developed and developing countries [4]. Research studies employing the WHO’s standardised knowledge and perception survey tools have identified gaps between theoretical knowledge and practical application, but these tools fail to address contextual needs within specific healthcare facilities [7]. An incorporation of core aspects into evaluation tools such as the HH method, the timing of hand rubbing/washing and HH impact are critical for identifying the gap between theory and practice. HH programs addressing the institutional and regional realities is essential for strengthening knowledge, improving skills, and enhancing compliance [8].
WHO global benchmark reflects minimum achievable standard across diverse healthcare systems whereas the nationwide healthcare safety and performance assessment report 2024 stated the national benchmark standard as 89.9% which reflects Qatar’s higher expectations for healthcare quality and patient safety [9]. A health safety performance assessment report from the Ministry of Public Health, Qatar specified that the HH compliance rate increased modestly from 73% to 78% (2022–2024) at Al Ahli Hospital [9]. Routine infection control training was conducted, with a focus on essential aspects of standard and transmission-based precautions. Despite a common infection control training program, compliance rates remain below the national and international benchmark standard. Moreover, this training content often lacks clarity regarding the in-depth HH scope, limiting the integration of knowledge into practice. This highlights the crucial need for tailored interventions of periodic, contextualised, comprehensive assessment to initiate strategies to improve compliance. To address this issue, this study aimed to assess healthcare workers’ (HCWs’) knowledge, perceptions, and practices, and examine their relationships and associations with sociodemographic characteristics.
Materials and methods
Study design, setting and participants
A cross-sectional study was conducted between December 2023 and February 2024 to assess HH knowledge, perceptions, and self-reported practices among HCWs working at Al Ahli Hospital, a 250-bed, tertiary care hospital, an Australian Council on Healthcare Standards International (ACHSI) accredited. Ethics approval was obtained from the Institutional Review Board (IRB) of Al Ahli Hospital, Qatar.
Sample size
The target population was all licensed HCWs, those who delivered direct patient care. The workforce ratio within an institution is approximately three nurses to one doctor or allied healthcare professionals (AHPs - physiotherapists, respiratory therapists and technologists). A total of 768 licensed HCWs, including physicians, nurses, and AHPs were eligible to participate in the study. The sample size was calculated for a cross-sectional prevalence study assuming an expected prevalence of 30%, a 95% confidence level (Z = 1.96), and a 5% margin of error (d = 0.05). The initial calculated sample size was 323. This sample size was adjusted using the finite population correction for the defined target population of 768 HCWs resulting in a minimum estimated sample size of 228. With the possibility of 10% attrition rate, the final required sample size was 251 participants. 437 HCWs voluntarily responded to the survey which exceeded the estimated minimum required sample size of 251, ensuring the desired level of precision and reliability.
Study instrument
A structured, self-administered questionnaire was adapted from the WHO’s HH knowledge and perception survey and CDC hand hygiene training resources [6, 10]. A self-administered questionnaire was used to minimise interviewer influence and social desirability bias. A total of 26 items cover the HH knowledge core aspects, perceptions and self-reported practices. The internal consistency of the scale was validated with a good reliability score of Cronbach’s alpha values of 0.84 for HH knowledge, 0.81 for perception and 0.75 for self-reported practice.
The four sections of the questionnaire were sections A, B, C and D. Section A focused on sociodemographic characteristics (age, gender, professional group, years of experience, education and department). Section B included 15 knowledge questions, with the core components of the WHO five moments, glove use, pathogen-specific HH practices consisting of eight multiple choice questions, and seven close-ended questions with yes/no or true/false options. The maximum achievable score was 34, categorised as high (89–100%), moderate (45–88%), and low (0–44%) knowledge.
Section C evaluated HH perception via six statements rated on a four and five-point Likert scale to measure perceived importance, impact on HAIs and the effort required to perform HH. The first three statements determine the HCWs’ perception of how HAIs affect patient outcomes, the institutional burden and HH effectiveness on prevention of HAIs. Sixth statement reflecting personal evaluation of HH effort and willingness to comply. Whereas the fourth and fifth statement measures the HCWs’ perception of institutional prioritisation on HH, its importance and patient expectations on HH.
Section D assessed the behavioural dimension of HH, self-reported practices via four items related to routine HH frequency before and after patient contact and glove use, along with one open-ended item exploring perceived barriers. Self-reported practice scores were categorised from lowest (5–29%) to highest (> 95%) compliance, corresponding to “novice” to “expert” levels.
Data collection
The participants were informed about the study’s nature, voluntary participation, electronic informed consent, privacy and confidentiality of the data. The survey was conducted via Google and Microsoft forms that were developed in alignment with CHERRIES (Checklist for reporting Results of Internet E-Surveys) guidelines and responses to ensure methodological transparency [11]. All the questions were set as mandatory and the response per user was limited to ensure completeness and avoid duplication. Completion of the survey required approximately 20 min. The collected responses were anonymised, coded and stored securely with a protected password accessible only to the research team.
