• Users Online: 270
  • Print this page
  • Email this page

Table of Contents
Year : 2021  |  Volume : 4  |  Issue : 2  |  Page : 130-134

Hand hygiene perception and handshaking practices among pediatric inpatient caregivers: A cross-sectional study at a teaching hospital in Saudi Arabia

1 Department of Pediatrics, College of Medicine, King Saud University, King Saud University Medical City; Prince Abdullah Ben Khalid Celiac Disease Research Chair, Riyadh, Saudi Arabia
2 Department of Pediatrics, College of Medicine, King Saud University, King Saud University Medical City, Riyadh, Saudi Arabia
3 Faculty of Medicine, Assiut University, Assiut, Egypt
4 College of Medicine, King Saud University, Riyadh, Saudi Arabia
5 Surrey and Sussex Healthcare NHS Trust, Surrey, UK
6 David Geffen School of Medicine at UCLA, USA
7 Department of Pathology and Laboratory Medicine, Microbiology Unit, College of Medicine, King Saud University, King Saud University Medical City, Riyadh, Saudi Arabia

Date of Submission01-Jul-2020
Date of Decision08-Aug-2020
Date of Acceptance09-Aug-2020
Date of Web Publication26-Nov-2020

Correspondence Address:
Ali Mohammed Somily
Department of Pathology and Laboratory Medicine, College of Medicine, King Saud University and King Saud University Medical City, P.O. Box 2925, Riyadh 11461
Saudi Arabia
Login to access the Email id

Source of Support: None, Conflict of Interest: None

DOI: 10.4103/JNSM.JNSM_80_20

Rights and Permissions

Background: Direct or indirect hand contact plays a significant role in health-care-associated infections. Family members of pediatric patients may have various hand hygiene practices. We aimed to evaluate the perceptions of hand hygiene and handshaking practices among family caregivers of hospitalized children in a tertiary care hospital. Methods: A cross-sectional study was conducted using a pretested two-part questionnaire for a randomly selected caregiver of hospitalized children at King Khalid University Hospital, Riyadh, Saudi Arabia, between January 21 and March 8, 2018. The survey data were analyzed using SPSS version 21. Results: One hundred and eighty caregivers voluntarily participated in the study. The mean age was 35.1 years, and female parents comprised 85.6% of the sample. The majority of participants (82.8%) did not receive any previous formal education on hand hygiene. Most of the participants (relative importance index of 84.6%) had correct answers on a modified version of the World Health Organization “Perception Survey for Health-Care Workers.” However, handshaking avoidance was low in general, with caregivers reporting their handshaking practices did not change even when dealing with people who have flu-like symptoms. There was no significant correlation between the participants' characteristics and handshaking avoidance practice, except for those who were working in the medical field, who showed a significantly higher handshaking avoidance. Conclusion: Formal education for hospitalized children's caregivers on hand hygiene and handshaking practice is lacking. Information on appropriate hand hygiene and potential risks of infection spread is required, especially for those parents without a previous medical background.

Keywords: Hand hygiene, handshaking, parents, pediatric inpatient

How to cite this article:
Temsah MH, Alsohaime FM, Al-Eyadhy A, Hasan G, Alarfaj A, Bajri H, Al-Judi T, Al-Mazyad G, Al-Shammari A, Jawad M, Sklansky MS, Al-Subaie S, Somily AM. Hand hygiene perception and handshaking practices among pediatric inpatient caregivers: A cross-sectional study at a teaching hospital in Saudi Arabia. J Nat Sci Med 2021;4:130-4

How to cite this URL:
Temsah MH, Alsohaime FM, Al-Eyadhy A, Hasan G, Alarfaj A, Bajri H, Al-Judi T, Al-Mazyad G, Al-Shammari A, Jawad M, Sklansky MS, Al-Subaie S, Somily AM. Hand hygiene perception and handshaking practices among pediatric inpatient caregivers: A cross-sectional study at a teaching hospital in Saudi Arabia. J Nat Sci Med [serial online] 2021 [cited 2021 Jun 13];4:130-4. Available from: https://www.jnsmonline.org/text.asp?2021/4/2/130/301706

