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\def\RunningAuthor{Lata Kanyal Butola et al.}
\firstPage{2726}
\articleType{Original Article}
\receivedDate{11 Nov 2020}
\acceptedDate{17 Dec 2020}
\revisedDate{12 Dec 2020}
\journalVolume{2020, 11 (SPL4)}
\journalDoi{ijrps.v11iSPL4.4546}
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\title{\textbf{Knowledge, Attitude and Practice regarding hand hygiene among Medical Students and Nurses - A questionnaire based survey in tertiary care hospital}}
\author{Deepika~Kanyal\textsuperscript{1}, 
            Lata~Kanyal~Butola\textsuperscript{*}\textsuperscript{2}~\\[5pt]{\textsuperscript{1}Department of Hospital Administration, Jawaharlal Nehru Medical College, Datta Meghe Institute of Medical Sciences, Sawangi, Wardha, Maharashtra, India}~\\{\textsuperscript{2}Department of Biochemistry, Jawaharlal Nehru Medical College, Datta Meghe Institute of Medical Sciences, Sawangi, Wardha, Maharashtra, India}}

\begin{abstract}
Hand hygiene is a milestone to control infectious diseases and prevent cross transmission of microorganism and reduces the incidence of healthcare associated infections, improved hand hygiene practice has been recognized as an important public health measure. The study was carried out in a Tertiary care teaching hospital over a period of three months. A total two seventy six (276) students were included in this study. A descriptive approach was adopted, including collection of information through questionnaire based survey. Structured knowledge questionnaires were prepared according to W.H.O. criteria. The present study concluded that the knowledge regarding hand hygiene was found to be average, 186 (67.4\%) of the medical students and nurses attending tertiary care hospital, whereas 190 (68.8\%) had average score for attitude of hand hygiene and 173 (62.7\%) had average score for practice of hand hygiene. So frequent orientation, regular training, workshops, seminars and hand hygiene education should be given mandatory for all the students and staffs for understanding the importance of hand hygiene were improved hand hygiene practice should reduce the healthcare cost which help in preventing hospital acquired infections. 
\end{abstract}\def\keywordstitle{Keywords}

\begin{keywords}Hand Hygiene,\newline Knowledge,\newline Attitude and Practice,\newline Nurses and Medical Students
\end{keywords}
\twocolumn[ \maketitle {\printKwdAbsBox}]
\makeatletter{\raggedright\textsuperscript{*}Corresponding Author\par Name:\ Lata~Kanyal~Butola~\\ Phone:\ 7892390212~\\  Email:\ kanyallata1010@gmail.com
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\section{Introduction}
According to the World Health Organization, Hand hygiene is a common term which is applicable to hand washing, antiseptic hand rub, antiseptic hand wash or surgical hand antisepsis. \unskip~\citep{982918:21217381} Hand Hygiene helps in preventing cross-transmission of microorganism and controlling the prevalence of healthcare associated infections. The most appropriate hand hygiene behaviour is considered as the keystone for preventing health care associated infections. \unskip~\citep{982918:21217378,982918:21217383} The World Health Organization (W.H.O.) has introduced the concept of ``My five moments for Hand hygiene'' for Global Patients Safety Challenges, it includes:-


  
  \begin{enumerate}
  \item \relax Moments before touching a patient
  \item \relax Before performing aseptic and clean procedures 
  \item \relax After being at risk of exposure to body fluids
  \item \relax After touching a patient
  \item \relax After touching patient and surrounding
  \end{enumerate}
  So the application and adherence to hand hygiene practices can prevent Healthcare Acquired Infections (HAI). \unskip~\citep{982918:21217385} This concept of hand hygiene is used to improve, training, understanding, monitoring and reporting hand hygiene among the Health Care Workers. It is recommended in all National and International Infection Control Guidelines. \unskip~\citep{982918:21217389}