The survey was administered to all 768 eligible HCWs via the learning management system to ensure the privacy and confidentiality of the data. Initially, 321 (42%) respondents responded voluntarily. Although the minimum sample size was achieved, HCWs were encouraged to voluntarily participate in the study through an email reminder. In total, 437 HCWs responded. After data integrity screening, three responses were excluded due to significant missing values resulting in a final analytic sample of 434 participants. 434 (57%) HCWs’ responses were only eligible for analysis confirming the adequate sample size to determine the statistical power of the study objectives and its application of correlation and one-way analysis of variance (ANOVA) to evaluate the small to moderate effect size.
Statistical analysis
The collected data were analysed statistically via R software V4.3.1 [12]. Sociodemographic characteristics and HH knowledge, perception, and self-reported practice scores were analysed by applying descriptive statistics (frequency, percentage, mean, and standard deviation (SD)). A non-parametric chi-square test was used to analyse the associations between categorical variables, whereas in the case of fewer than five expected cell counts, Fisher’s exact test was applied. A parametric test of Pearson’s correlation coefficient was employed to measure linear relationships between continuous variables of hand hygiene. Correlation coefficients range from − 1 to + 1, indicating negative to positive linear relationships. Furthermore, a parametric test of one-way ANOVA was used to examine differences in mean perceptions and self-reported practice scores across professional categories (physicians, nurses, and allied health professionals). When ANOVA indicated significant variation, post-hoc Bonferroni analysis was employed to control the type I error. This ensures that identified differences between specific groups are robust and reliable, thereby enhancing the precision of the study findings. Statistical significance was set at p < 0.05 for all statistical tests applied in this study indicating that the relationship exists within the population which is unlikely to be due to chance in the sample.
Results
Sociodemographic characteristics
A final analytical sample of 434 (57%) HCWs responses was analysed in the study. The mean age was 29.5 years, with the largest proportion aged 31–40 years (45%). A total of 68% of the respondents were female. Nurses constituted the majority of participants, 275 (63%) followed by AHPs, 102 (24%), and physicians, 57 (13%) (Table 1).
Table 1.
Sociodemographic characteristics of healthcare workers (N = 434)
| Sociodemographic characteristics | Frequency (N) | Percentage (%) |
|---|---|---|
| Age (Years) | ||
| 21–30 | 105 | 24 |
| 31–40 | 196 | 45 |
| 41–50 | 73 | 17 |
| > 50 | 60 | 14 |
| Gender | ||
| Male | 139 | 32 |
| Female | 295 | 68 |
| Professional groups | ||
| Physicians | 57 | 13 |
| Nurses | 275 | 63 |
| Allied health professionals | 102 | 24 |
| Years of experience | ||
| < 1 | 35 | 8 |
| 1–5 | 83 | 19 |
| 6–10 | 106 | 25 |
| 11–15 | 80 | 18 |
| > 15 | 130 | 30 |
| Education | ||
| Certificate | 9 | 2 |
| Diploma | 72 | 17 |
| Degree | 289 | 67 |
| Masters | 42 | 9 |
| PhD or Doctorate | 22 | 5 |
| Department | ||
| Inpatient unit | 113 | 26 |
| Outpatient unit | 149 | 34 |
| Operation theatre | 62 | 14 |
| Emergency unit | 34 | 8 |
| Other services (laboratory, radiology, physiotherapy) | 76 | 18 |
There was no significant association between HH and sociodemographic variables except for the professional groups of physicians, nurses, and allied health professionals at P < 0.05. Hence, chi-square, one-way ANOVA and post-hoc Bonferroni analysis were employed to evaluate the associations between professional group and each knowledge, perception and self-reported practice items.
Knowledge
HCWs demonstrated a predominance of high-level HH knowledge. Among the total sample, 281(65%) HCWs presented high HH knowledge, whereas 141(33%) HCWs were shown as moderate knowledge, and the remaining 12(2%) presented low knowledge (Fig. 1). The mean knowledge score was 24.9 (SD ± 2.8) while the majority of HCWs were knowledgeable in applying HH principles. However, a notable proportion of moderate and low knowledge highlights potential areas for targeted educational reinforcement.
Fig. 1.
