Educational sessions may not be enough to improve knowledge about hand hygiene : Assessing the knowledge about hand hygiene of health workers before and after an educational workshop in Sudan

In an attempt to defeat the high prevalence of health care Background: associated infections, by raising the awareness about hand hygiene, we implemented a quasi-experimental study as part of a quality improvement project to evaluate the efficacy of focused educational workshop on knowledge about hand hygiene among health care workers in Sudan. Seventy-three participants were recruited from two public Methods: hospitals and one private hospital in Khartoum, Sudan in September 2017. The knowledge before and after the educational workshop was assessed for each participant using the World Health Organization hygiene associated infection questionnaire. We analyzed data using SPSS v22 and used McNemar’s test to compare knowledge before and after the workshop. Around 40% of participants worked in general ward and 85% of Results: them were women. Almost 70% were midwives or nurses. The mean age of participants was 28.4 years. We compared the knowledge of hand hygiene between nurses and doctors before the workshop, and the results showed that nurses had better knowledge in almost all aspects of hand hygiene. When we compared the knowledge before and immediately after the workshop for all participants, we found that there was no significant improvement in almost all aspects of knowledge about hand hygiene (P>0.05). Comparing the knowledge before and after the workshop, we Conclusion: found no significant improvement in almost all aspects of hand hygiene. Of note, nurses’ knowledge about hand hygiene was consistently higher than doctors. Additional studies are needed to identify the optimal design of educational sessions.


Introduction
Health-care associated infections (HAIs) are regarded as a major health problem endangering hospital-admitted patients in particular 1 . In developed countries, 5-15% of hospitalized patients were at risk to acquire infections, especially those admitted to intensive care units; HAIs in Europe and USA were 4.6-9.3% and 4.5%, respectively 2 . In contrast, the prevalence in some developing countries is as high as (19.1-14.8%) 3 . Health care associated infections (HAIs) results in prolonged hospital stay as it can add 18-24 days to the length of hospital stay and may result in more deaths. For instance, in Europe HAIs are responsible for 50,000-135,000 deaths out of 5,000,000 cases of HAIs, annually 4 . Moreover, it contributes to €13-24 billion of added healthcare costs 5 . All these facts highlight the morbidity and mortality from HAI.
Hand hygiene is a general term, referring to any action of hand cleansing using water and detergent and/or the use of alcohol-based hand sanitizers for the removal of transient microorganisms from hands 6 . It is widely accepted that improved hand hygiene compliance contributes to the prevention of HAIs 7 . This consensus has been supported by several studies. For example, a hand hygiene culture changing program was conducted by Grayson et al. (2008) over two years in six Australian hospitals. This study demonstrated that the incidence of Methicillinresistant-Staphylococcus aureus (MRSA) bacteraemia and the number of MRSA-positive clinical isolates were significantly reduced at the end of the study period 5 . Hand hygiene is found to be the single most effective measure to guard against healthcare-associated pathogens 8 .
There are various educational methods adopted to improve knowledge about hand hygiene as a key element to control HAI. For instance knowledge about hand hygiene could be included in the curriculum for medical and nursing students 9 . Another way is by taking advantage and to introduce the appropriate knowledge about hand hygiene to health care professionals gathered at conferences and professional meetings 8 . In addition educational workshops and sessions about hand hygiene among hospital staff should be arranged from time to time 8 . Lastly, educational hand-outs and posters about hand hygiene should be available in the working environments of health workers 1 .
Implementation of different approaches regarding boosting hand hygiene knowledge shows a wide range of variability in the efficacy between educational and interventional approaches. Hand hygiene compliance improvement has been shown to be greater using educational approaches than practical interventions 10 . For instance, after delivery of an educational hand-out and poster campaign the rate of study participant complying with hand-washing guidelines was 83% 1 . In addition, after two years of commencement of The Australian National Hand Hygiene Initiative in 2009, hand hygiene compliance increased from 43.6% to 67.8% 7 . Thus, giving educational lectures and workshops about hand hygiene practice appeared to have a noticeable impact on the knowledge and practice of hand hygiene among health care workers in these settings.
This study aimed to evaluate the knowledge about hand hygiene among heath care workers in Sudan. In addition, we assessed the role of an educational session as a recommended tool to improve the knowledge about hand hygiene among these same health care workers.

