Hand hygiene knowledge, attitudes, and perceptions of chiropractic students pre- and post-COVID-19 pandemic

Abstract

Objective

The objective of this study was to compare the hand hygiene knowledge, attitudes, and perceptions of chiropractic students from a graduating class before (pre-COVID-19) and after the COVID-19 pandemic (post-COVID-19) using the World Health Organization (WHO)’s standardized questionnaires.

Methods

The questionnaire was distributed to participating pre-COVID-19 (n = 55) and post-COVID-19 (n = 51) cohorts of chiropractic interns doing their clinical training at an academic institution in South Africa (May 2019 and August 2023). Frequencies, descriptive statistics, and cross-tabulations were used to describe the outcome of analysis and P = < .05 was considered the level of significance.

Results

Participants focused more on environmental contributions as a possible cause of healthcare-associated infections, rather than on the risk of poor hand hygiene among health care workers and the patient being a vector for cross-contamination. The participants may have perceived the transmission of pathogens to the patient as minimal after treatment of the patient and leaving the clinical or practice environment. Less consideration was also given to the risk of transmission to the health care worker before the commencement of treatment. An exceptionally high percentage use of alcohol-based hand rub was indicated, irrespective of whether it was pre-COVID-19 or post-COVID-19, which may be related to the physical requirements of the chiropractic environment. An increased need for peers or colleagues to be aware that hand hygiene was being performed, especially among the post-COVID-19 group, was noted.

Conclusion

A decline in hand hygiene knowledge among chiropractors as it relates to the understanding of healthcare-associated infection transmission was noted. Misconceptions and an overemphasis on surface transfer—likely influenced by COVID-19 messaging—highlight the need for re-education aligned with WHO guidelines. The low awareness of the WHO Five Moments for Hand Hygiene model points to the importance of incorporating structured training into chiropractic education.

INTRODUCTION

It has been reported that hand hygiene (HH) is the most effective way to prevent the transfer of healthcare-associated infections (HCAIs) by health care professionals.1 Specific mandatory HH practices were put in the forefront during the COVID-19 pandemic as they formed part of the prevention strategies in the transmission of the SARS-CoV-2 virus; as was social distancing and the wearing of facial masks.2 Assessing HH knowledge, attitudes, and perceptions (KAP) among health care workers (HCWs) may guide areas in need of improvement or inform on strategies for HH education and training. The World Health Organization (WHO) developed standardized tools to specifically ascertain HH KAP, including the “Hand Hygiene Knowledge Questionnaire for Health Care Workers”3 and the “Perception Survey for Health Care Workers”.4 The validity and reliability of the questionnaires have been tested and documented in the literature.5

Chiropractors use a hands-on approach in diagnosing and treating patients and focus on physical adjustments to improve basic functioning of “neuro-musculoskeletal” disorders in patients.6 The physical approach to the examination of the patient, manual adjustments, manipulative therapies, and possibly needling or strapping techniques can potentially facilitate the easy, rapid transfer and spread of pathogens.6 Research identified the presence of multidrug-resistant bacteria on chiropractors’ hands (26.9%) after they reported that HH protocols were followed as prescribed for patient interactions.7 This finding underscored the potential risk for hand-to-surface bacterial transfer, specifically highlighting the chiropractor’s environment as an additional factor where the transfer of pathogens is possible. Only 8.7% of chiropractors reported practicing HH following contact with patient surroundings, while 4.3% admitted not practicing HH during their workday.7 A study conducted by Amod et al8 demonstrated bacterial transfer from patients to chiropractors during the manipulation of the patient’s back. It was indicated that the bacterial count on the hands of some of the chiropractors was higher before commencing treatment of the patient.8 This may suggest poor HH practices between the treatment of patients, or obviously, that potential cross-contamination from previous patients or environmental sources was possible.