Healthcare workers’ hand hygiene knowledge level
Chi-square analysis revealed that the majority of the HCWs responded correctly, and a notable percentage of HCWs answered incorrectly. Overall, the correct answers were provided by nurses, then physicians, followed by AHPs (Table 2). Moreover, the results revealed statistically significant differences in certain questions among HCWs (Table 2). A total of 364 (84%) HCWs indicated correct hand hygiene method to practice while caring for patients with C. diff, whereas less than one fourth of the above percentage, 84 (19%) HCWs, indicated only the correct HH method effectiveness which was significantly different across professions (p = 0.001). Similarly, knowledge of alcohol-based hand rubs (ABHR) and hand wash duration across professional groups (physicians, nurses, and AHPs), was significantly different (p = 0.006 and p = 0.001). Overall, these significant profession-specific variations determine the limited awareness of HH duration and effectiveness, which contributes to inconsistent practices and noncompliance, suggesting the need for targeted, specific HH modular training.
Table 2.
Level of knowledge among healthcare workers
| Question on knowledge | Total N (%) | Physicians N (%) | Nurses N (%) | AHPs N (%) | P value |
|---|---|---|---|---|---|
| Hand hygiene action and timing | |||||
| Which hand hygiene method is more effective at killing bacteria? | |||||
| • Soap and water (I) | 350 (81) | 31(7) | 234 (54) | 85(20) | 0.001a *** |
| • Alcohol-based hand rub (foam or gel) (C) | 84 (19) | 26(6) | 40(9) | 18(4) | |
| Which hand hygiene method would you perform after caring for a patient with a spore-forming organism e.g. C. diff? | |||||
| • Soap and water (C) | 364(84) | 39(9) | 246(57) | 79(18) | 0.001a *** |
| • Alcohol-based hand rub (foam or gel) (I) | 70(16) | 18(4) | 31(7) | 23(5) | |
| Alcohol does not act at all against spore-forming organisms, e.g. C. diff | |||||
| • Yes (C) | 319(74) | 38(9) | 202(47) | 79(18) | 0.337a |
| • No (I) | 115(26) | 19(4) | 73(17) | 23(5) | |
| How long should you rub your hands together when washing with soap and water? | |||||
| • 40-60 secs (C) | 325(75) | 33(8) | 212(49) | 80(18) | 0.006a *** |
| • 20-30 secs/10-20 secs/15-30 secs (I) | 109(25) | 24(5) | 63(15) | 22(5) | |
| How long should you rub your hands together when washing with a hand sanitiser? | |||||
| • 20-30 secs (C) | 269(62) | 24(5) | 175(41) | 70(16) | 0.001a *** |
| • 0-5 secs/10-15 secs/5-10 secs (I) | 165(38) | 33(8) | 100(23) | 32(7) | |
| What is the minimal time needed for alcohol-based hand rub (ABHR) to kill most germs on your hands? | |||||
| • 20 seconds (C) | 338(78) | 39(9) | 219(51) | 80(18) | 0.172a |
| • 1 min/10 secs/30 secs (I) | 96(22) | 18(4) | 56(13) | 22(5) | |
| Which hand hygiene method is less damaging to your skin? | |||||
| • Soap and water (I) | 332(76) | 43(10) | 210(48) | 79(18) | 0.986a |
| • Alcohol-based hand rub (foam or gel) (C) | 102(24) | 14(3) | 63(15) | 25(6) | |
| Source of Pathogen transmission | |||||
| Which of the following is the main route of cross-transmission of potentially harmful germs between patients in a healthcare facility? | |||||
| • Unclean hands of healthcare workers (C) | 313(72) | 47(11) | 198(46) | 68(15) | 0.109a |
| • Air circulating in the hospital/ Patients’ exposure to colonised surfaces/Sharing non-invasive objects (I) | 121(28) | 10(2) | 77(18) | 34(8) | |
| What is the most frequent source of germs responsible for healthcare-associated infections? | |||||
| • Germs already present on or within the patient (C) | 270(63) | 33(8) | 175(41) | 64(14) | 0.715a |
| • The hospital air/environment/water system (I) | 164(37) | 24(5) | 100(23) | 40(9) | |
| Glove use | |||||
| When to do hand hygiene while using gloves? | |||||
| • Before wearing gloves (C=Yes) | 408(94) | 51(12) | 260(60) | 97(22) | 0.407b |
| • After wearing gloves (C=No) | 213(49) | 39(9) | 130(30) | 44(10) | 0.009a *** |
| • After removing gloves (C=Yes) | 419(96) | 53(12) | 270(62) | 95(22) | 0.108a |
| Hand hygiene and the WHO five moments | |||||
| Which of the following hand hygiene actions prevents transmission of germs to the patient? | |||||
| • Before touching a patient (C=Yes) | 424(98) | 56(13) | 272(63) | 97(22) | 0.359a |