Ethical approval
Ethical approval was obtained from Soba University Teaching Hospital and Soba Centre for Audit and Research (approval no S248). All participants were fully informed about the workshop and the study prior to participation. Written consent was obtained from all participants for participation.

Study design
We implemented a quasi-experimental study as part of a quality improvement project designed and implemented by Soba University Hospital, University of Khartoum, to evaluate the efficacy of focused educational workshop on knowledge about hand hygiene among health care workers.
All health care providers in departments of emergency and internal medicine (73 participants) were recruited from two public hospitals (Soba Teaching Hospital and Saad Abuelela Hospital) and one private hospital (Fedail Hospital) in Khartoum, Sudan, in September 2017. Participants were recruited by the departments of infection control in their hospitals to enrol in this quality improvement project. Their knowledge before and after the educational workshop (see below) was assessed using the World Health Organization (WHO) HAI questionnaire.

WHO hygiene associated infection questionnaire
The questionnaire is composed of 20 single best answer questions. The first seven questions assess demographic variables; hospital name, ward, age, gender, profession, and previous hand hygiene training. The remaining questions assess different aspects of knowledge about hand hygiene 11 .

Educational workshop
The educational workshop was composed of lectures and practical sessions delivered over eight working hours (see Supplementary File 1). The workshop was delivered by a qualified instructor who has completed a PhD on infection control. The knowledge about hand hygiene measures was delivered mainly through lectures, while the practical sessions focused on training about proper hand washing technique according to the WHO 11 .

Statistical analysis
We analyzed data using SPSS v22. We used McNemar's test to compare knowledge of participants before and after the educational workshop

Descriptive statistics
Around 40% of participants worked in general ward and 85.9% of them were women. Almost 70% were midwives or nurses. The mean age of participants was 28.4 years. Table 1 shows the demographic characteristics of the participants.

Multivariate analysis
We compared the knowledge of hand hygiene between nurses and doctors, and the results showed that nurses had a better knowledge in almost all aspects of hand hygiene. When we compared the knowledge immediately after the workshop we found out that there was no significant improvement in almost all aspects of knowledge about hand hygiene (P>0.05). Table 2 illustrates these findings in more details. The text in bolds are the correct answers. P values in bold are the significant probabilities.     10 . In contrast, a casecontrol study that evaluated the effect of using educational activities and posters on hand hygiene compliance revealed a significant improvement in hand hygiene compliance compared to control hospitals 8 . Similarly, Abdraboh et al. (2012) concluded that performing educational sessions was among the most important activities to attain better health care worker hand hygiene compliance 3 .
But why didn't we improve hand washing knowledge after administration of the workshop? This could be attributed to deficiency in contents, environment, and teaching methods. Regarding teaching methods; the lecture duration was 3 hours which may not only make some of the candidates fail to follow the instructor but may also make it difficult for the instructor to stay focused. Moreover, the large number of participants (n=73) might make it difficult for instructors to deliver effective education. The present result might be of help to alert instructors to review their teaching methods and these results emphasize the importance of feedback in improving learning methods. Cook in the article 'Twelve tips for evaluating educational programs' strongly advises that instructors should seek evaluation from stakeholders such as students and administrators. In addition, designing and validating an evaluation tool to evaluate the quality and effectiveness of educational programs would be of great help because it enables reliable evaluation and monitoring of the progress of the program 14 .

Conclusions
In conclusion, to meet the objectives of educational workshops we recommend that contents should be revised and cover all the hand hygiene guidelines that are stated by WHO. In addition, taking into consideration the language factor in delivering the information in understandable language to all participants. Lastly, the number of participants as well as the duration of the workshop should be reduced to a level that facilitates proper information delivery.

Data availability
Dataset 1: Participant responses to the WHO handwashing questionnaire data before and after the educational session. DOI 10.5256/f1000research.13029.d199687 15

Competing interests
No competing interests were disclosed.

Grant information
The author(s) declared that there were no grants involved in supporting this study.

Is the study design appropriate and is the work technically sound? Partly
Are sufficient details of methods and analysis provided to allow replication by others? No

If applicable, is the statistical analysis and its interpretation appropriate? Partly
Are all the source data underlying the results available to ensure full reproducibility? Yes

Are the conclusions drawn adequately supported by the results? Partly
No competing interests were disclosed.

Competing Interests:
Reviewer Expertise: My area of research is in infection prevention in acute care settings I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard, however I have significant reservations, as outlined above.
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