F1000Research F1000Research 2046-1402 F1000 Research Limited London, UK 10.12688/f1000research.13029.1 Research Article Articles Preventive Medicine Science & Medical Education 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

[version 1; peer review: 2 approved with reservations]

 Abdalrahman Ihab B. Conceptualization Data Curation Formal Analysis Methodology Project Administration Resources Supervision Writing – Original Draft Preparation Writing – Review & Editing 1 Shamat Sara Data Curation Formal Analysis Methodology Supervision Writing – Original Draft Preparation https://orcid.org/0000-0002-6677-379X 2 Mamoun Sara Data Curation Formal Analysis Methodology Writing – Original Draft Preparation 2 Abdelraheem Reem Data Curation Formal Analysis Writing – Original Draft Preparation 2 Salah Esraa Data Curation Formal Analysis Writing – Original Draft Preparation 2 Elkhalifa Mohammed Data Curation Formal Analysis Writing – Original Draft Preparation https://orcid.org/0000-0002-1149-6377 2 Farah Abduraheem Data Curation Formal Analysis Writing – Original Draft Preparation 2 Ali Duaa Data Curation Formal Analysis Writing – Original Draft Preparation 2 Abdalla Abdelmohaymin A. Data Curation Formal Analysis Methodology 2 Saeed Eman Data Curation 2 Dafaalla Mohamed Formal Analysis Methodology Software Writing – Original Draft Preparation Writing – Review & Editing https://orcid.org/0000-0003-4625-2775 a 2 Acute Care Medicine, Soba University Hospital, University of Khartoum, Khartoum, Sudan Soba Center for Audit and Research, Soba University Hospital, Khartoum, Sudan mdafaallah200@gmail.com

No competing interests were disclosed.

 11 4 2018 2018 7 449 29 3 2018 Copyright: © 2018 Abdalrahman IB et al. 2018 This is an open access article distributed under the terms of the Creative Commons Attribution Licence, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Background: In an attempt to defeat the high prevalence of health care 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.

Methods: Seventy-three participants were recruited from two public 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.

Results: Around 40% of participants worked in general ward and 85% of 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).

Conclusion: Comparing the knowledge before and after the workshop, we 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.

 Educational sessions hand hygiene infection control nurses and doctors workshop health-care associated infections The author(s) declared that no grants were involved in supporting this work. 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 Methicillin-resistant-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.

 Methods 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

 Results 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.

Demographic characteristics of the participants.
%
Ward worked in General 40.0
Private 51.4
Not applicable 8.6
Gender Female 85.9
Male 14.1
Profession Nurse/midwife 69.8
Doctor/resident 30.2
Received training in hand hygiene previously Yes 33.8
No 66.2
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.

Results of health-care associated infections questionnaire before and after an education workshop on hand hygiene.

( A) Hand disinfection topics; ( B) hand rubbing, hand washing, and accessories topics. We used McNemar’s test to compare knowledge of participants before and after the educational workshop. P values <0.05 indicates significant difference.