| • Immediately before a clean/aseptic procedure (C=Yes) | 400(92) | 51(12) | 260(60) | 89(20) | 0.043b*** |
| • Immediately after a risk of body fluid exposure (C=No) | 38(9) | 8(2) | 17(4) | 13(3) | 0.036b*** |
| • After exposure to the immediate surroundings of a patient (C=No) | 45(10) | 23(5) | 1 1(3) | 11(3) | 0.622a |
| Which of the following hand hygiene actions prevents transmission of germs to the health care worker? | |||||
| • After touching a patient (C=Yes) | 414(95) | 55(13) | 266(61) | 93(21) | 0.075b |
| • Immediately after a risk of body fluid exposure (C=Yes) | 410(95) | 52(12) | 264(61) | 94(22) | 0.160b |
| • Immediately before a clean/aseptic procedure (C=No) | 382(88) | 49(11) | 245(57) | 88(20) | 0.691a |
| • After exposure to the immediate surroundings of a patient? (C=Yes) | 403(93) | 53(12) | 262(60) | 91(21) | 0.098b |
| Types of hand hygiene methods required in special situations | |||||
| • Before palpation of the abdomen (C=rubbing) | 429(99) | 56(13) | 273(63) | 100(23) | 0.118b |
| • Before giving an injection (C=rubbing) | 424(98) | 55(13) | 272(63) | 97(22) | 0.304b |
| • After emptying a bedpan (C=rubbing) | 423(98) | 54(13) | 272(63) | 97(22) | 0.044b*** |
| • After removing examination gloves (C=rubbing) | 425(98) | 55(13) | 272(63) | 98(22) | 0.168b |
| • After making a patient's bed (C=rubbing) | 429(99) | 56(13) | 273(63) | 100(23) | 0.117b |
| • C. After visible exposure to blood (C=Washing) | 424(98) | 56(13) | 273(63) | 95(22) | 0.197b |
| Hand hygiene Grooming | |||||
| Which of the following should be avoided, associated with an increased likelihood of colonisation of hands with pathogens? | |||||
| • Wearing Jewellery (C=Yes) | 419(96) | 54(12) | 270(62) | 95(22) | 0.032b*** |
| • Damaged Skin (C=Yes) | 401(92) | 53(12) | 257(59) | 94(21) | 0.367b |
| • Artificial fingernails (C=Yes) | 414(95) | 55(13) | 265(61) | 94(21) | 0.236b |
| • Regular use of hand cream (C=No) | 322(74) | 33(7) | 217(50) | 72(17) | 0.003a *** |
| Which of the following statements on alcohol-based hand rub and handwashing with soap and water are true? | |||||
| • Hand rubbing is more rapid for hand cleansing than hand washing (C=True) | 346(79) | 44(10) | 222(51) | 80(18) | 0.785a |
| • Hand rubbing causes skin dryness more than hand washing (C=False) | 304(70) | 36(8) | 202(47) | 66(15) | 0.123a |
| • Hand rubbing is more effective against germs than hand washing (C=True) | 138(32) | 20(5) | 92(21) | 27(6) | 0.379a |
| • Handwashing and Hand rubbing are recommended to be performed in sequence (C=False) | 93(21) | 25(6) | 39(9) | 29(6) | 0.001a *** |
C=Correct responses; I- Incorrect responses by the participants. aChi-square test; bFisher's exact test; *** p<0.05
HCWs demonstrated prominent levels of knowledge of the “WHO Five Moments”, and its rationale, but there was a significant difference among professional groups when HH performed ‘immediately before clean/aseptic procedures’. In contrast, low-level knowledge was reported ‘immediately after risk of body fluid exposure’ which was associated with extremely limited awareness of understanding with a statistically significant difference among the groups (p = 0.043). Although HCWs are well-informed about HH practices in routine care, specific gaps remain in understanding pathogen transmission dynamics.
HCWs had strong baseline knowledge of glove use, HH grooming and factual statements about ABHR and hand washing. However, notable misconceptions were significantly different among professional groups which were more prevalent among nurses than among physicians and AHPs in the specific domains of ‘wearing jewellery’ (p = 0.032), ‘regular use of hand cream’ (p = 0.003) and ‘handwashing and alcohol-based hand rubbing are recommended to be performed in sequence’ (p = 0.001). These findings highlight the need for tailored HH modular training with behavioural interventions.
Perception
The HH perception mean score was high (mean 25.5 ± 2.69) indicating that HH practice was perceived as a strong priority contributing to patient safety. The majority of HCWs, ranging from 57% to 90% HCWs, perceived HH and its impact on HAIs as extremely important, whereas 1% to 6% of HCWs perceived HH importance at the extremely lowest level (Fig. 2).
Fig. 2.