  Introduction Top

Health-care-associated infections (HCAIs) represent a significant safety concern for both health-care workers (HCWs) and patients.[1] HCAIs result in increased morbidity and mortality, increased hospitalization period, financial burden on both the health systems and the patients, and increased antibiotic resistance.[1],[2] More than half of these infections could be prevented by caregivers properly cleaning their hands at critical moments in patient care.[3] The World Health Organization (WHO) is encouraging patients and their family members to join health workers in their efforts to practice good hand hygiene.[3]

Creating public awareness and patient participation are the key to enhance opportunities for patient safety. Many health facilities educate and encourage patients and their families to participate in hand hygiene. According to a new survey conducted by the WHO and its Collaborating Centre on Patient Safety, patient participation is considered a useful strategy for improving hand hygiene and creating a positive patient safety climate in the facilities implementing it.[4]

Patients' and family members' compliance with hand hygiene is challenging to assess due to the complex nature of the clinical environments.[5] In addition, most literature focuses on the hand hygiene practices of HCWs, with few studies focusing on assessing the knowledge and attitudes of patients or their caregivers.[6] Moreover, the practice of handshake between the patient or caregiver and physician can do more than convey warmth, welcome, and professionalism.[7] It can also transmit troublesome pathogens, including respiratory viruses, methicillin-resistant Staphylococcus aureus, vancomycin-resistant enterococci, Clostridium difficile, and Escherichia coli.

We hypothesized that handshaking avoidance among pediatric inpatient caregivers is low. To the best of our knowledge, there is a paucity of studies exploring visitors' and family members' caregivers' perceptions of hand hygiene and handshake practice. In this study, we are aiming at evaluating the hand hygiene perceptions and practices among visitors and caregivers of hospitalized children in the pediatric wards of King Khalid University Hospital (KKUH), Riyadh, Saudi Arabia.


Study design

This cross-sectional study involved caregivers and visitors who were providing direct care of admitted children at KKUH, Riyadh, Saudi Arabia, in the period from January 21 to March 8, 2018.

Sample size

Using the G-power program assuming a correlation analysis was tested, the desired sample size was computed with an intent of detecting a moderate effect size (F2 = 0.15) with a power of 95% confidence interval and hence an error probability of 5%, and the desired sample size was found to be 180 parents.

Sampling technique

The list of all newly admitted pediatrics patients was reviewed daily, and it ranged from 4 to 6 admissions. We randomly selected half of the admitted children. Subsequently, parents who consented to participate were given the questionnaire. The questionnaire contained demographic information, hand hygiene perception, and handshaking practice questions.

Questionnaire design and validation

The questionnaire for this study contained two parts. Part A included ten demographic questions, and Part B included four hand hygiene perception questions that were based on the “WHO Hand Hygiene Perception Survey for Health-Care Workers.”[8] These questions were modified to be more suitable to the participants. Moreover, the research team added six questions as a parameter for handshaking and personal hand hygiene practices.

The questionnaire was face-validated by the research team and based on a pilot study that was conducted on 31 caregivers and visitors.

The questionnaire was translated according to the WHO back translation manual “Process of translation and adaptation of instruments”[9] and provided in bilingual (Arabic and English) in hard copy format.

Data analysis

All hard copy questionnaires were entered into an electronic format. At the end of the collection, the data were analyzed using the IBM Corp. Released 2012. IBM SPSS Statistics for Windows, Version 21.0. Armonk, NY: IBM Corp and IBM Excel spreadsheets. Means and standard deviations (SDs) were used to describe continuous metric variables and frequencies and percentages to describe the categorical and nominal variables. The relative importance index (RII) was used for ranking. The RII computation method as devised by Holt, 2014,[10] with percentages between 0% and 100%: an item with an RII between 0% and 25% is a highly insignificant contributor, RII between 25% and 50% is an insignificant contributor to its concept, 50%–75% is significant, while any item with an RII >75% is a highly significant contributor to its domain concept. A Chi-squared test was done to determine whether there is a significant association between demographic characteristics and handshaking practice.