The COVID-19 pandemic brought about the implementation of a new set of rules, as it was indicated that primary transmission of the SARS-CoV-2-virus occurred via respiratory droplets from person to person. Frequent hand washing became compulsory during this period but adherence to these requirements after the pandemic remains a challenge. It was specified for instance that only 68% of practicing chiropractors indicated that they would continue with disinfection after the COVID-19 pandemic, and 57% intended to maintain HH practices at required COVID-19 levels.9 A survey conducted just after chiropractic students returned to campuses post the COVID-19 pandemic in South Africa, revealed that 73.2% felt that personal protective equipment was hindering them in their work, while 66.3% thought it may restrict patient care.10

The current study provided the opportunity to compare the KAP towards HH of chiropractic students after the outbreak of the COVID-19 pandemic to that of before the pandemic, utilizing the same WHO questionnaires.3,4 The purpose was to ascertain if there was any change in KAP towards HH practices or if HH practice patterns returned to pre-COVID-19 levels.

METHODS

Study Design

This was an explorative cross-sectional study design using quantitative research methods.

Ethics

Ethical approval for the study was obtained from the University of Johannesburg, Faculty of Health Sciences Research Ethics Committee (REC-241112-035) and approval was received from the University of Johannesburg to conduct the study, as enrolled students at the institution were participating in the study. All tenets of the Declaration of Helsinki were followed.

Participants

The study was employed in 2019 and 2023 to investigate the KAP of HH of chiropractic interns at the University of Johannesburg Chiropractic Clinic (UJCC) during the pre- and post-COVID-19 period. All first- and second-year students, registered for the master’s degree in chiropractic at the University of Johannesburg doing clinical training, were invited to participate in the study (2019: n = 64; 2023: n = 58).

Survey Tool

A combined KAP questionnaire consisting of the WHO “Hand Hygiene Knowledge Questionnaire for Health Care Workers”3 and the “Perception Survey for Health Care Workers”4 was used to gather data for both groups. The 2019 cohort received printed copies, while the 2023 cohort was sent a link via WhatsApp Messenger to complete the questionnaire. In both groups consent to participate in the study was obtained before the KAP questionnaire was completed. Three questions specifically about chiropractic were added to the questionnaire for the post-COVID-19 study. These were “Have you heard of the 5 Moments for Hand Hygiene?”; “How many steps would you have done in the early stage of the pandemic?” and “How many steps would you have done in the UJCC?”. An additional option of “I don’t know” was also added to selected knowledge questions for the “post-COVID-19” group, which was not an option in the initial pre-COVID-19 study.11

Statistical Analysis

The data were prepared, screened, coded, and analyzed using IBM SPSS Statistics v29.0.0. (2023, Armonk, NY). Data were analyzed using nonparametric methods of analysis (Fisher exact test) and tests of normality were completed. Cross tabulations, frequency tables, and comparative analyses were completed related to the data of the pre- and post-COVID-19 groups. In all calculations, P < .05 was considered as the level of significance and the effect size between the variables was determined.

RESULTS

The demographic information of the pre- and post-COVID-19 groups is shown in Table 1. Fifty-five and 51 of the potential participants completed the questionnaire in the pre- and post-COVID-19 groups. The response rates were 85.9% and 87.9%, respectively. Although the 2 groups had similar average ages, there was a shift towards females in the post-COVID-19 group.

Table 1.

Demographics of the pre- and post-COVID-19 participants

	Pre-COVID-19 (n = 55)	Post-COVID-19 (n = 51)
Sex
Female	33 (60%)	39 (76.5%)
Male	22 (40%)	12 (23.5%)
Age (y)	24.65 (SD ± 2.084)	24.96 (SD ± 2.341)

The first general question was aimed at determining whether the participants had received any formal training in HH within the past 3 years. Among the pre-COVID-19 group, 78.2% reported having received formal training, whereas only 70.2% of the post-COVID-19 group indicated the same response. There was, however, no statistically significant difference between the responses of the 2 groups (P = .37). The second question probed students’ use of alcohol-based hand rub (ABHR) for routine HH. In this instance, the results were equal between the 2 groups, with 94.5% of the pre-COVID-19 group and 94.1% of the post-COVID-19 group reporting regular ABHR use.

As both the “Hand Hygiene Knowledge Questionnaire for Health Care Workers” and the “Perception Survey for Health Care Workers”3,4 were utilized, the results pertaining to HH knowledge will be presented first.