Healthcare workers’ perceptions of hand hygiene
Nurses perceived HH practice as more positively than physicians and AHPs. However, these magnitudinal differences among professional groups were small to moderate. Significant differences in selected HH perception items across professional groups were examined by one-way ANOVA. Nurses consistently reported higher perception mean scores than physicians and AHPs related to optimal hand hygiene and the perceived effort required to perform good HH practices. AHPs demonstrated intermediate scores, whereas physicians reported comparatively lower scores on these dimensions. These findings suggest profession-specific differences in perceived behavioural demands regarding HAIs impact, hand hygiene importance and its effort (Table 3). Furthermore, the post-hoc Bonferroni analysis revealed significant differences between nurses and physicians and nurses and AHPs (p = 0.048 and p = 0.056). There was no significant difference between the physicians and AHPs group. These findings confirm that nurses differ significantly from both physicians and allied health professionals, whereas physicians and allied health professionals did not differ from each other.
Table 3.
Associations between hand hygiene perceptions and healthcare workers
| Perception statement | Physicians N-57 | Nurses N -275 | AHPs N-102 | F value | P value | |||
|---|---|---|---|---|---|---|---|---|
| Mean | SD | Mean | SD | Mean | SD | |||
| Impact on healthcare-associated infections | ||||||||
| Impact of health care-associated infections on clinical outcomes | 3.65 | 0.55 | 3.35 | 0.94 | 3.58 | 0.72 | 6.19 | 0.003*** |
| Impact of health care-associated infections on facility expenditures | 3.58 | 0.62 | 3.29 | 0.92 | 3.52 | 0.71 | 5.62 | 0.004*** |
| Effectiveness of hand hygiene to prevent health care-associated infections | 3.81 | 0.44 | 3.79 | 0.57 | 3.72 | 0.65 | 0.64 | 0.53 |
| Hand hygiene importance | ||||||||
| Among all patient safety issues, how important is hand hygiene at your institution | 3.82 | 0.42 | 3.91 | 0.3 | 3.86 | 0.44 | 1.19 | 0.309 |
| What importance do patients attach to the fact that HCWs perform optimal hand hygiene | 4.26 | 0.76 | 4.61 | 0.65 | 4.3 | 0.84 | 8.94 | 0.000*** |
| Efforts required for hand hygiene | ||||||||
| How do you consider the efforts required by yourself to perform good hand hygiene as high | 4.02 | 1.36 | 4.56 | 0.93 | 4.53 | 0.79 | 4.12 | 0.018*** |
SD- standard deviation; ***p<0.05 One -way ANOVA. HCWs – Healthcare workers; AHPs -Allied health professionals
Self-reported practice
The self-reported HH practice scores were high overall (mean 18.0 ± 2.99), with most participants reporting advanced or expert level compliance (Fig. 3). 86% of HCWs self-reported glove use most often (> 95% of the time) when exposed to contaminated body fluids. In comparison, HH practices before and after patient contact and after touching only surfaces of patient surroundings were reported by 59% to 66% of HCWs. HCWs at the novice and beginner levels self-reported practice as reliable, and attention should be given to implementing strategies to address the HH improved performance at the expert level.
Fig. 3.
Healthcare workers’ self-reported hand hygiene practices
Significant differences in self-reported hand hygiene practices were observed across professional categories for hand hygiene before and after patient contact, after touching patient surroundings, and after glove removal. Analysis of the mean scores revealed that nurses reported the highest compliance levels, followed by AHPs, whereas physicians reported comparatively lower self-reported compliance for several practice indicators. Post-hoc Bonferroni analysis revealed that there was no significant difference between physicians and allied health staff and nurses. However, the significant differences observed between physicians and nurses (p = 0.01) and between nurses and AHPs (p = 0.05), which demonstrate greater adherence to routine hand hygiene, potentially reflect their greater frequency of direct patient contact and stronger institutional emphasis on hand hygiene within nursing practice (Table 4). These findings indicate that professional role was associated with differing outcomes, with the observed variation unlikely to be due to chance (p < 0.001).
Table 4.
Associations between self-reported hand hygiene practices and healthcare workers
| Self-reported practice questions | Physicians N-57 | Nurses N -275 | AHPs N-102 | Mean Square | F value | P value | |||
|---|---|---|---|---|---|---|---|---|---|
| Mean | SD | Mean | SD | Mean | SD | ||||
| How often do you practice hand hygiene | |||||||||
| both before and after having contact with a patient? | 4.36 | 0.89 | 4.61 | 0.79 | 4.18 | 1.11 | 7.24 | 9.07 | .000*** |
| after touching only surfaces in the patient's room? | 3.98 | 1.2 | 4.43 | 0.97 | 4.04 | 1.18 | 8.59 | 7.69 | .001*** |
| after removing gloves? | 4.10 | 1.17 | 4.60 | 0.74 | 4.27 | 1.12 | 8.32 | 9.98 | .000*** |
| Glove use | |||||||||
| How often do you wear gloves when hands may be contaminated with body fluids? | 4.87 | 0.57 | 4.79 | 0.67 | 4.58 | 1.01 | 2.05 | 3.57 | .029*** |
AHPs -Allied health professionals; SD- standard deviation; ***p<0.05 one -way ANOVA
Overall, the ANOVA findings indicate that professional category is an important determinant of HH perception and self-reported practice, with nurses consistently demonstrating more favourable outcomes than physicians and allied health professionals. These profession-specific variations underscore the need for targeted, role-specific hand hygiene education and behavioural interventions, particularly among professional groups demonstrating lower perception or practice scores.