The major cause of mortality and morbidity in admitted patients is due to Health care associated infections (HAI) contributing to 7-10\% of the total hospital infections.\unskip~\citep{982918:21217387}\ensuremath{^{}} The significance of hand hygiene first identified in 1840s by Dr. Oliver Wendell Holmer to prevent Childbed fever.\unskip~\citep{982918:21217382}\ensuremath{^{}} Later Ignaz Semmelweis introduced the concept of Hand hygiene and antisepsis by demonstration that the contaminated hand cleansing with an antiseptic agents into patient contact reduces the transmission of infectious diseases effectively than just washing hands with plain soap and water.\unskip~\citep{982918:21217390}\ensuremath{^{}}


\begin{table}[!htbp]
\caption{\boldmath {Allocation of the table study subjects according to socio-demographic variables.} }
\label{tw-6f16b00b68da}
\def\arraystretch{1.1}
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\begin{tabulary}{\linewidth}{p{\dimexpr.5084666666666667\linewidth-2\tabcolsep}p{\dimexpr.28906666666666666\linewidth-2\tabcolsep}p{\dimexpr.20246666666666666\linewidth-2\tabcolsep}}
\tbltoprule \rowcolor{kwdboxcolor}Socio-demographic variables (n=276) &  (N) & (\%)\\
\tblmidrule 
\textbf{Age (Years)} &
   &
  \\
18-25 &
  214 &
  77.5\\
26-35 &
  49 &
  17.8\\
{\textgreater}35 &
  13 &
  4.7\\
\textbf{Gender} &
   &
  \\
Male &
  164 &
  59.4\\
Female &
  112 &
  49.6\\
\textbf{Profession } &
   &
  \\
Nurse &
  102 &
  37.0\\
Medical Students  &
  174 &
  63.0\\
\textbf{Qualification} &
   &
  \\
Diploma  &
  60 &
  21.7\\
Bachelors &
  216 &
  78.3\\
\tblbottomrule 
\end{tabulary}\par 
\end{table}
In 2002, the Centers for Disease and Control and Preventions (CDC), USA and Healthcare Infection Control Practices Advisory Committee published comprehensive guidelines for hand hygiene in health care settings, mainly to overcome the lack of awareness among workers regarding the importance of hand hygiene in preventing the disease transmission.

The recommended duration for hand washing is between 30 seconds to one minute. It is noted that Alcohol based hand antiseptics are used in most of the countries for rapid antimicrobial effects, broad spectrum coverage, better patient tolerability and also ease of application.\unskip~\citep{982918:21217379}

The maximum of health care workers are composed by the nurses which are appraised as ``nucleus of the healthcare system'', it is very crucial in preventing the diseases among the hospitalized patients.

Hand hygiene is also used in the prevention of Hospital Acquired Infections or Nosocomial infections; these are obtained during patient hospitalization within 48-72 hours.\unskip~\citep{982918:21217386}  For preventing cross infections and Healthcare associated infections, several countries worldwide started their national campaigns to improve hand hygiene as a part of the World Health Organization's `Clean Care is Safer Care' Campaign.\unskip~\citep{982918:21217380,982918:21217391}

Two types of micro-organism are found over the human skin:-


  
  \begin{enumerate}
  \item \relax Resident's flora (organisms that normally inhabited in skin).
  \item \relax Transient's flora (Contaminates).
  \end{enumerate}
  Transient's flora causes most hospital acquired infections by cross-transmission, but it can be comfortably removed by hand cleaning. So regular hand washing by doctors and nurses decreases the colonization of skin with transient flora and render safe for next patient's contact.\unskip~\citep{982918:21217388}

According to the W.H.O., prevalence of nosocomial infections is 19\% in developing countries, so the personal hygiene and standard universal safety precautions should be included.\ensuremath{^{}} W.H.O. estimated that washing hands with soap and water reduces the death caused by diarrhea up to 50\%. Hand washing prevents acute respiratory infections by 16\%.\unskip~\citep{982918:21217384}

As per our knowledge, very few community studies have been conducted regarding the awareness of hand hygiene in India. The staff has exposed to a variety of infectious throughout the process of day to day nursing activities and they are at higher risk in contacting infections. Hand hygiene education should be mandatory for all clinical courses.

Hence, present study has undertaken to determine the ``Knowledge, Attitude and Practices about hand hygiene among medical students and nurses.