Ethical considerations

All participants were provided with a consent form on the first page of the questionnaire that contained information about the purpose of the study and their right to withdraw at any time without any obligation toward the research team. Participants were anonymous, with no individual identifiers. There was an appreciation for all the participants with no incentives or rewards. The Institutional Review Board approval was obtained before sample collection, and the study was performed in accordance with the Declaration of Helsinki.

  Results Top

We collected 180 questionnaires from inpatient pediatric family member caregivers. The mean age of the respondents was 35.1 (SD = 7.8) years, with a range of 14–56 years. The majority of the participants were females (85.6%), and children's parents constituted 93.3%; the rest were older siblings or other close family members. There was a significant lack of formal hand hygiene education among the caregivers, with 82.8% of them not receiving any formal education. Caregivers accompanying a child admitted with an infectious disease diagnosis represented 23.3% of the participants. The other demographics are displayed in [Table 1].
Table 1: Pediatric parents/caregivers' demographic characteristics (n=180)

Click here to view

The caregivers perceptions about the effectiveness of hand hygiene in preventing HCAIs, and their belief in the importance of hand hygiene was significantly high, with RII of 84.6%. Caregivers perceived the effort needed to perform good hand hygiene as relatively low (49.9%). All handshaking avoidance practices that ranged from handshaking with healthy individuals or those with upper respiratory tract infection, HCWs, or with other family members were low in general, with various RII, as shown in [Table 2].
Table 2: Pediatric parents/caregivers perceived indicators of hand hygiene (n=180)

Click here to view

The caregivers' categorical demographic characteristics associated with their perceived avoidance of handshaking did not differ statistically on their own mean perceived avoidance of handshaking. However, health-care professionals among the caregivers had significantly higher avoidance of handshaking on average compared to nonhealth-care/professional medical caregivers. The rest of the results are displayed in [Table 3].
Table 3: Factors that are associated with self-reported handshaking practices (n=180)

Click here to view

  Discussion Top

Hand hygiene of HCWs was proven to be a significant factor in the transmission of infections in the health-care setting for nearly two centuries.[11] However, there is still a poor hand hygiene compliance of HCWs, in particular physicians. The visitors' compliance was found to be even lower than that of HCWs.[5],[12]

Handshakes represent a deeply established social custom with deep meanings, which makes it important in the health-care setting. Patients and relatives need the sympathy and trust that can be reinforced with the handshake. However, with the increased recognition of hands as vectors for infection transmission, many individuals make their own efforts to avoid handshaking.[13] We believe that the complete banning of handshaking in the hospital setting may be quite challenging; however, making people more aware of their handshaking habits in a relevant clinical and epidemiological health-care setting is required. Studying the factors associated with increased awareness of handshaking habits in the personal surroundings of sick children may be a key factor in reducing infection transmission and enhancing hand hygiene practices in the pediatric wards.

This study showed that participating caregivers had a moderately high understanding of the effect of HCAIs on the patient's health, and this is in agreement with the results of the previous similar study.[14] Caregivers had high perceptions as to the importance of hand hygiene in health care and the effectiveness of hand hygiene in preventing HCAIs, although it did not reflect practically on their behavior of handshaking habit. This might be explained by the belief of caregivers that handshake avoidance is not considered a hand hygiene precaution due to a lack of sufficient hand hygiene education.

We found that the caregiver's perception of the effort required to perform hand hygiene as medium (4.9/10) was lower than that of a previous similar study where it was perceived as very easy in other populations.[14] This might be explained by the variability in cultural appreciation of hand hygiene practice, or it may reflect variable local parents' teachings or the accessibility of hand hygiene stations in our setting. HCWs and parents of hospitalized children reported that the availability of alcohol-based hand rub was the most effective action in improving compliance with hand hygiene.[14]

As the professional medical caregivers reported more avoidance of handshaking in the hospital setting, this is probably explained by their awareness of infection transmission and HCAIs. This could open more opportunities to utilize such parents with a medical background in leading community awareness about proper hand hygiene practices and how to reduce the potential risks of infection spread.