Hand Hygiene Knowledge

The main route of cross-contamination of potentially harmful pathogens between patients in a health care facility is due to inadequate HH performed by the HCW.12 With the pre-COVID-19 group, only 29.1% (n = 16) correctly identified this route of transmission, and 21.6% (n = 11) in the post-COVID-19 group. A higher proportion of participants indicated the incorrect answer following the pandemic (78.4%). There was no statistical difference between the 2 groups (P = .83). The majority of participants in both groups selected the incorrect option of “patients’ exposure to colonized surfaces” with 60% of the pre-COVID-19 group and 58.8% of the post-COVID-19 group opting for this choice.

The next question addressed the most frequent source of pathogens that may be responsible for HCAIs. This may be attributed to “germs already present on or inside the patient.”12 Only 29.1% (n = 16) of the pre-COVID-19 group and 25.5% (n = 13) of the post-COVID-19 group answered correctly to identify the source. The majority of participants in both groups indicated that “the hospital environment (surfaces)” may be the major source for HCAIs (61.8%; n = 34 for pre-COVID-19 and 62.7%; n = 32 for post-COVID-19). This can be interpreted as contamination of the clinical environment that the chiropractor works in. During the COVID-19 pandemic, great emphasis was placed on surface disinfection, as it was reported that the SARS-CoV-2 virus may spread by other means, including that of “porous” and “nonporous” surfaces.13 It may have impacted misperception regarding the primary source associated with HCAIs.

When the groups were asked about the minimum required time for ABHR to kill most pathogens on their hands, 34.5% in the pre-COVID-19 group indicated that 20 seconds12 is required, compared with only 17.6% of the post-COVID-19. There was a statistically significant difference between the responses of the 2 groups (P = .04; φ = −0.192). Participants post-COVID-19 (72.5%) indicated that 1 minute was necessary for an ABHR to effectively kill all pathogens on the HCW’s hands.

When asked about the validity of the statement relating to ABHR and handwashing with soap and water, participants had to indicate if the statement “Hand rubbing is more effective against germs than handwashing” was true or false. According to the WHO¹² guidelines, the statement is true. Among the pre-COVID-19 group, 54.5% correctly identified the statement, but this decreased to only 15.7% among the post-COVID-19 group. A statistically significant difference was determined (P = .00) with a medium effect size (φ = −0.405), as the majority of the post-COVID-19 group believed the statement to be “false”. This finding may link to some extent that 72.5% of the post-COVID-19 group incorrectly indicated that 1 minute was needed for ABHR as an effective HH measure. The post-COVID-19 group possibly did not believe that hand rubbing was a good HH option to get rid of pathogens, which seems counterintuitive given the COVID-19 HH training provided. Furthermore, a statistically significant difference (P = .02) with a small effect size (φ = −0.240) was obtained related to the answer whether hand rubbing would cause greater skin dryness than hand washing. The majority of the post-COVID-19 group (80.4%) indicated that hand rubbing would cause skin dryness, which is a false statement.12

The WHO framework “My 5 Moments for Hand Hygiene” (5MHH) includes 5 instances where HH should be performed: before touching a patient, before a clean/aseptic procedure, after body fluid exposure risk, after touching a patient, and after touching patient surroundings.14 The post-COVID-19 group was specifically asked about their knowledge of the 5MHH model. Only 23.5% of this group indicated that they were aware of the model, while 76.5% indicated no knowledge. The next questions asked were based on HH practices relating to this model and are aimed at preventing the transmission of pathogens to the patient (Table 2) and the HCW (Table 3). As indicated in Table 2, both the pre- and post-COVID-19 group answered incorrectly to the options “immediately after a risk of body fluid exposure” and “after exposure to the immediate surroundings of a patient”. No statistically significant difference was obtained between the responses of the 2 groups. It would appear from the answers that the participants may have perceived the risk of HCAIs to the patient as minimal after treatment of the patient and after the patient left the clinical or practice environment.

Table 2.

