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 Table of Contents  
Year : 2020  |  Volume : 9  |  Issue : 2  |  Page : 48-53

Wash and wipe to win over COVID-19

1 Associate Professor, Department of Anatomy, Faculty of Medicine and Health Sciences, SGT Medical College, Gurgaon, Haryana, India
2 Professor and Head, Department of Anatomy, Faculty of Medicine and Health Sciences, SGT Medical College, Gurgaon, Haryana, India
3 Reader, Department of Pathology, Manav Rachna Dental College, Manav Rachna University, Faridabad, Haryana, India
4 Demonstrator, Department of Anatomy, Faculty of Medicine and Health Sciences, SGT Medical College, Gurgaon, India
5 Post Graduate student, Department of Anatomy, Faculty of Medicine and Health Sciences, SGT Medical College, Gurgaon, India

Date of Submission15-Jun-2020
Date of Decision14-Jul-2020
Date of Acceptance28-Jul-2020
Date of Web Publication10-Sep-2020

Correspondence Address:
Saha Susmita
Department of Anatomy, Faculty of Medicine and Health Sciences, SGT Medical College, Budhera, Gurgaon - 122 505, Haryana
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/NJCA.NJCA_8_20

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Background and Objectives: The COVID-19 is a serious issue in every corner of the globe affecting frontline warriors and other individuals. Appropriate hand hygiene measures are considered to be the most basic but effective steps to control this disease. The objective of the study was to assess the knowledge, awareness, and proper practice of hand hygiene among university undergraduate medical and nonmedical students. Materials and Methods: The present cross-sectional survey was conducted on 703 university undergraduate medical students (MBBS, BDS, BPT, nursing, and allied) and nonmedical students (engineering, law, commerce, etc.) at Shree Guru Gobind Singh Tricentenary University, Gurugram, Haryana, through the Google Forms by a prevalidated questionnaire to assess the knowledge and attitude regarding hand hygiene practices in this COVID-19 pandemic era. Results: The correct responses for questions based on recommended time of handwash (29.7%), minimum time required for alcohol-based hand rub to kill germs (70.1%), recommended concentration of hand rub (50.5%), and effective method of handwash (38.8%) were observed. Only 73% of the medical students and 58% of the nonmedical students knew exact steps of handwashing (as per the World Health Organization guidelines). Ninety-one percent of all the respondents agreed that they became more conscious about hand hygiene during COVID-19 pandemic. Eighty-two percent of the participants opined that the steps of hand hygiene must be included in routine curriculum. Conclusions: The results of the current survey presented an average score regarding hand hygiene knowledge and practices among university students for both medical and nonmedical streams in this COVID-19 pandemic era.

Keywords: COVID-19, hand hygiene, infection, survey, World Health Organization handwashing steps

How to cite this article:
Susmita S, Aneja PS, Savita B, Vaidya VK, Paras K. Wash and wipe to win over COVID-19. Natl J Clin Anat 2020;9:48-53

How to cite this URL:
Susmita S, Aneja PS, Savita B, Vaidya VK, Paras K. Wash and wipe to win over COVID-19. Natl J Clin Anat [serial online] 2020 [cited 2022 Jan 23];9:48-53. Available from: http://www.njca.info/text.asp?2020/9/2/48/294752

  Introduction Top

The new COVID-19 or coronavirus disease was named by the World Health Organization (WHO) which is caused by severe acute respiratory syndrome coronavirus 2; first presented with unexplained lower respiratory symptoms detected in Wuhan, China.[1],[2] The infection is highly contagious and transmitted through respiratory droplets and in close contact with the infected person.[3] It mainly affects the lung, but in severe illness, it can lead to respiratory distress gradually leading to multiple organ failure.[4] This coronavirus disease was a major challenge in China at first, but now, the increasing number of cases of COVID-19 has made a pandemic situation throughout the world.[2],[3] Therefore, rapid measures should be taken for the prevention and treatment of this serious illness as it spreads very fast. To control the rapid spread, immediate identification, isolation and testing are mandatory for human well-being.[5] This infection can also easily spread to health-care providers when the patients are admitted to the hospital and can be a major cause of health-care-associated infections (HCAIs).[6],[7] This type of occupational infection can increase the mortality rate in developing countries with major financial loss. The scenario has been well estimated by the WHO that hundreds of millions of patients get HCAIs every year.[8] Numerous causative factors can give a contribution to the occurrence of HCAIs; among all, lack of knowledge and practices of hand hygiene along with inability to follow aseptic precaution for procedures and being an immunosuppressant patient, etc., might play a major role.[5] Therefore, knowledge of these precautionary measures along with their proper application may help in the reduction of HCAIs.[9],[10] Among all, the most basic and simplest measure is hand hygiene. Many studies report a significant reduction of number of HCAIs due to proper hand hygiene.[5],[11] Along with health-care providers, the medical students and paramedical students are also prone to this type of infection as they are in also close contact during their clinical postings.[9] The principal of “My five moments for hand hygiene” should be followed by all health-care providers to reduce HCAIs.[10],[12] Nonmedical students can also acquire infection indirectly while visiting the hospital accompanying patients or while receiving health-care facilities directly. Therefore, all the students should comply with proper practices of handwashing, so that they can further spread the awareness to the community, especially during COVID-19 pandemic and after that also. Keeping this in mind and observing the current scenario, this current survey was conducted to assess the knowledge and proper practice of hand hygiene among university undergraduate students. It is expected that this type of survey will be an addition to their knowledge and will further help the general population to fight against public health emergencies and to win over infections like COVID-19.