Table 2A
Before % After % Difference % P value Nurse/ midwife Doctors
Use alcohol handrub Yes 76.9 74.3 -2.60 0.68 81.4 57.9
No 23.1 25.7 2.60 18.6 42.1
Germ transmission between patients Healthcare workers' hands when not clean 75.8 77.5 1.70 0.31 75.0 73.7
Air circulating in the hospital 6.1 1.4 -4.70 2.3 0.0
Patients' exposure to colonized surfaces 15.2 12.7 -2.50 13.6 15.8
Sharing non-invasive objects between patients 3.0 8.5 5.50 9.1 10.5
Source of germs The hospital's water system 6.1 5.7 -0.40 0.21 4.7 10.5
The hospital air 1.5 4.3 2.80 4.7 5.3
Germs already present on or within the patient 10.6 18.6 8.00 20.9 21.1
The hospital enviroment (surface) 81.8 71.4 -10.40 69.8 63.2
Hand disinfection before touching a patient Yes 95.5 92.5 -3.00 0.37 93.0 88.9
No 4.5 7.5 3.00 7.0 11.1
Hand disinfection immediately after a risk of body fluid exposure Yes 71.2 65.0 -6.20 0.3 66.7 57.1
No 28.8 35.0 6.20 33.3 42.9
Hand disinfection after exposure to the immediate surroundings of a patient Yes 75.8 64.4 -11.40 0.17 64.1 71.4
No 24.2 35.6 11.40 35.9 28.6
Hand disinfection immediately before a clean aseptic procedure Yes 81.8 74.6 -7.20 0.3 74.4 78.6
No 18.2 25.4 7.20 25.6 21.4
Hand disinfection after touching a patient Yes 86.4 81.0 -5.40 0.581 92.9 57.1
No 13.6 19.0 5.40 7.1 42.9
Hand disinfection immediately after a risk of body fluid exposure Yes 83.1 80.3 -2.80 0.15 82.1 80.0
No 16.9 19.7 2.80 17.9 20.0
Hand disinfection immediately before a clean aseptic procedure Yes 67.7 56.7 -11.00 0.02 50.0 60.0
No 32.3 43.3 11.00 50.0 40.0
Hand disinfection after exposure to the immediate surroundings of a patient Yes 80.0 79.7 -0.30 1.0 80.5 80.0
No 20.0 20.3 0.30 19.5 20.0
Hand rubbing is more rapid for hand cleaning than hand washing True 75.8 60.3 -15.50 0.02 64.9 50.0
False 24.2 39.7 15.50 35.1 50.0
Hand rubbing causes skin dryness more than hand washing True 63.6 54.1 -9.50 0.15 57.9 50.0
False 36.4 45.9 9.50 42.1 50.0
Hand rubbing is more effective against germs than handwashing True 47.0 58.6 11.60 0.38 67.6 42.9
False 53.0 41. -11.60 32.4 57.1
Handwashing and hand rubbing are recommended to be performed in sequence True 75.8 67.8 -8.00 0.82 68.4 64.3
False 24.2 32.2 8.00 31.6 35.7
Minimal time needed for alcohol based hand rubbing to kill most of germs 20 seconds 69.7 28.4 -41.30 0.001 34.1 22.2
3 seconds 3.0 9.0 6.00 14.6 0.0
1 minute 21.2 40.3 19.10 31.7 61.1
10 seconds 6.1 22.4 16.30 19.5 16.7
Table 2B
Before % After % Difference % P value Nurse/ midwife% Doctors %
Type required before palpation of the abdomen Rubbing 50.0 43.9 -6.10 0.26 43.9 47.
Washing 43.9 53.0 9.10 53.7 47.1
None 6.1 3.0 -3.10 2.4 5.9
Type required before giving an injection Rubbing 34.8 34.4 -0.40 0.56 43.6 17.6
Washing 60.6 62.5 1.90 53.8 76.5
None 4.5 3.1 -1.40 2.6 5.9
Type required after emptying a bedpan Rubbing 24.2 38.8 14.60 0.025 41.5 33.3
Washing 71.2 59.7 -11.50 58.5 61.1
None 4.5 1.5 -3.00 0.0 5.6
Type required after removing examination gloves Rubbing 21.2 40.0 18.80 0.12 39.0 25.0
Washing 75.8 60.0 -15.80 61.0 75.0
None 3.0 0.0 -3.00 0.0 0.0
Type required after making a patient bed Rubbing 45.5 37.9 -7.60 0.33 46.3 17.6
Washing 48.5 62.1 13.60 53.7 82.4
None 6.1 0.0 -6.10 0.0 0.0
Type required after visible exposure to blood Rubbing 36.4 44.8 8.40 0.096 53.7 33.3
Washing 59.1 55.2 -3.90 46.3 66.7
None 4.5 0.0 -4.50 0.0 0.0
Avoid wearing jewellery Yes 97.0 82.5 -14.50 0.012 75.0 100.0
No 3.0 17.5 14.50 25.0 0.0
Avoid contacting damaged skin Yes 87.9 84.4 -3.50 0.267 82.5 88.2
No 12.1 15.6 3.50 17.5 11.
Avoid having artificial fingernails Yes 93.9 83.1 -10.80 0.065 77.5 88.2
No 6.1 16.9 10.80 22.5 11.8
Avoid regular use of hand cream Yes 53.0 33.9 -19.10 0.017 30.8 43.8
No 47.0 66.1 19.10 69.2 56.3
Discussion

