Insight into the knowledge, attitude and practices of hand hygiene with alcohol based hand rubs in a public sector tertiary care hospital of a developing country

Fizra Balkhi, Aamna Nasir, Ayesha Asghar, Farhan Patel, Marium Zafar, Anum Nasir


Background: Health care worker’s hands are mostly responsible for transmission of healthcare associated infections (HCAI). In such instances, alcohol based hand rubs have been endorsed by WHO as the gold standard for hand hygiene for visibly clean hands; whereas, for visibly dirty hands soap and water is recommended. In developing countries (like Pakistan), affected people frequently exceed 25%. However, limited infrastructure in these countries hinders the performance of hand hygiene, but the use of alcohol-based hand rubs in such adverse situations is a practical solution to these constraints.

Methods: In January 2021, we initiated a 12 week cross-sectional study in a public sector tertiary care hospital of Karachi, Pakistan. All participants were given a self-designed questionnaire with a consent form thereby giving us permission to use the data. Data was analyzed using statistical package for the social sciences (SPSS version 23).

Results: 84.3% of the participants had received prior instructions on hand hygiene; however 71.7% respondents did not have access to alcohol based hand rubs. When questioned if they followed WHO’s five moments of hand hygiene, only 50.5% use alcohol based hand rubs before patient contact; 88.6% used it after patient contact; 83.2% after body fluid exposure risk; 77% before an aseptic task and 78.6% after contact with patient’s surroundings.

Conclusions: There is a dire need for concerned authorities to enforce proper hand hygiene in public hospitals of developing countries in order to curb health care associated infections and prolonged hospital stays.


Healthcare associated infections, Hand hygiene, Developing country, Alcohol based hand rub, WHO, Tertiary care hospital

Full Text:



Aliyu I, Lawal T, Olawale W, Monsudi K, Zubayr B. Hand hygiene practices among doctors in health facility in a semi-urban setting. BLDE Univ J Health Sci. 2018:3(1):43-4.

Allegranzi B, Pittet D. Role of hand hygiene in healthcare-associated infection prevention. J Hosp Infect. 2009:73(4):305-15.

Magill SS, Edwards JR, Bamberg W, Beldavs ZG, Dumyati G, Kainer MA, et al. Multistate point-prevalence survey of healthcare-associated infections. N Engl J Med. 2014:370(13):1198-208.

WHO. Fact sheet: Summary/Guideline: health hygiene in healthcare, 2009. Available at: Accessed on 17 March 2021.

Centers for Disease Control and Prevention. Fact sheet: Guideline: hand hygiene in healthcare settings, 2015. Available at: Accessed on 17 March 2021.

Gold NA, Mirza TM, Avva U. Alcohol sanitizer. Treasure Island (FL): StatPearls; 2018.

Sax H, Allegranzi B, Uçkay I, Larson E, Boyce J, Pittet D. My five moments for hand hygiene': a user-centred design approach to understand, train, monitor and report hand hygiene. J Hosp Infect. 2007:67(1):9-21.

Pittet D, Allegranzi B, Storr J, Nejad SB, Dziekan G, Leotsakos A, et al. Infection control as a major World Health Organization priority for developing countries. J Hosp Infect. 2008:68(4):285-92.

Anwar MA, Rabbi S, Masroor M, Majeed F, Andrades M, Baqi S. Self-reported practices of hand hygiene among the trainees of a teaching hospital in a resource limited country. J Pak Med Assoc. 2009:59(9):631-4.

Maheshwari V, Kaore NCM, Ramnani VK, Gupta SK, Borle A, Kaushal R. A study to assess knowledge and attitude regarding hand hygiene amongst residents and nursing staff in a tertiary health care setting of Bhopal City. J Clin Diagn Res. 2014:8(8):4-7.

Bakarman MA, Baig M, Malik AA, Gazzaz ZJ, Mostafa MM, Zayed MA, et al. Hand hygiene knowledge and attitude of medical students in western Saudi Arabia. Peer J. 2019:7:6823.

Nair S, Hanumanthappa R, Hiremath S, Siraj M, Raghunath P. Knowledge, attitude, and practice of hand hygiene among medical and nursing students at a tertiary health care centre in Raichur, India. ISRN Prev Med. 2014:608927.

Hamadah R, Kharraz R, Alshanqity A, AlFawaz D, Eshaq A, Abu-Zaid A. Hand hygiene: knowledge and attitudes of fourth-year clerkship medical students at alfaisal university, college of medicine, Riyadh, Saudi Arabia. Cureus. 2015:7(8):310.

Irek EO, Aliyu AA, Dahiru T, Obadare TO, Aboderin AO. Healthcare-associated infections and compliance of hand hygiene among healthcare workers in a tertiary health facility, southwest Nigeria. J Infect Prev. 2019:20(6):289-96.

Ahmed J, Malik F, Memon Z, Arif TB, Ali A, Nasim S, et al. Compliance and knowledge of healthcare workers regarding hand hygiene and use of disinfectants. Cureus. 2020:12(2):7036.

Munir M, Maqbool M, Bilal S, Hussain M, Ghani Z, Yaqub A. Handwashing practices in health care professionals of allied hospitals of Rawalpindi medical university. Ann Pak Inst Med Sci. 2018:14(4):269-73.

Songa J, VanRoekel K, Mawangi J, Noel L. A study on handwashing practices among health care workers in Embu referral hospital, Embu County. PMMS. 2015:2(6):780-4.

Cruz J, Cruz C, Al-Otaibi A. Gender differences in hand hygiene among Saudi nursing students. Int J Infect Cont. 2015:11(4).

Basu S, Roberts C. Towards a public health curriculum in undergraduate medicine. Educ Health (Abingdon). 2012:25(2):98-104.

Boyce JM, Pittet D. Guideline for hand hygiene in health-care settings. recommendations of the healthcare infection control practices advisory committee and the HICPAC/SHEA/APIC/IDSA hand hygiene task force. Society for healthcare epidemiology of America/association for professionals in infection control/infectious diseases society of America. MMWR Recommend Rep. 2002:51:1-45.

Lam BCC, Lee J, Lau YL. Hand hygiene practices in a neonatal intensive care unit: a multimodal intervention and impact on nosocomial infection. Pediatrics. 2004:114(5):565-71.

Mathai AS, George SE, Abraham J. Efficacy of a multimodal intervention strategy in improving hand hygiene compliance in a tertiary level intensive care unit. Indian J Crit Care Me. 2011:15(1):6-15.