\begingroup
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\caption{\boldmath {Percentage of correct response of nurses and medical students related to knowledge on handhygiene. } }
\label{tw-614bb4d5b8b4}
\def\arraystretch{1.1}\\\endfirsthead \hline \noalign{\vskip3pt} \noalign{\textit{Table \thetable\ continued}} \noalign{\vskip3pt} 
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\rowcolor{kwdboxcolor} & Knowledge related questions & \multicolumn{2}{p{\dimexpr(.5982\linewidth-2\tabcolsep)}}{\cAlignHack Nurses and MBBS students (276)}\\
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\tblmidrule \endhead \hline \noalign{\vskip3pt} \noalign{\textit{\hfill Continued on next page}} \noalign{\vskip3pt} \endfoot \endlastfoot 
\tbltoprule \rowcolor{kwdboxcolor}Sl. No. & N = 276  & \multicolumn{2}{p{\dimexpr(.5982\linewidth-2\tabcolsep)}}{\cAlignHack Frequency rate}\\
\rowcolor{kwdboxcolor} & Knowledge related questions & \multicolumn{2}{p{\dimexpr(.5982\linewidth-2\tabcolsep)}}{\cAlignHack Nurses and MBBS students (276)}\\
\rowcolor{kwdboxcolor} &  & \cAlignHack F & \cAlignHack (\%)\\
\tblmidrule 
1 &
  When is the World Hand Hygiene Day? &
   &
  \\
A. &
  5th May &
  \cAlignHack 220 &
  \cAlignHack 79.7\\
B. &
  15th October &
  \cAlignHack 21 &
  \cAlignHack 7.6\\
C. &
  1st May &
  \cAlignHack 32 &
  \cAlignHack 11.6\\
D. &
  1st December &
  \cAlignHack 3 &
  \cAlignHack 1.1\\
 &
   &
   &
  \\
2 &
  Which is the best hand hygiene method for killing bacteria? &
   &
  \\
A. &
  Plain water and soap. &
  \cAlignHack 231 &
  \cAlignHack 83.7\\
B. &
  Antimicrobial soap and water. &
  \cAlignHack 15 &
  \cAlignHack 5.4\\
C. &
  Alcohol based hand. &
  \cAlignHack 30 &
  \cAlignHack 10.9\\
D. &
  None &
  \cAlignHack 0 &
  \cAlignHack 0\\
 &
   &
   &
  \\
3 &
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  \cAlignHack  &
  \cAlignHack \\
A. &
  Ethanol 70\% &
  \cAlignHack 67 &
  \cAlignHack 24.3\\
B. &
  Isopropyl alcohol 99\% &
  \cAlignHack 48 &
  \cAlignHack 17.4\\
C. &
  Ethanol 80\% &
  \cAlignHack 18 &
  \cAlignHack 6.5\\
D. &
  Isopropyl alcohol 70\% &
  \cAlignHack 143 &
  \cAlignHack 51.8\\
 &
   &
   &
  \\
4 &
  Which moment of hand hygiene is not captured by electronic monitoring system? &
  \cAlignHack  &
  \cAlignHack \\
A. &
  Moment 1\& 2 &
  \cAlignHack 179 &
  \cAlignHack 64.9\\
B. &
  Moment 2 \& 3 &
  \cAlignHack 29 &
  \cAlignHack 10.5\\
C. &
  Moment 1 \& 4 &
  \cAlignHack 41 &
  \cAlignHack 14.9\\
D. &
  Moment 3 \& 4 &
  \cAlignHack 27 &
  \cAlignHack 9.8\\
 &
   &
   &
  \\
5 &
  Gold standard for determining hand hygiene compliance is &
  \cAlignHack  &
  \cAlignHack \\
A. &
  Measurement of product used direct &
  \cAlignHack 48 &
  \cAlignHack 17.4\\
B. &
  Observation of HCW's &
  \cAlignHack 206 &
  \cAlignHack 74.6\\
C. &
  Observation by patients &
  \cAlignHack 19 &
  \cAlignHack 6.9\\
D. &
  Electronic system time &
  \cAlignHack 3 &
  \cAlignHack 1.1\\
 &
   &
   &
  \\
6 &
  5 moments of W.H.O. except? &
  \cAlignHack  &
  \cAlignHack \\
A. &
  Before touching a patient &
  \cAlignHack 29 &
  \cAlignHack 10.5\\
B. &
  After body fluid exposure risk &
  \cAlignHack 26 &
  \cAlignHack 9.4\\
C. &
  After touching a patients surrounding &
  \cAlignHack 22 &
  \cAlignHack 8.0\\
D. &
  After touching patient &
  \cAlignHack 16 &
  \cAlignHack 5.8\\
E. &
  Before touching patient file &
  \cAlignHack 183 &
  \cAlignHack 66.3\\
 &
   &
   &
  \\
7 &
  When is the Global hand washing day? &
  \cAlignHack  &
  \cAlignHack \\
A. &
  5th May &
  \cAlignHack 113 &
  \cAlignHack 40.9\\
B. &
  15th October &
  \cAlignHack 85 &
  \cAlignHack 30.8\\
C. &
  1st May &
  \cAlignHack 29 &
  \cAlignHack 10.5\\
D. &
  1st December &
  \cAlignHack 49 &
  \cAlignHack 17.8\\
 &
   &
   &
  \\
8 &
  What is the minimum time needed to kill germs by alcohol based hand rub? &
  \cAlignHack  &
  \cAlignHack \\
A. &
  20 sec &
  \cAlignHack 88 &
  \cAlignHack 31.9\\
B. &
  1 sec &
  \cAlignHack 49 &
  \cAlignHack 17.8\\
C. &
  30 sec &
  \cAlignHack 125 &
  \cAlignHack 45.3\\
D. &
  10 sec &
  \cAlignHack 14 &
  \cAlignHack 5.1\\
 &
   &
   &
  \\
9 &
  What is the minimum duration of hand washing to kill germs with soap and water? &
  \cAlignHack  &
  \cAlignHack \\
A. &
  10 sec &
  \cAlignHack 62 &
  \cAlignHack 22.5\\
B. &
  20 sec &
  \cAlignHack 100 &
  \cAlignHack 36.2\\
C. &
  30 sec &
  \cAlignHack 97 &
  \cAlignHack 35.1\\
D. &
  40 sec &
  \cAlignHack 17 &
  \cAlignHack 6.2\\
 &
   &
   &
  \\
10 &
  Which of the following prevents transmission of germs to the patients? &
  \cAlignHack  &
  \cAlignHack \\
A. &
  After touching a patient &
  \cAlignHack 117 &
  \cAlignHack 42.4\\
B. &
  Immediately after a risk of body fluid exposure &
  \cAlignHack 110 &
  \cAlignHack 39.9\\
C. &
  After exposure to immediate surroundings of a patient &
  \cAlignHack 01 &
  \cAlignHack 0.4\\
D. &
  Immediately before a clean/ aseptic procedure. &
  \cAlignHack 48 &
  \cAlignHack 17.4\\
\tblbottomrule 
\end{longtable}
\endgroup
\makeatletter\@ifundefined{TwoColDocument}{}{\twocolumn}\makeatother 