  Materials and Methods Top

Study instrument

The present survey was conducted among university undergraduate students. This included students from medical – MBBS, BDS, BPT, nursing, and allied courses – and nonmedical streams – engineering, law, commerce, and other courses – in the Shree Guru Gobind Singh Tricentenary (SGT) University, Gurugram, Haryana. It was a questionnaire-based prospective observational cross-sectional survey through the Google Forms to assess the knowledge and skill of hand hygiene among the undergraduate students. To cover the survey, a systematized questionnaire was formulated by following previous research articles with some modifications.[5],[7] The questionnaire was validated by the experts in the field of infection control to assess the content validity. Reliability of the questionnaire was measured by Cronbach's alpha score in terms of internal consistency. All the participants had to attempt total items including some WHO hand hygiene picture-based questions.[7],[12] The questionnaire was filled by the participants only in electronic format.

The questionnaire for the survey was submitted to Dean of the respective colleges of SGT University for the circulation among the students, and participation in the survey was voluntary. No participant identifying information was obtained. Further, the information was anonymized and randomly coded so as to ensure delinking with any identity of the participant and was not involve any collection of materials (vide materials and methods section of the project). Approval for the project including waiver of consent was accorded by the Institutional Screening Ethics Committee, Faculty of Medicine and Health Sciences, SGT University (SEC/FMHS/F/13/05/20-4).

Inclusion criteria

All students of medical and nonmedical streams consenting to take the survey were included.

Exclusion criteria

The students who were unavailable at the time of circulation of the questionnaire or were not interested to fill the questionnaire were directly excluded from the survey.

The data were analyzed and calculated in the percentages as frequencies. It was mandatory for the participants to attempt all the questions before submitting so that the score can be generated. The completed questionnaire has been assessed, and results were calculated. For each correct answer one point and for the incorrect answer zero point were considered for the calculated, and proper gradation of knowledge and skill regarding hand hygiene will be scored as no knowledge, average, good, very good, and excellent. Total 16 points were considered for the assessment of knowledge and skill regarding hand hygiene; out of 16 marks/points, the 1st 4 points were for questionnaires regarding knowledge of hand hygiene and 12 points were exclusively for the WHO-recommended handwashing steps[12] to assess the practice of handwashing steps. A score of ≥15 was termed as excellent, a score of 12–14 was for very good, marks 8–11 were considered as good score, a score of 5–7 points was termed as average, and finally, a score ≤4 was marked as no knowledge.

Sample size

The study of Modi et al.[7] observed that overall hand hygiene knowledge was good in 12.2% of the respondents. Taking this value as reference, the minimum required sample size with a 2.5% margin of error and 5% level of significance is 659 participants. To reduce the margin of error, the total sample size taken is 703. The formula used is – N≥ (p [1−p])/(ME/zα)2, where Zα is the value of Z at a two-sided alpha error of 5%, ME represents the margin of error, andp is the proportion of respondents with good knowledge of hand hygiene.

Calculations: n ≥ (0.122 × [1−0.122])/(0.025/1.96)2 = 658.39 = 659 (approximately).

Statistical analysis

Categorical variables have been presented in number and percentage and continuous variables have been presented as mean ± standard deviation (SD) and median. The analysis was done with the Statistical Package for the Social Sciences (SPSS) version 21.0. Continuous variables were presented as mean ± SD and median. Normality of data was tested by the Kolmogorov–Smirnov test. If the normality was rejected, then nonparametric test was used. Quantitative variables were compared using the Mann–Whitney test (as the data sets were not normally distributed) between the two groups. Qualitative variables were compared using the Chi-square test. P < 0.05 was considered statistically significant.

  Results Top

Among 703 total numbers of participants, 562 were from medical including paramedical group and 141 nonmedical students (total number of students were based on the calculated sample size, but both the groups showed an unequal distribution as participation was voluntary). Out of total nonmedical students, 97 were males and 44 were females. On the other hand, 412 medical students were females and 150 students were males.