Answers related to the hand hygiene actions that may prevent transmission of pathogens to the patient

	Pre-COVID-19 (n = 55)			Post-COVID-19 (n = 51)
	Yes	No	I don’t know	Yes	No	I don’t know
Before touching a patient	96.4%*	3.6%	0%	90.2%*	3.9%	5.9%
Immediately after a risk of body fluid exposure	87.3%	12.7%*	0%	84.3%	13.7%*	2.0%
Immediately before a clean/aseptic procedure	87.3%*	12.7%	0%	80.4%*	15.7%	3.9%
After exposure to the immediate surroundings of a patient	78.2%	21.8%*	0%	70.6%	25.5%*	3.9%

^*The correct answer according to the World Health Organization.12

Table 3.

Answers to the hand hygiene actions preventing transmission of pathogens to the health care worker

	Pre-COVID-19 (n = 55)			Post-COVID-19 (n = 51)
	Yes	No	I don’t know	Yes	No	I don’t know
After touching a patient	90.9%*	9.1%	0%	84.3%*	13.7%	2.0%
Immediately after a risk of body fluid exposure	92.7%*	7.3%	0%	90.2%*	7.8%	2.0%
Immediately before a clean/aseptic procedure	78.2%	21.8%*	0%	80.4%	15.7%*	3.9%
After exposure to the immediate surroundings of a patient	87.3%*	12.7%	0%	70.6%*	25.5%	3.9%

^*The correct answer according to the World Health Organization.12

Table 3 presents the answers to the question regarding which HH actions may prevent the transfer of pathogens to the HCW. The risk of transmission to the HCW would be less before the commencement of a procedure if the relevant HH practices are performed as stipulated. Appropriate knowledge was indicated in terms of prevention of transfer to the HCW after completing a procedure, after possible exposure to body fluids, and after leaving the patient environment. Knowledge of exposure to pathogens before a clinical procedure was low (21.8% pre-COVID-19) and even lower post-COVID-19 (15.7%). No statistically significant difference was obtained between the 2 groups.

The participants’ knowledge of appropriate HH practices for specific clinical procedures (Table 4) to be performed and relevant practices associated with a possible increase in pathogenic colonization (Table 5) were also evaluated. Analysis of responses (Table 4) revealed a statistically significant difference (P = .05) between groups, with a higher proportion of the post-COVID-19 group correctly recognizing that handwashing is necessary after visible blood exposure, instead of hand rubbing. However, the effect size was small (φ = 0.186). More participants in the post-COVID-19 group indicated that hand washing is appropriate after needling a patient (66.7%) than was the case for the pre-COVID-19 group (45.5%). According to the WHO,12 hand rubbing would be the appropriate action. A statistically significant difference (P = .02) was found.

Table 4.

Hand hygiene actions required to be performed

	Pre-COVID-19 (n = 55)				Post-COVID-19 (n = 51)
	Rubbing	Washing	None	I don’t know	Rubbing	Washing	None	I don’t know
Before abdominal palpation	58.2%*	41.8%	0%	0%	54.9%*	33.3%	7.8%	3.9%
After removing examination gloves	58.2%*	34.5%	7.3%	0%	52.9%*	39.2%	3.9%	3.9%
After visible exposure to blood	27.3%	70.9%*	1.8%	0%	9.8%	86.3%*	0%	3.9%
Before needling a patient	54.5%*	45.5%	0%	0%	31.4%*	66.7%	0%	2.0%

^*The correct answer according to the World Health Organization.12

Table 5.

Hand hygiene practices that are associated with an increased likelihood of pathogenic colonization

	Pre-COVID-19 (n = 55)			Post-COVID-19 (n = 51)
	Yes	No	I don’t know	Yes	No	I don’t know
Wearing jewelry	80%*	20%	0%	88.2%*	3.5%	7.8%
Damaged skin	90.9%*	9.1%	0%	98%*	0%	2.0%
Artificial nails	90.9%*	9.1%	0%	88.2%*	3.9%	7.8%
Regular use of hand cream	58.2%	41.8%*	0%	45.1%	35.3%*	19.6%

^*The correct answer according to the World Health Organization.12

Table 5 consists of the responses relating to which HH practices may be associated with an increased likelihood of pathogenic colonization. No significant difference was seen between the 2 groups, although the post-COVID-19 participants were more aware of colonization when wearing jewelry, as well as when the skin is damaged. More students post-COVID-19 were also of the opinion that regular use of hand cream would increase the risk of colonization (64.7%) opposed to 58.2% pre-COVID-19, though not statistically significant. The use of hand cream does not increase the likelihood of pathogenic colonization.14