Our study revealed that knowledge about hand hygiene and HAI is better among nurses and midwifes in comparison to doctors. Some studies concluded the same results. In a study conducted by Ameer et al. nurses were found to have a better hand hygiene compliance rate (43.08%) compared to doctors (31.25%). Another study by Han et al. revealed that nurses’ knowledge score was significantly higher than doctors 12 . On the other hand, other studies showed opposite results. For example, Ekwere et al. conducted a study in a tertiary hospital in Southwest Nigeria and concluded that doctors had no significant better knowledge of hand washing than nurses 13 .

Overall there was no significant improvement in knowledge about hand hygiene and HAI after the educational workshop. Similarly, in a study done by Lee et al. there was no significant improvement in hand hygiene compliance or alcohol-based hand rub consumption following education 10 . In contrast, a case–control 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

The data referenced by this article are under copyright with the following copyright statement: Copyright: � 2018 Abdalrahman IB et al.

Data associated with the article are available under the terms of the Creative Commons Zero "No rights reserved" data waiver (CC0 1.0 Public domain dedication).

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

Supplementary material

Supplementary File 1: Educational workshop content.

Click here to access the data.

 Creedon SA : Healthcare workers' hand decontamination practices: compliance with recommended guidelines. J Adv Nurs. 2005;51(3):208–216. 16033588 10.1111/j.1365-2648.2005.03490.x World Health Organization: Improved hand hygiene to prevent healthcare-associated infections. Patient Safety Solutions, [online]2007;1(Solution 9). Reference Source Abdraboh SN Milaat W Ramadan IK : Hand hygiene and health care associated infection: an intervention study. American Journal of Medicine and Medical Sciences. 2016;6(1):7–15. Reference Source WHO Guidelines for Hand Hygiene in Health Care: First Global Patient Safety Challenge: Clean Care is Safer Care. Reference Source van De Mortel TF Kermode S Progano T : A comparison of the hand hygiene knowledge, beliefs and practices of Italian nursing and medical students. J Adv Nurs. 2012;68(3):569–579. 21722171 10.1111/j.1365-2648.2011.05758.x Nabavi M Alavi-Moghaddam M Gachkar L : Knowledge, Attitudes, and Practices Study on Hand Hygiene Among Imam Hossein Hospital's Residents in 2013. Iran Red Crescent Med J. 2015;17(10):e19606. 26568858 10.5812/ircmj.19606 4640061 McLaws ML : The relationship between hand hygiene and health care-associated infection: it's complicated. Infect Drug Resist. 2015;8:7–18. 25678805 10.2147/IDR.S62704 4319644 Mathai E Allegranzi B Seto WH : Educating healthcare workers to optimal hand hygiene practices: addressing the need. Infection. 2010;38(5):349–356. 20857314 10.1007/s15010-010-0047-7 Ojulong J Mitonga KH Iipinge SN : Knowledge and attitudes of infection prevention and control among health sciences students at University of Namibia. Afr Health Sci. 2013;13(4):1071–1078. 24940334 10.4314/ahs.v13i4.30 4056508 Li Y Wang Y Yan D : Self-reported hand hygiene practices, and feasibility and acceptability of alcohol-based hand rubs among village healthcare workers in Inner Mongolia, China. J Hosp Infect. 2015;90(4):338–43. 25990195 10.1016/j.jhin.2015.04.006 4664070 World Health Organization: Clean Care is Safer Care, tools for evaluation of hand hygiene practices and related perception and knowledge at a health-care facility is one vital element of the strategy to improve hand hygiene. Reference Source Han K Dou FM Zhang LJ : [Compliance on hand-hygiene among healthcare providers working at secondary and tertiary general hospitals in Chengdu]. Zhonghua Liu Xing Bing Xue Za Zhi. 2011;32(11):1139–1142. 22336552 10.3760/cma.j.issn.0254-6450.2011.11.019 Ekwere TA Okafor IP : Hand hygiene knowledge and practices among healthcare providers in a tertiary hospital, south west, Nigeria. Int J Infect Control. 2013;9(4). 10.3396/IJIC.v9i4.032.13 Cook DA : Twelve tips for evaluating educational programs. Med Teach. 2010;32(4):296–301. 20353325 10.3109/01421590903480121 Abdalrahman IB Shamat S Mamoun S : Dataset 1 in: 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. F1000Research. 2018. Data Source 10.5256/f1000research.14127.r135018 Reviewer response for version 1 Liddelow Caitlin 1 Referee https://orcid.org/0000-0003-1083-5979 University of Wollongong, Northfields Ave, Wollongong, NSW, Australia