Hand hygiene knowledge among medical and nonmedical university students

The recommended time for handwashing is 40 s–60 s. Only 29% of all the students had correct response. Almost 70% of the students of both the groups had a knowledge for minimal time required for alcohol-based hand rub, which was 20 s. Only 50% of all the students with high frequency among medical streams had knowledge of recommended concentration of hand rub or sanitizer that normally should be more than 70% alcohol. Only 38.83% of the medical students gave correct response regarding more effective method of hand hygiene [Figure 1]. Washing hands with soap and water is the more effective method of handwashing [Table 1].
Figure 1: Percentage of participants' knowledge and attitude for the World Health Organization handwashing steps (12 steps were asked in the questionnaires carrying 12 points; one point each for one individual step)

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Table 1: Exhibiting the response for knowledge of hand hygiene (the 1st four questionnaires) among the participants according to scoring system as correct and incorrect response; score has been calculated for total 4, each one carries one point

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Nearly 70% of all the participants had knowledge for the WHO-recommended handwashing steps. Medical students have given significantly more correct answers in comparison to nonmedical students (P < 0.001).

It was observed that both the groups have an average score of 5–7 points regarding knowledge and practice of hand hygiene and the percentage of participants comes almost 29.73%, as elaborated in [Figure 2]. The mean value with standard deviation of scores of the medical and nonmedical groups is 8.94 ± 4.15 and 7.06 ± 3.44, respectively (P < 0.0001; Mann–Whitney test, 29,659.5).
Figure 2: Graphical representation of cumulative scores of medical and nonmedical students indicating knowledge regarding hand hygiene

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Overall, females scored higher in hand hygiene knowledge questions among nonmedical students. However, there was no difference between the scores of female students of the medial and nonmedical groups (P = 0.487; Chi-square test, 3.3438) [Figure 3]. Knowledge score for good and very good was seen among female students [Table 2]. A comparison of score between the genders among nonmedical is presented in [Table 2] and medical participants in [Figure 3] (the calculated P = 0.487; Chi-square test, 3.3438).
Figure 3: Comparison of score between both genders among medical students in percentages

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Table 2: Comparison of score between males and females among nonmedical participants

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Nearly 81.79% of the participants agreed that this questionnaire has improved their knowledge about the hand hygiene. 85.4% of the medical female students and 68.18% of the nonmedical female students agreed that this questionnaire improved their knowledge.

It was noted that nearly 91% of all the participants responded that this pandemic made them consciously follow proper hand hygiene steps. [Figure 4] shows the medical and nonmedical participants' details.
Figure 4: Comparison between male and female students of medical and nonmedical groups regarding consciously following hand hygiene steps

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The medical students were significantly more aware of hand hygiene before COVID-19 pandemic as compared to nonmedical students (P = 0.011, Chi-square test, 6.459) [Figure 5]. Male students in both the groups showed more response (for medical streams: P = 0.047, Chi-square test, 6.13; nonmedical group: P = 0.594, Chi-square test, 1.042) to know proper handwashing guidelines before COVID-19 pandemic. It was observed that 71.63% of the nonmedical and 81.32% of the medical students had knowledge of proper handwashing guidelines before COVID-19 pandemic. Almost 81.79% of the total students had a positive response in forwarding their knowledge through the questionnaire.
Figure 5: Comparison of medical and nonmedical participants in percentages regarding awareness of proper hand hygiene before COVID-19 pandemic

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More than 83% of the medical and 71% of the nonmedical students agreed that proper hand hygiene techniques must be regularly included in university curriculum [Figure 6].
Figure 6: Responses of medical and nonmedical students for inclusion of hand hygiene techniques in university curriculum

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  Discussion Top

Based on the WHO's data, it is documented that almost a million of patients acquired HCAIs every year.[8] Such HCAIs are observed more in developing countries than the developed countries in the world.[13] This can be effectively reduced by practicing proper knowledge and practice of handwashing.[6] The WHO has provided “My five moments for hand hygiene” to define the key moments that should be remembered by the health-care professionals while delivering health-care facilities.[14] As hands are the major source of germ transmission, so hand hygiene should be followed by everyone to fight against infectious disease.[6],[5]

Medical and paramedical students are the vulnerable groups to acquire infection directly, but nonmedical students also get affected indirectly while visiting the hospital to receive health-care facilities. Hence, awareness of hand hygiene should be adopted by all students to prevent the community from such health issues.