Perception of Hand Hygiene

Concerning the perception of HH, participants were asked to evaluate if HH was effective in the prevention of HCAIs. Response options included “very low,” “low,” “high,” and “very high” with the post-COVID-19 group having the additional option of “I don’t know”. Figure 1 illustrates the perceptions of the 2 groups. More pre-COVID-19 participants considered HH to be highly effective against HCAIs than the post-COVID-19. Statistical analysis revealed no significant difference between the 2 groups.

Figure 1.

The effectiveness of hand hygiene in preventing healthcare-associated infections.

The questionnaire also probed the perception of participants regarding the impact of HCAIs on the clinical outcome of the patient. This is a critical consideration in any health care profession, as the health care practitioner can serve as an intermediary in pathogen transfer if proper HH practices are not adhered to. Figure 2 presents the responses related to the perceived impact of HCAIs on the clinical outcome of the patient. For statistical analysis purposes, the responses “very low” and “low” were grouped, as were “high” and “very high”. A statistically significant difference (P = .004) was obtained between the responses of the 2 groups. A greater proportion of pre-COVID-19 participants thought that HCAIs could have a high/very high impact on the patient’s clinical outcome (96.3%) compared with 75.6% of the post-COVID-19 group. This finding is particularly interesting in the context of the COVID-19 pandemic as knowledge transfer regarding infection control and prevention would have been expected to reinforce the importance of HCAI in clinical settings.

Figure 2.

Perception relating to the impact of healthcare-associated infections on the patient’s clinical outcome.

The concept of patient safety and the importance that the institution attaches to it was regarded as a high to very high priority for both groups, with the pre-COVID-19 (67.3%) and post-COVID-19 (70.6%) group, respectively, indicating this level of priority. Although the difference between the groups was not statistically significant, it is good to note that a perceived increase was reported related to patient safety by the institution following the COVID-19 pandemic.

A Likert scale was used (1 = no importance and 5 = very high importance) when the participants were asked regarding the importance their peers/colleagues would attach to the fact that HH was being performed. This question would relate to the attitude toward the practice of HH. A total of 74.6% of the pre-COVID-19 group attached a high or very high importance to the fact that their peers/colleagues should be aware that HH practices were being performed. This percentage dropped slightly to 72.6% for the post-COVID-19 group. The same Likert scale was employed when the groups were asked if patients would attach any importance to the fact that HH would be performed. In the pre-COVID-19 group, 67.3% of participants considered this aspect important, whereas the post-COVID-19 group demonstrated a slight increase in this perception, with 72.6% acknowledging the significance of patient awareness regarding HH practices.

DISCUSSION

We compared the KAP towards HH of the pre-COVID-19 groups with those of the post-COVID-19 group to determine whether the heightened awareness of HH requirements during the pandemic period persisted post-COVID-19, and whether the knowledge gained from training, the institution and public health media campaigns resulted in any behavioral changes and remained at pre-COVID-19 levels. Some important trends and areas requiring attention in HH education were revealed. The results highlight both the gaps and shifts that the advent of the pandemic may have influenced.

This survey study shows a shift towards female participants, similar to a perceived behavioral modifications study during COVID-19 in South Africa,10 where most of their respondents were also female. A study on hygiene behavior of chiropractors before, during and after COVID-19 in South Africa also reported a slight shift towards female chiropractors.15 It may be indicative of enrollment patterns at the institution or certain trends within the chiropractic profession but is unlikely to significantly influence knowledge or perceptions of HH.