\begin{table*}[!htbp]
\caption{\boldmath {Allocation of nurses and medical students, regarding the level of knowledge on hand hygiene} }
\label{tw-3b73c047daed}
\def\arraystretch{1.1}
\ignorespaces 
\centering 
\begin{tabulary}{\linewidth}{p{\dimexpr.17720000000000002\linewidth-2\tabcolsep}p{\dimexpr.3228\linewidth-2\tabcolsep}p{\dimexpr.25\linewidth-2\tabcolsep}p{\dimexpr.25\linewidth-2\tabcolsep}}
\tbltoprule \rowcolor{kwdboxcolor}Sl. No & Knowledge Level & \cAlignHack Frequency & \cAlignHack Percentage\\
\tblmidrule 
1 &
  Poor 0-4  &
  \cAlignHack 25 &
  \cAlignHack 9.1\% \\
2 &
  Average 5-7  &
  \cAlignHack 186 &
  \cAlignHack 67.4\% \\
3 &
  Good {\textgreater}7  &
  \cAlignHack 65 &
  \cAlignHack 23.6\% \\
\multicolumn{2}{p{\dimexpr(.50\linewidth-2\tabcolsep)}}{\cAlignHack Total} &
  \cAlignHack 276 &
  \cAlignHack 100\%\\
\tblbottomrule 
\end{tabulary}\par 
\end{table*}
\textbf{Research methodology}

The methodology adapted for the study including research settings, design, research approach, population and sampling technique, data collection tools, collection process, analysis technique and operational definitions.

\textbf{Study period}

1 year 

\textbf{Research approach}

A descriptive cross sectional study approach had approach.