Competing interests: No competing interests were disclosed.

 4 5 2022 Copyright: © 2022 Liddelow C 2022 This is an open access peer review report distributed under the terms of the Creative Commons Attribution Licence, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. recommendation approve-with-reservations

I would like to thank the editor and the authors for allowing me the opportunity to review this paper. It addresses an important topic, hand hygiene in healthcare, which has been of particular interest the last few years. The paper is mostly well-written (some minor grammatical and language expressions that could be improved), however I am concerned by the lack of critical thinking and discussion in the introduction and discussion. There is a lot of behaviour change literature out there, lots with a focus on hand hygiene behaviours, which do not appear in this paper. There are also some details in the methods and results that should be included. I believe once my below comments have been addressed, the paper will be much improved.

Abstract:

The abstract is clear and presents all of the necessary information required for an abstract.

Introduction:

Page 3: Please provide some examples of health-care associated infections, for readers that may not be in health-care specifically.

Page 3: For consistency, please remove the second (HAIs) from the first paragraph, as you have already done this in the first sentence.

Page 3: Given the experimental study is based in Sudan, are there any statistics or figures regarding the prevalence of HAIs or HAI associated deaths in Sudan? This would be good to include in the introduction.

Page 3: Your reference/citation for this sentence/study is incorrect. You talk about an Australian study by Grayson et al. but there is not Grayson et al. in your reference list. Please fix this: “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”.

Page 3: Whilst you provide a good overview of the current literature in the hand hygiene area, there have been numerous studies that have come out since the beginning of the Covid-19 pandemic that look at hand hygiene interventions. It would be good to see some of these studies cited in your introduction.

Page 3: Your introduction lacks some critical thinking and review. I am curious as to why you have decided to do an experimental study on the impact of an education session on hand hygiene when the previous literature already shows this is effective? What is the reason for doing this study given these past studies? Is it because there are differences in the Sudanese culture that may not yield the same results as other studies? More of a rationale for why you have decided to do this specific study is needed.

Methods:

Page 3: Please provide an example question from the WHO hygiene questionnaire.

Page 3: How was this questionnaire scored? Was it a score out of 20? Did participants get separated into groups (e.g., low knowledge / high knowledge)?

Page 3: Some more information on the workshops would be useful. Was it all delivered in one day? Was it in person or online? Was it conducted in one large group at each hospital, or multiple smaller groups? Where was the content in the workshops/lectures derived from? Did the practical sessions involve watching videos, role play, etc.? If possible, matching some of the components of the workshop to Behaviour Change Techniques (see Michie et al., 2013 1 ) would be useful.

Page 3: You say you “used McNemar’s test to compare knowledge of participants before and after the educational workshop” but on page 4 under “multivariate analysis” you say that you compared between groups (doctors vs. nurses). This needs to be clearer on page 3.

Page 3: Why was McNemar’s test conducted rather than a paired samples t-test (for before vs. after) or independent samples t-test (for doctors vs. nurses)? It is unclear why you would use a McNemars test (which is used with nominal data) when it appears, or is assumed, the score from the WHO questionnaire is scale data. More information and a rationale is required.

Results:

Page 3/4: Did you collect information on how long participants had been in the profession? I would expect this would be important to know as it likely influences the results (i.e., if they have worked longer, they are more likely to have higher knowledge).