Barriers influencing regular hand hygiene practices
The most frequently reported barriers to HH compliance were workload or time constraints, skin irritation related to HH products and prioritisation of patient care over HH practices. Limited access to HH resources and supply shortages were reported less frequently (Fig. 4).
Fig. 4.
Barriers influencing regular hand hygiene practices
Relationships among HH knowledge, perceptions and self-reported practices
A statistically significant but weak positive correlation was observed between HH knowledge and self-reported practice scores (r = 0.215, p < 0.001), indicating that greater knowledge was associated with greater self-reported HH practices. This association represented a small effect size. No significant correlation was observed between knowledge and perception.
Discussion
Hand hygiene is the first and foremost preventive measure used for the prevention of HAIs. HCWs play a crucial role in compliance with HH practices to promote patient safety. Achieving targeted HH compliance remains challenging, and its impact on HAIs morbidity and mortality in both developing and developed countries is diverse [13]. In Qatar, few research studies have been conducted on HH knowledge, attitudes and practices in different healthcare facilities and universities, and the findings differ contextually [16].
Our study revealed that a high level of self-reported HH practice and perception, accompanied by moderate to high knowledge levels, revealed profession-specific differences and modest associations between knowledge and practice. Importantly, the observed statistical associations were generally small in magnitude, underscoring the need for cautious interpretation and targeted interventions and were consistently reported in research studies [14, 15].
The demographic characteristics of this study are consistent with those reported in previous hand hygiene studies, which frequently document a predominance of participants aged 31–39 years and female participants [14, 16–18]. Nurses represented the dominant population category of this research study, which is consistent with previous systematic reviews, similar quantitative and qualitative study findings [14, 19, 20]. This recurring pattern reflected the workforce composition, 2.8 nurse:1 doctor ratio in Qatar [16].
The HH knowledge level findings of this study were comparable to those of similar studies of HHs from Saudi Arabia and Bahrain [18, 21, 22]. In contrast, a public hospital in Cyprus reported that physicians had higher levels of knowledge than nurses and AHPs [23]. However, notable knowledge gaps persist in specific domains, particularly regarding the relative effectiveness of ABHR compared with soap and water. Although most participants correctly identified appropriate HH practices for C.diff infection, misconceptions surrounding routine microbial elimination suggest that knowledge acquisition alone remains incomplete [17, 22]. These findings were not addressed in earlier studies, emphasising the need for focused, context-specific education rather than reliance on general infection prevention training [24].
Knowledge of the WHO’s five moments was remarkably notable in research studies from the Middle Eastern, Western, and Asian regions. However, findings have failed to analyse the incorrect responses [7, 17, 21–23, 25, 26]. Self-protection and safety measures are suggested to be the major reasons for these notable incorrect responses [20]. These findings highlight the need for in-depth gap analysis to identify appropriate targeted interventions rather than generic infection control training [18, 26].
The perception scores related to HH importance, patient safety, and institutional priority were uniformly high across all professional groups, reflecting a widespread recognition of hand hygiene as a critical infection prevention measure [7, 26–28]. HH perception was higher among nurses which revealed strong recognition of the importance of hand hygiene for patient safety, particularly with respect to patients’ appreciation of HH and the effort required to maintain optimal practices [29]. Professional categories of nurses, physicians and AHPs influenced perceptions of the impact of HAIs, suggesting that institutional priority implies a key role. These differences were statistically significant, confirming that the effect sizes were small to moderate. Furthermore, the practical magnitude of these differences is limited. This finding suggests that perception-based interventions should be professionally tailored but system-wide rather than narrowly targeted. These strategies can reinforce positive perceptions, mitigate perceived barriers and support improved compliance and patient safety outcomes.
The self-reported HH practice scores were notably high, with most participants reporting advanced or expert level compliance across WHO hand hygiene moments. Nurses again demonstrated higher self-reported compliance compared than physicians did and AHPs did, a pattern consistently reported in the Qatar National Survey research study [16]. Several international studies have reported that the average HH compliance rate remains low (< 40%) worldwide, with rates being lower among physicians than among nurses because of a lack of role models and evidence supporting HH in preventing HAIs [5,7,17,18,29 ]. The key reason for noncompliance has been identified as a lack of sufficient knowledge about guidelines and protocols with suboptimal practice behaviours [30, 31]. Critical analysis of these self-reported findings revealed that actual compliance was overestimated compared with the directly observed compliance. However, statistically significant practice mean group differences echo the perception of a significant difference in small to moderate effect sizes. It is essential to interpret that profession alone does not fully explain HH behaviour and that structural and behavioural determinants play a substantial role.