\textbf{Research design}

The collection of information and data directly from the study through a predesigned and pretested questionnaire scheduled.

\textbf{Population}

The population for this study included the medical students and nurses working in Tertiary teaching hospital of Jawaharlal Nehru Medical College. 

\textbf{Sample size}

 Sample size of the study is two hundred and seventy six (276), health care workers. 

\textbf{Construction of tool }

The tool was a predesigned and pretested questionnaire schedule constructed using review of literature from books, journals and published research studies.

\textbf{Description of tool}

The structured questionnaire had three sections as follows

\textbf{Section 1 }

It consists of items related with selected demographic variables such as age, gender, qualification and profession.

\textbf{Section 2 }

A structured questionnaire was used to access the awareness. It consists of items related to assess the awareness regarding hand hygiene practice among medical students and nurses in hospital.

\textbf{Section 3}

It consists of items related to source of awareness for students about hand hygiene.

\textbf{Data collection process }

Step-I =The investigator procured permission from respective authority to conduct the study.

Step-II = Investigator introduced herself to the participants and notifies about his{\tt\string\ \unskip}her aim, objectives and obtains written informed consent from all the study subjects.

Step-III = Conducted survey using structured Performa.

\textbf{Data analysis technique}

Variables were tested using chi-square tests and Data analyses were conducted using MS excel and SPSS version 20, p{\textless}0.05 was considered statistically significant. 
    
\section{Results}
Table~\ref{tw-3b73c047daed} showed that 25 (9.1\%) subjects had poor knowledge, 186 (67.4\%) subjects had average knowledge and 65 (23.6\%) subjects had good knowledge regarding hand hygiene.

Table~\ref{tw-de1b186890b6}  showed that 33 (12.0\%) subjects had poor attitude, 190 (68.8\%) subjects had average attitude and 53 (19.2\%) had good attitude.

Table~\ref{tw-29d83773d1dc} indicates that 60 (21.7\%) subjects had poor practice, 173 (62.7\%) subjects had average level of practice, and 43 (15.6\%) had good level of practice regarding hand hygiene.
    
\section{Discussion}
The discussion includes


  
  \begin{enumerate}
  \item \relax  Socio-demographic variables of medical students and nurses.
  \item \relax Findings related the knowledge, Attitude and Practice of hand hygiene among young medical undergraduates' students and nurses. 
  \end{enumerate}
  \textbf{S}\textbf{ocio-demographic variables of }\textbf{medical students and nurses} \textbf{\space }

In this study, 214 (77\%) students age of 18 - 25 years, 49 (17.8\%) between 26 - 35 years and 13 (4.7\%) were age of above {\textgreater}35 years. 

The majority of 164 (59.4\%) were males and 117 (49.6\%) were females. Where majority of the participants, 174 (102\%) were medical students and 63 (37\%) were nurses. 

The finding is similar to the study is done in Mangalore, in 2014. Hundred (100) nursing students were included in the study, yielding a response rate 94\%. 

About (95\%) of the respondents were between the ages of 20-22 years. Majority (95\%) were females and (5\%) were males. About (6\%) of the respondents had attended seminars and workshop. (Table~\ref{tw-6f16b00b68da}).