Page 4/5: Please be consistent with your reporting of percentages and p-values. Some have 1 decimal place, some have 2 decimal places and some have 3.

Page 4: It would be nice to see a combined hand hygiene knowledge score/percentage correct of participants from before the workshop to after the workshop.

Discussion:

Page 6: Please include a correct citation and reference for Ameer et al. and Han et al. in the first paragraph of your discussion. You should not be discussing studies that you have not properly referenced.

Page 6: It would be good if you included further discussion on why you/the authors think you received the results you did. In the first paragraph you provide evidence that is inline with your finding and then evidence that is the opposite. Why do you think nurses and midwives had greater knowledge compared to doctors?

Page 6: There is an abundance of literature and research that says that providing education alone is not enough to change behaviour. This may be why you did not see any significant improvements after the workshop, as it was only education based. Some discussion of this is warranted, particularly in paragraph 2. See: Arlinghaus  K. R., & Johnston, C. A. (2017). Advocating for Behavior Change With Education 2 .

Page 6: Please fix this in-text citation “Cook in the article ‘Twelve tips for evaluating educational programs’.

Page 6: More discussion of the theoretical and/or practical implications of this study is needed. For example, what do the findings tell us about hand hygiene knowledge amongst this sample, specifically in Sudan? What does it tell us about the difference between nurses and doctors?

Page 6: There is no mention of strengths or limitations, or any suggestions for future research in this area. Please consider including some.

Is the work clearly and accurately presented and does it cite the current literature?

Partly

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

Is the study design appropriate and is the work technically sound?

Yes

Are the conclusions drawn adequately supported by the results?

Yes

Are sufficient details of methods and analysis provided to allow replication by others?

No

Reviewer Expertise:

Behaviour change, health psychology, health interventions

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.

References : The behavior change technique taxonomy (v1) of 93 hierarchically clustered techniques: building an international consensus for the reporting of behavior change interventions. Ann Behav Med .2013;46(1) : 10.1007/s12160-013-9486-6 81-95 23512568 10.1007/s12160-013-9486-6 : Advocating for Behavior Change With Education. Am J Lifestyle Med .12(2) : 10.1177/1559827617745479 113-116 30283247 10.1177/1559827617745479 10.5256/f1000research.14127.r34546 Reviewer response for version 1 Creedon Sile A. 1 Referee University College Cork, Cork, Ireland

Competing interests: No competing interests were disclosed.

 25 6 2018 Copyright: © 2018 Creedon SA 2018 This is an open access peer review report distributed under the terms of the Creative Commons Attribution Licence, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. recommendation approve-with-reservations

Thank you for the opportunity to review this paper.  I hope my comments are useful to you.

Introduction: Can you check the accuracy of the figures related to HCAI in developing countries please.

Intervention: The design of the educational intervention was face to face workshop.  Given that this was the intervention, it needs to be described in much more detail.  What other types of educational interventions were considered and why was this type chosen? Can you please add a referenced section to the introduction. 

Design: The study design was quasi experimental.  The authors need to explain more fully how the study met the criteria for quasi experimentation.  Could it be more accurately described as an interventional study? 

Sample: The participants were chosen by the infection prevention staff in each hospital. How did this occur?  it needs a better explanation and the threat of bias also needs to be discussed.  It seems to me that this may lead to targeting only staff who were 'known to' or perhaps were friendly with the infection prevention team.  

Discussion: The discussion section needs to be developed more fully.  In the opening paragraph, the authors state that there was no improvement in either knowledge or prevalence of HCAI's after the workshop. Did the study measure prevalence of HCAI's before and after the work shop?  If not, then you might review making this statement.  

There is an attempt made to elucidate why the intervention did not work but it needs more than this. It would benefit from discussion of the design. Is there value in assessing knowledge immediately post intervention?  Did you consider a longitudinal design? 

Overall, there is some merit in this paper but it needs further development.

Is the work clearly and accurately presented and does it cite the current literature?

Partly

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

Is the study design appropriate and is the work technically sound?

Partly

Are the conclusions drawn adequately supported by the results?

Partly

Are sufficient details of methods and analysis provided to allow replication by others?

No

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.