A statistically significant positive correlation between HH knowledge and self-reported practices revealed that higher knowledge levels were significantly associated with an expert level of self-reported HH practices. However, a weak positive association with the small effect size (r = 0.215) revealed that improved knowledge alone is inadequate, resulting in a limited proportion of variance in HH behaviour. These findings are consistent with research studies from Qatar and Sudan suggesting that compliance is influenced by behavioural, organisational, and environmental determinants along with educational interventions [22, 26]. However, there is no significant correlation between knowledge and perception, perception and practice reflecting that a positive perception and belief do not necessarily transform into practice and consistent clinical behaviour within the context of pressurised clinical environments [14, 32].
The identified barriers to HH practices echo the results of the research studies from both developing and developed countries, indicating the need for regional and contextual action along with global action [7, 13, 17]. These common barriers have traditionally been reported as key obstacles, and it highlights the need for physical, environmental, and behavioural factors and challenges persisting within the healthcare setting, irrespective of reported high knowledge levels, positive perceptions and compliance [14]. Isolated training initiatives were ineffective and suggested the need for a collaborative approach with leadership engagement and environmental optimisation, along with multimodal strategies to create change in the behaviour culture [33].
Changes in the healthcare system featuring the multifaceted SWITCH approach increased the compliance rate from 60.78% to 94.14% in Al Wakra Hospital, Qatar. A multimodal approach involving behavioural changes in encouragement and motivation along with physical facilities improved HH practices [5]. In 2019, a report from a primary healthcare centre in Qatar described the positive influence of HH compliance behaviour and culture when management rewarded HCWs for compliance [33]. Weill-Cornell Medicine in Qatar suggested blended learning, scenario-based learning and reflections as the most effective teaching methods in IPC practices, but training on continuous ongoing HH specialised training was not emphasised [22]. A publication from a university hospital in Sudan highlighted the lack of training in HH as the cause of the increased number of HAIs and recommended urgent training of all staff [26]. The identification of these barriers has led infection prevention specialists to introduce specialised HH learning modules to increase knowledge and perceptions for prioritising HH in clinical routine. Multifaceted approaches such as educational activities, use of HH tools, monitoring and feedback promote the active participation of physicians, nurses and allied HCWs efficiently and increase the HH compliance rate [34]. Critical discussion of these identified gaps and barriers of HCWs’ knowledge, perceptions and practices recommended the need for practical, evidence-based specific HH modular training that is tailored to profession-specific groups. These tailored educational intervention addresses the HH behaviour change and an effective HH practice culture supporting improved HH compliance and better patient safety.
Limitations
The study findings and identified gaps were contextualised to the defined professional groups working in the tertiary care hospital setting within the private sector. This should be carefully interpreted to limit the broader applicability but could serve as a baseline for future similar and interventional educational studies. The nature of the cross-sectional design and the single-centre setting limit the generalizability of the study. The self-administered survey introduces the potential for recall or social desirability bias instead of reporting the actual practice. An adequate sample size was used in this study, and the data were analysed through appropriate parametric tests, Pearson’s correlation, one-way ANOVA with post-hoc Bonferroni. However, interpretation of these findings should be based on practical relevance rather than statistical significance alone owing to small to moderate effect sizes. Furthermore, the study findings reflect associations within the study sample, which limits the generalizability of the findings to wider healthcare populations.
Regardless of these limitations, the inclusion of different educational approaches, profession-specific engagement, behaviour change strategies, and a specific HH module, including system -level support, could have better facilitated HH knowledge and practice. This study provides a comprehensive overview of HH practices, suggesting the need for a collaborative approach to strengthen the implementation of regular reassessment and effective interventions promoting HH compliance and sustainability.
Conclusion
This study suggests the disparity between self-reported HH practices and the perceived knowledge level of physicians, nurses and AHPs, despite higher knowledge levels and positive perceptions. These identified notable gaps highlight the importance of integrating knowledge and perceptions into practice to improve HH compliance. Addressing these gaps through innovative targeted educational interventions, specific HH modular training, behavioural interventions, and simulation-based reinforcement are essential to complement positive perceptions and reported behaviours and reduce variability across professional groups. Furthermore, adequate infrastructure, elimination of perceived barriers, periodical reassessment, continuous monitoring, frequent quality checks, and reinforcement efforts are necessary to enhance uniform compliance and safe cultural practices. A collaborative approach involving policymakers, hospital leaders, infection prevention teams, quality management professionals, nursing leaders, and frontline HCWs is essential to translate knowledge and perceptions into consistent, effective hand hygiene behaviour. By implementing effective strategies in an integrated manner, healthcare institutions can strengthen hand hygiene compliance, thereby reducing the burden of HAIs and MDROs and contributing to improved patient safety outcomes.