\begin{table*}[!htbp]
\caption{\boldmath {Percentage of correct response of nurses and medical students related to the item pertaining to attitude on Hand hygiene} }
\label{tw-0efa9c9f2768}
\def\arraystretch{1.1}
\ignorespaces 
\centering 
\begin{tabulary}{\linewidth}{p{\dimexpr.1254\linewidth-2\tabcolsep}p{\dimexpr.5508\linewidth-2\tabcolsep}p{\dimexpr.1466\linewidth-2\tabcolsep}p{\dimexpr.1772\linewidth-2\tabcolsep}}
\tbltoprule \rowcolor{kwdboxcolor}SL. No & Attitude related questions & \multicolumn{2}{p{\dimexpr(.32379999999999995\linewidth-2\tabcolsep)}}{\cAlignHack Frequency rate}\\
\rowcolor{kwdboxcolor} &  & \multicolumn{2}{p{\dimexpr(.32379999999999995\linewidth-2\tabcolsep)}}{\cAlignHack MBBS students and nurses (276 )}\\
\rowcolor{kwdboxcolor} &  & \cAlignHack F & \cAlignHack (\%)\\
\tblmidrule 
1 &
  Hand hygiene forms an important practice to prevent cross infections. &
   &
  \\
 &
  Yes &
  \cAlignHack 276 &
  \cAlignHack 100\\
 &
  No &
  \cAlignHack 0 &
  \cAlignHack 0\\
\multicolumn{1}{p{\dimexpr(.1254\linewidth-2\tabcolsep)}}{\multirow{3}{\linewidth}{2}} &
  Hand hygiene practices prevent an individual from getting infections &
   &
  \\
 &
  Yes &
  \cAlignHack 276 &
  \cAlignHack 100\\
 &
  No &
  \cAlignHack 0 &
  \cAlignHack 0\\
3 &
  Monitoring of hand hygiene compliance in high risk areas should be done at least once in: &
   &
  \\
A. &
  1 Month &
  \cAlignHack 35 &
  \cAlignHack 12.7\\
 &
  3 Month &
  \cAlignHack 66 &
  \cAlignHack 23.9\\
C. &
  6 Month &
  \cAlignHack 174 &
  \cAlignHack 63.0\\
D. &
  12 Month &
  \cAlignHack 1 &
  \cAlignHack 0.4\\
4 &
  What is the reason for healthcare workers to practice good hand hygiene? &
   &
  \\
A. &
  To prevent transfer of bacteria from hospital to home. &
  \cAlignHack 76 &
  \cAlignHack 27.5\\
B. &
  To prevent transfer of bacteria from home to hospital. &
  \cAlignHack 58 &
  \cAlignHack 21.0\\
C. &
  To remove visible soiling from hands. &
  \cAlignHack 16 &
  \cAlignHack 5.8\\
D. &
  To prevent infections that patients acquire in the hospital. &
  \cAlignHack 126 &
  \cAlignHack 45.7\\
\multicolumn{1}{p{\dimexpr(.1254\linewidth-2\tabcolsep)}}{\multirow{3}{\linewidth}{5}} &
  Feel secure and safe from any infections. &
   &
  \\
 &
  Yes &
  \cAlignHack 216 &
  \cAlignHack 78.3\\
 &
  No &
  \cAlignHack 56 &
  \cAlignHack 20.3\\
6 &
  Wearing gloves reduce the need for hand hygiene. &
   &
  \\
 &
  Yes &
  \cAlignHack 220 &
  \cAlignHack 79.7\\
 &
  No &
  \cAlignHack 56 &
  \cAlignHack 20.3\\
\tblbottomrule 
\end{tabulary}\par 
\end{table*}

\begin{table*}[!htbp]
\caption{\boldmath {Frequency and percentage distribution of nurses and medical students regarding hand hygiene} }
\label{tw-de1b186890b6}
\def\arraystretch{1.1}
\ignorespaces 
\centering 
\begin{tabulary}{\linewidth}{p{\dimexpr.20209999999999994\linewidth-2\tabcolsep}p{\dimexpr.3879\linewidth-2\tabcolsep}p{\dimexpr.2175\linewidth-2\tabcolsep}p{\dimexpr.1925\linewidth-2\tabcolsep}}
\tbltoprule \rowcolor{kwdboxcolor}Sl. No & \cAlignHack Attitude Level & \cAlignHack  Frequency & \cAlignHack Percentage\\
\tblmidrule 
1 &
  \cAlignHack Poor (0-3)  &
  \cAlignHack  33 &
  \cAlignHack 12.0\%\\
2 &
  \cAlignHack Average (4-5)  &
  \cAlignHack  190 &
  \cAlignHack 68.8\%\\
3 &
  \cAlignHack Good ({\textgreater}6) &
  \cAlignHack  53 &
  \cAlignHack 19.2\%\\
\multicolumn{2}{p{\dimexpr(.5899999999999999\linewidth-2\tabcolsep)}}{\cAlignHack  Total } &
  \cAlignHack 276 &
  \cAlignHack 100\%\\
\tblbottomrule 
\end{tabulary}\par 
\end{table*}