In 2009, it was concluded that only 4.7% of the physicians decontaminated hands before contact with their patients in Pakistan. It was also noted that only 17% of the physicians were actually aware of WHO-recommended hand hygiene techniques, with an overall compliance of hand hygiene being 38.8%.[15] Lack of knowledge regarding hand hygiene was also observed among health-care providers in Brazil.[11] Studies have been conducted among medical students of Saudi Arabia to evaluate the knowledge of hand hygiene.[16] Even in 2013, it was observed a poor compliance with hand hygiene practices among medical students of New Zealand.[17] Limited knowledge and practice of hand hygiene were also documented among Chinese medical students.[18]

A study conducted among health-care workers at armed forces military hospitals in Taif where it was found that 25.9% of them have not been properly instructed for hand hygiene in their training session.[19] In 2015, among health-care providers in Karnataka region in India, moderate knowledge among the students regarding hand hygiene was observed.[20] It was also observed that only 9% of the medical students had good knowledge and 16% had good attitude and 6% of the students had fair practice of hand hygiene in Sri Lanka in 2015.[21] In the present survey, the score for knowledge and practice of hand hygiene was better than other studies conducted among medical students, as the score was average among 28% of the medical students followed by 22% of the students having good knowledge.

In 2016, a survey in Poland was conducted to reveal the proper professional practice for hospital hygiene and documented that 22.9% of the students did not receive any training regarding the hospital hygiene[22] and almost 28% of the students had no training for hand hygiene during the internship.[22] Even in Ghana, a study was performed to assess hand hygiene knowledge and practice among health-care workers where the knowledge was only fair.[23]

In 2017, a cross-sectional survey was conducted among Indian medical graduates in a well-known medical college of Maharashtra to assess the knowledge and awareness of hand hygiene practices and was observed that the awareness was low and nearly 57% of the participants never received any formal training in hand hygiene throughout their training period.[7] Nearly 68.6% of the students were unaware of the handwashing steps given by the WHO and 71% of the participants claimed for using the alcohol-based hand rub routinely. Similarly, among Indian medical graduates in Haryana region mentioned in the present survey, it was observed that almost 73.13% of the students had knowledge regarding handwashing steps recommended by the WHO, but among the nonmedical students, it was only 58.87% regarding handwashing steps' knowledge. Among the university students including both the groups, the frequency was 70%.

Very recently, in 2019, a study was conducted on health-care providers in Saudi Arabia, where score for knowledge and awareness regarding hand hygiene was 50%–75%, respectively, among male students and minimal time needed for alcohol-based hand rub to fight against the germs which was correct among 49.6% of the students. Nevertheless, in our survey, the percentage of students regarding knowledge of handwashing steps was less. It was observed in the present survey that 79.37% of the participants had knowledge of handwashing guidelines before COVID-19 pandemic, more among medical graduates. Apart from that, almost 71% of the medical participants who were quite higher in our survey were observed to have knowledge of minimal time needed for alcohol-based hand rub. Regarding the knowledge for recommended concentration of hand rub, it was around 50% of all the participants and more among medical graduates along with the correct response for more effective method of hand hygiene that was seen only in 38.83% of the students; these were not mentioned in the previous enlisted surveys.

Observing the current scenario, in the present survey, questions were also asked regarding awareness of hand hygiene which was not enquired in the previous studies among medical graduates of India as well as other countries of the world. Around 81% of all the students responded to the forwarding of knowledge of hand hygiene through the questionnaire in both the groups. Finally, it was also concluded that all students are now very much conscious regarding hand hygiene after COVID-19 pandemic and around 81% of both the groups think that these basic precautionary techniques should be implemented in regular university curriculum. In 2012, medical students of Kenya showed a tremendous improvement as hand hygiene practices were incorporated in their curriculum to increase the sense of responsibility.[24] Recently, the Medical Council of India has already implemented demonstration for the skills of proper handwashing and personal protective equipment in the foundation course for the undergraduate medical education program (1st phase) students which will be followed in the subsequent Indian medical graduate students' batches.[25]

This type of survey should be conducted among university students not only for medical streams but also for students from other professional areas. This will help them to become more conscious of basic handwashing practices to prevent the community from such health issues. Based on the present survey, it can be recommended that young budding doctors should be taught about the hand hygiene practices by the senior experienced health professional to make an impact in their attitude and practices. All health-care professionals must be encouraged to enroll themselves for short online training session in light of COVID-19 infection control provided by the WHO team. Medical professionals can also deliver small seminars or lectures to the nonmedical professional addressing about positive health practices for further improvement, which may be expected to create a stop gear for this COVID-19 pandemic.

  Conclusions Top

The results of the current survey presented an average score regarding hand hygiene knowledge and practices among university students for both medical and nonmedical streams in this COVID-19 pandemic Era. Our survey also ensures a positive influence among university students to become more conscious about proper practice of handwashing techniques to wipe off health emergencies like COVID-19. Upgradation of their knowledge can be done by implementing these basic health practices in the regular university curriculum.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

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  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 6], [Figure 5]

  [Table 1], [Table 2]


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