A slight decline in the percentage of participants who received formal HH training in the post-COVID-19 group (8%) was contradictory to what was expected. Considering that this questionnaire was completed after the COVID-19 pandemic, which was characterized by a period of increased awareness and education regarding infection control measures, it was anticipated that the post-COVID-19 group would report a higher level of HH training, compared with pre-COVID-19. It is worth noting that this was still a high percentage of formal training reported. However, the lack of a statistically significant (P = .37) difference suggests that the reduction may not have been substantial enough to indicate a systematic decline in HH training at the institution, but a possible gap in formal HH education or a possible variation in the interpretation of the concept of “formal training”. Constantinou et al16 reported that in Cyprus, for example, 77.3% of physicians, 51.8% of nurses, and 85.2% of physiotherapists had not received HH training in the preceding 3 years, reflecting a substantial gap in professional education. It was emphasized by Miraglia et al7 that HH training should be integrated into formal chiropractic education, given the potential role that the chiropractor’s practice environment can play in the transmission of HCAIs.

Both groups reported exceptionally high use of ABHR, which correlates with chiropractic requirements in terms of patient interaction (human-to-human contact through manipulation and adjustments), but also concerning infection control protocols in the clinical or practice settings. It is also suggestive of good clinical and professional standards, irrespective of HH requirements mandated during the COVID-19 pandemic. The WHO14 still indicates that ABHR remains the choice in all clinical environments according to the 5MHH model. The use of ABHR remains very high for the groups studied in comparison with a study completed at a public hospital in Pakistan, for example, where it was indicated that 71.7% of participants did not have access to ABHR.17 Miraglia et al7 reported that 47.8% of chiropractors did not use ABHR in their practices, and Casaroto et al18 reported that no significant increase was observed during the COVID-19 pandemic in relation to the use of ABHR in an ICU unit.

The substantially high use of ABHR may be unique to the chiropractic profession due to the hands-on approach and may not be as high in other health care professions. It was, however, reported by the post-COVID-19 group that hand-rubbing (with ABHR) would cause skin dryness, which is not a true statement according to the WHO.12 It is in stark contrast with the high reported use of ABHR. A much higher knowledge level regarding ABHR use and skin dryness among the last semester nursing students and registered nurses (90%) and 68% among first semester students were reported in a study in 2024.19

From the results it appears that participants are focused on environmental causes as possible sources of HCAI, not considering the contribution of poor HH of the HCW, contrary to their reported high use of ABHR. Less than 30% in both groups correctly identified inadequate HH by the HCW as the main cause for cross-contamination. It was indicated that the “patients’ exposure to colonized surfaces” may be the source of HCAI. This argument may be supported by Puhl et al20 who found that the hand rests and face pieces (not covered by paper) of the chiropractic beds may be reservoirs for the collection of bacteria, in particular, Staphylococcus aureus. D’Alessandro et al21 reported that medical and nursing students in Italy also indicated that the environment is the source for HCAI, instead of the hands of the HCW, which corresponds with the current study. Suleyman et al,22 however, reported that environmental contamination and HCAI were linked to cross-contamination from the HCW, but also directly from the patient.

Only 29.1% (pre-COVID-19) and 25.5% (post-COVID-19) correctly identified “germs already present on or inside the patient” as the primary source of pathogens responsible for HCAIs, with most (61.8%, pre-COVID-19; 62.7%, post-COVID-19) incorrectly choosing the hospital environment (surfaces) as the cause for HCAIs. These findings suggest a persistent overemphasis on surface transfer, likely amplified by COVID-19 messaging about the lifespan of the virus on inanimate objects.13 This mistake may divert focus from the critical role of HCW HH in preventing HCAIs. The results also compared with a study by Ntaote et al23 in Lesotho where only 22% of student nurses indicated that HCAIs were caused by “germs already present on or inside the patient”. It identifies a critical gap in terms of HH education and infection control measures as it pertains to patient-to-HCW transfer, rather than surface transfer.