\begin{table*}[!htbp]
\caption{\boldmath {Percentage of correct response of nurses and medical students, related to the item pertaining to practice of hand hygiene} }
\label{tw-466dcf6b9089}
\def\arraystretch{1.1}
\ignorespaces 
\centering 
\begin{tabulary}{\linewidth}{p{\dimexpr.13119999999999997\linewidth-2\tabcolsep}p{\dimexpr.55080000000000005\linewidth-2\tabcolsep}p{\dimexpr.1427\linewidth-2\tabcolsep}p{\dimexpr.1753\linewidth-2\tabcolsep}}
\tbltoprule \rowcolor{kwdboxcolor}Sl. No. & Practice related questions regarding hand hygiene & \multicolumn{2}{p{\dimexpr(.318\linewidth-2\tabcolsep)}}{\cAlignHack Frequency}\\
\rowcolor{kwdboxcolor} &  & \multicolumn{2}{p{\dimexpr(.318\linewidth-2\tabcolsep)}}{\cAlignHack  (n= 276)}\\
\rowcolor{kwdboxcolor} &  & \cAlignHack F & \cAlignHack N (\%)\\
\tblmidrule 
1. &
  Best method for hand hygiene is &
   &
  \\
A &
  Soap and water &
  \cAlignHack 202 &
  \cAlignHack 73.2\\
 &
  Alcohol based hand rub &
  \cAlignHack 61 &
  \cAlignHack 22.1\\
C &
  Antimicrobial soap &
  \cAlignHack 10 &
  \cAlignHack 3.6\\
D &
  Plain water &
  \cAlignHack 3 &
  \cAlignHack 1.1\\
2. &
  How long should you rub your hand while washing with soap and water? &
   &
  \\
A &
  5 sec &
  \cAlignHack 88 &
  \cAlignHack 31.9\\
 &
  10-20 sec &
  \cAlignHack 176 &
  \cAlignHack 63.8\\
C &
  20-30 sec &
  \cAlignHack 12 &
  \cAlignHack 4.3\\
D &
  40-60 sec &
  \cAlignHack 0 &
  \cAlignHack 0\\
3. &
  Frequency of hand washing practice after handling every patient? &
   &
  \\
A &
  Always &
  \cAlignHack 276 &
  \cAlignHack 100\\
 &
  Sometimes &
  \cAlignHack 0 &
  \cAlignHack 0\\
C &
  Don't know &
  \cAlignHack 0 &
  \cAlignHack 0\\
D &
  Never  &
  \cAlignHack 0 &
  \cAlignHack 0\\
4. &
  Follow six steps of hand washing: &
   &
  \\
A &
  Yes &
  \cAlignHack 272 &
  \cAlignHack 98.6\\
 &
  No  &
  \cAlignHack 4 &
  \cAlignHack 1.4\\
5. &
  Reason for using items for proper hand washing? &
   &
  \\
A &
  Low cost &
  \cAlignHack  103 &
  \cAlignHack  37.3\\
 &
  Easy availability &
  \cAlignHack 164 &
  \cAlignHack 60.5\\
C &
  Most efficiency &
  \cAlignHack 4 &
  \cAlignHack 1.4\\
D &
  Hospital supply &
  \cAlignHack 2 &
  \cAlignHack 0.7\\
6. &
  Own a separate hand towel? &
   &
  \\
 &
  Yes &
  \cAlignHack 92 &
  \cAlignHack 33.3\\
 &
  No  &
  \cAlignHack 184 &
  \cAlignHack 66.7\\
7. &
  How long should you use alcohol based hand rub? &
   &
  \\
A &
  5 sec &
  \cAlignHack  2 &
  \cAlignHack  0.7\\
 &
  10-20 sec &
  \cAlignHack 63 &
  \cAlignHack 22.8\\
C &
  20-30 sec &
  \cAlignHack 211 &
  \cAlignHack 76.4\\
D &
  40-60 sec &
  \cAlignHack 0 &
  \cAlignHack 0\\
\tblbottomrule 
\end{tabulary}\par 
\end{table*}