Acknowledgements
The authors are deeply grateful to the faculty of the infection prevention and control department and to the healthcare workers who participated in the study at Al Ahli Hospital.
Abbreviations
- WHO
World Health Organisation
- HAIs
Healthcare-associated infections
- MDROs
Multidrug-resistant organisms
- C-diff
Clostridioides difficile
- HCWs
Healthcare workers
- HH
Hand hygiene
- ABHR
Alcohol-based hand rub
- AHPs
Allied health professionals
Biographies
Anbuselvi Danapalan MSN, CIC, FHEA
is an Infection Prevention Specialist at Primary Health Care Corporation, Doha, Qatar and pursuing a PhD in Nursing at Sri Ramachandra Institute of Higher Education and Research (DU), Chennai, India. She is the founder of INNO IPAC SiM, a simulation‑based mobile learning innovation for infection prevention education. Her research interest includes infection prevention and control, antimicrobial stewardship and innovative education and clinical excellence. She has contributed to peer‑reviewed publications, book chapter, curriculum design and policy development.
Dr Nalini Sriala Jagadeesh, PhD
is a Professor and Principal, Sri Ramachandra Faculty of Nursing, Sri Ramachandra Institute of Higher Education and Research (DU), also heads the Unit of Nursing Research. Her research interests include obstetrics and gynaecology nursing, infectious diseases, advanced nursing, nursing education, clinical practices and evidence-based nursing practices. She has published widely in international peer reviewed journals and actively contributed to national and international nursing councils, curriculum implementation, book chapters and patents.
Alexander Arthur Bialasiewicz, MD, PhD
is Head of the Department of Ophthalmology at Al Ahli Hospital, Doha, Qatar and Adjunct Professor at the University Eye Hospital Eppendorf, Hamburg, Germany. His research interests include infectious diseases and hygiene. He has published widely in international peer-reviewed journals and actively contributes to clinical research and scientific peer review.
Dr. Mohammed El-Ahmady, MD, PhD
is the Director of Pathology and Laboratory Medicine and Consultant of Microbiology and Immunology at Al-Ahli Hospital, Doha, Qatar and is a Professor of Microbiology and Immunology at the Faculty of Medicine, Zagazig University. His research interests include infectious diseases, antimicrobial resistance, tuberculosis, viral hepatitis, and infection control. He has published in numerous peer-reviewed journals and actively contributes to national and international infection prevention and control committees, patient safety and healthcare excellence.
Dr. Ashokkumar Palanivinayagam Ph.D
in Machine Learning from Vellore Institute of Technology (VIT), Vellore. He is currently serving as an Assistant Professor in the Department of Networking and Communications at the SRM Institute of Science and Technology, Chennai, India. His research interests encompass Machine Learning, Text Mining, Optimization Algorithms, Data Mining, and Artificial Intelligence, with a primary focus on developing intelligent and efficient computational models for solving complex real-world problems. Dr. Ashokkumar has contributed to several peer-reviewed journals, book chapters, and patents.
Author contributions
AD conceived and designed the research study. AD, AAB, and ME collected the data, AD, AAB, NSJ, ME and AP analysed and interpreted the results. AD prepared the original text. AP contributed to the figure’s generation with high resolution. AD, AAB, NSJ and ME contributed to the critical revision of the manuscript. All authors contributed to the article, reviewed and approved the submitted version.
Funding
No external funding was received for this study.
Data availability
The datasets generated and/or analysed during the current study are not publicly available due to the need to maintain the data privacy and the anonymity of participants and the confidentiality of the data. However, the datasets are available from the corresponding author on reasonable request.
Declarations
Ethics approval and consent to participate
The Institutional Ethics Committee of Al Ahli Hospital reviewed and approved this study (reference number AAH/10-2023). This study was performed in accordance with the ethical guidelines and regulations outlined in the Declaration of Helsinki and the measures of Ethical Review of Life Science and Medical Research involving Humans. Informed consent was obtained from all the participants electronically who participated in the survey. All the data collected were confidential and used only in this study.
Consent for publication
Not applicable.
Competing interests
The authors declare no competing interests.
Footnotes
Publisher’s note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Data Availability Statement
The datasets generated and/or analysed during the current study are not publicly available due to the need to maintain the data privacy and the anonymity of participants and the confidentiality of the data. However, the datasets are available from the corresponding author on reasonable request.