Significant differences emerged in terms of knowledge about ABHR efficacy, with less than a fifth of the post-COVID-19 group correctly identifying 20 seconds as the minimum time required for ABHR to take effect. Pires et al24 indicated that there was no significant difference between ABHR use for 10, 15, 20 seconds, and after 30 seconds. The knowledge level is low in comparison to that reported by Ntaote et al23 where 56% of student nurses indicated the correct time needed for ABHR to be effective. Knowledge of the WHO’s 5MHH was notably low, with only 23.5% of the post-COVID-19 group being aware of the model. Both groups struggled with identifying appropriate HH actions to prevent pathogen transmission to patients (Table 2) and HCWs (Table 3). Prevention of transmission of pathogens to the HCW before a clinical procedure equates to protecting the patient by not introducing a pathogen into a clean environment with similar levels for both groups understanding this risk. The same low perception of risk was reported by Ntaote et al23 where student nurses (20%) recognized the importance of HH compliance by the HCW before a procedure. Chang et al25 reported that HH compliance of HCW was much higher after a procedure was completed than before it commenced. The errors reported pre- and post-COVID-19 may indicate a lack of understanding of the need for the 5MHH, particularly the distinction between protecting the patient and the HCW, which is critical given the close contact in chiropractic settings. Enhanced training incorporated into the chiropractic curriculum is suggested that reviews the WHO 5MHH framework, together with evidence-based HH guidelines to improve clinical standards in patient care as it applies to chiropractic in specific.

A decline was observed (96.3% pre-COVID-19 vs 75.6% post-COVID-19) in perceptions of HCAIs and patient outcomes. This is concerning, given that the pandemic should have heightened participants’ awareness and vigilance regarding infection control procedures at the time. It may speak to a desensitization concerning the impact of HCAIs in general or possibly that participants did not consider the effect of HCAIs on the patient’s clinical diagnosis and treatment outcome.

Both groups rated peer awareness of HH practices as highly important, while patient awareness of HH actions was rated higher by the post-COVID-19 group. When HH practice adherence was evaluated in the presence of other HCWs,26 it was found that when a HCW was alone, HH compliance was only 20.85%, whereas it was 27.9% when other HCWs were present.26 Ntaote et al23 also reported that student nurses attached high importance (71%) to colleagues being aware that HH is being performed, while 50% indicated that it would be important for patients to see the HH actions being completed. The need for peer/colleague awareness should be further investigated and patient feedback regarding HH actions can be incorporated as a mechanism for improvement of patient care. Ongoing assessment of knowledge and perceptions can be instituted to determine and address gaps in the practice of HH.

Limitations

Participants were restricted to registered students in specific study years at the relevant University, limiting the sample size and restricting generalization to other health care students, professions or institutions. It was a cross-sectional, non-longitudinal study, where changes cannot solely be attributed to the impact of the COVID-19 pandemic. The study used only 1 tool to analyze knowledge and perceptions about HH. No observational component was completed to determine the application of this knowledge in practice. The high use of ABHR may not reflect the correct technique required or compliance with the WHO moments. Variation in questionnaire structure, including the “I don’t know” response option for the post-COVID-19 group only, may have introduced inconsistencies in responses between groups.

CONCLUSION

The results indicate a decrease in HH knowledge as it applies to the efficacy of ABHR and the minimum required time to be effective. There was a perceived misconception in terms of the source of HCAIs and their transmission routes, both in the pre- and post-COVID-19 groups. These gaps are concerning, especially as it relates to chiropractors, due to their close and direct patient contact, increasing the HCAI risk if HH is inadequate. The overemphasis on surface disinfection and fomite transfer may have been associated with the constant messaging from COVID-19 campaigns as it pertained to surface cleaning. This may warrant re-education targeted at aligning knowledge and perceptions according to WHO guidelines. The low awareness of the WHO 5MHH model underscores the need for structured training in the chiropractic curriculum (theoretical and physical), addressing the identified gaps and areas for improvement. The increased use of ABHR pre- and post-COVID-19 may be related to the requirements for the specific procedures being completed by the chiropractor, and not necessarily an indication of the widespread use of ABHR in clinical practice. The importance of peer awareness as it relates to HH practices is an area for future research to be investigated.

DECLARATIONS

Competing Interests

The authors declare no competing interests.

Data Availability

Data are available from the corresponding author upon reasonable request.

Artificial Intelligence

Artificial intelligence was not used to prepare this paper.

Contributorship

Concept development: TGB, MR. Design: TGB, MR. Supervision: MR, TGB. Data collection/processing: NM, MR, TGB. Analysis/interpretation: MR, TGB, NM. Literature search: MR, NM, TGB. Writing: MR, TGB. Critical review: MR, TGB.

Funding Statement

Funding No funding was received for this study.