\begin{table*}[!htbp]
\caption{\boldmath {Allocation of the study regarding the levels of hand hygiene practice} }
\label{tw-29d83773d1dc}
\def\arraystretch{1.1}
\ignorespaces 
\centering 
\begin{tabulary}{\linewidth}{p{\dimexpr.14079999999999998\linewidth-2\tabcolsep}p{\dimexpr.28790000000000003\linewidth-2\tabcolsep}p{\dimexpr.3213\linewidth-2\tabcolsep}p{\dimexpr.25\linewidth-2\tabcolsep}}
\tbltoprule \rowcolor{kwdboxcolor}Sl. No & Practice Level  &  Frequency & Percentage\\
\tblmidrule 
1 &
  Poor 0-4  &
  60 &
  21.7\%\\
2 &
  Average 5-6  &
  173 &
  62.7\%\\
3 &
  Good {\textgreater}6  &
  43 &
   15.6\%\\
\multicolumn{2}{p{\dimexpr(.42870000000000005\linewidth-2\tabcolsep)}}{\cAlignHack  Total} &
  276 &
  100\%\\
\tblbottomrule 
\end{tabulary}\par 
\end{table*}
\textbf{Findings }\textbf{related}\textbf{\space }\textbf{the}\textbf{\space }\textbf{knowledg}\textbf{e }\textbf{of hand hygiene among medical undergraduates }\textbf{students } \textbf{and nurses}

In the present study, majority of participants i.e. 186 (67.4\%) had average level of knowledge (5-7) regarding hand hygiene, 25 (9.1\%) participants had poor level of knowledge (0-4) and 65 (23.6\%) had good level of knowledge ({\textgreater}7). The reason could be that more than half of the respondents had attended the seminars. The mean knowledge score among 276 students, mean was 6.32, median 6, and mode 6, range 6 and standard deviation was 1.40, out of 10 questions.

The finding is similar to the study done at Aligarh, in 2015. About 130 students were included in study 71 (80\%) had average knowledge only (7\%) had good knowledge regarding hand hygiene. (Table~\ref{tw-614bb4d5b8b4}).

\textbf{Findings }\textbf{related }\textbf{to}\textbf{\space }\textbf{the Attitude of hand hygiene among}\textbf{\space }\textbf{medical undergraduates and nurses} \textbf{\space }

The present study majority of participants i.e. 33 (12.0\%) had poor level of attitude (0-3) regarding HH, 190 (68.8\%) participants had average attitude (4-5) and 53(19.2\%) had good attitude ({\textgreater}6). The reason could be that more than half of respondents had attended workshops and had good education about it. The mean attitude score among 276 students, mean was 4.66, median 5, mode 5, range 4 and standard deviation 0.944, Out of 6 questions.

The finding is similar to the study done at Raichur, Karnataka, in 2013. About 144 students were included in the study (52.1\%) had average attitude only (20\%) had good attitude regarding hand hygiene where they had received a formal training. (Table~\ref{tw-0efa9c9f2768})

\textbf{Findings }\textbf{relate}\textbf{\space }\textbf{the Practice of hand hygiene among}\textbf{\space }\textbf{medical} \textbf{undergraduates' and nurses}

In the present study majority of participants 173 (62.7\%) had a through aware about the practices (5-6), 43 (15.6\%) had good practice regarding hand hygiene ({\textgreater}6) and 60 (21.7\%) had poor practice (0-4). More of the participants daily practiced the hand hygiene moments and monthly they got the training from the hospital. The mean practice score among 276 participants mean 5.39, median 6, mode 6, range 5 and standard deviation 1.101. Out of given 7 questions. The finding is similar to the study done in  Sri Lanka, in 2013. About 289 students were included in the study where (5.53\%) had good practice, (26.9\%) had average practice and two-third (67\%) has low HH practice. (Table~\ref{tw-466dcf6b9089})
    
\section{Conclusions}
The present study concludes, in the current study overall level of knowledge in medical students and nurses was average 186 (67.4\%), attitude was average 190 (68.8\%) and practice was average 173 (62.7\%). The knowledge scoring for hand hygiene was found to be average (score 5-7), for attitude the average score was (4-5) and for practice score was average (5-6). The present study concluded that knowledge, attitude and hand hygiene practice among medical students and nurses was found to be adequate among the study group was satisfactory. There is need to continue training program for nurses and medical students on major concept of hand hygiene. Continuous vigilance, assessment and supervision regarding hand hygiene can be a logical solution to improve the KAP among medical students and nurses for awareness.

\textbf{Conflict of interest}

The authors declare that they have no conflict of interest for this study.

\textbf{Funding support}

The authors declare that they have no funding support for this study.
    

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