At our hospital, most caregivers of admitted children are females, which explains the higher percentage of females compared to males in our study. Surprisingly, higher socioeconomic parameter scores (housing type, educational level, and household income) and living in Riyadh, the capital of Saudi Arabia, did not have a significant effect on the caregivers' awareness of handshaking.

The implementation of fist bumps rather than handshakes was found to have a lower surface area with less contact time, and the normal flora on the fist of the hand was four times less than that of the palm.[15] However, it has been suggested that the implementation of a handshaking ban may convey the impression that patients and those caring for them are harmful to one another.[16] Some clusters of the novel coronavirus COVID-19 were attributable to direct interactions, with handshaking and sharing of meals being reported among participants in one COVID-19 cluster.[17]

We expected that previous hospitalization of any family member might have given the caregiver a higher chance of visiting a hospital and encountering some hand hygiene education, making them more aware of infection transmission, but this factor did not have a significant effect. A high percentage of caregivers reported that they have never received any formal hand hygiene education. This is concerning, and further studies are required to explore this issue and work toward appropriate recommendations. In a recent systemic review about the role of parents in the promotion of hand hygiene in the pediatric, that revealed scarce literature on the subject, yet, it revealed that parents were more comfortable to remind HCWs about hand hygiene if they had previously been instructed to do so.[18]

The limitation of this study is a single-center and self-reported parental experience. Nonetheless, we believe that this research provides eye-opening messages and promotes future studies.

  Conclusion Top

Formal education on hand hygiene is advisable for hospitalized children's caregivers and visitors, with emphasis on reducing handshaking practices in relevant health-care settings as an infection-control measure to prevent infectious disease spread among this vulnerable population and their families.


We want to thank Manal Abouelanin, Saud Khalaf Alhothaly, and Yazeed Ibrahim Al-Dossare for their valuable participation in data collection for this research. We also thank hodhodata.com for their statistical analysis and input.

Financial support and sponsorship

This research has been financially supported by Prince Abdullah Bin Khalid Celiac Disease Research Chair, under the Vice Deanship of Research Chairs, King Saud University, Riyadh, Kingdom of Saudi Arabia.

Conflicts of interest

There are no conflicts of interest.

  References Top

Mehta Y, Gupta A, Todi S, Myatra S, Samaddar DP, Patil V, et al. Guidelines for prevention of hospital acquired infections. Indian J Crit Care Med 2014;18:149-63.  Back to cited text no. 1
[PUBMED]  [Full text]  
Diwan V, Gustafsson C, Rosales Klintz S, Joshi SC, Joshi R, Sharma M, et al. Understanding healthcare workers self-reported practices, knowledge and attitude about hand hygiene in a medical setting in rural India, Kumar S, editor. PLoS One 2016; 11:e0163347. Available from: http://dx.plos.org/10.1371/journal.pone. 0163347. [Last accessed on 2020 Sep 28].  Back to cited text no. 2
World Health Organization. WHO Encourages Patient Participation for Hand Hygiene in Health Care. Available from: https://www.who.int/mediacentre/news/releases/2013/hand_hygiene_20130503/en/. [Last accessed on 2020 Sep 28].  Back to cited text no. 3
World Health Organization. Guide to Implementation: A Guide to the Implementation of the WHO Multimodal Hand Hygiene Improvement Strategy; 2009. Available from: https://www.who.int/gpsc/5may/Guide_to_Implementation.pdf?ua=1. [Last accessed on 2020 Sep 28].  Back to cited text no. 4
Randle J, Firth J, Vaughan N. An observational study of hand hygiene compliance in paediatric wards. J Clin Nurs 2013;22:2586-92.  Back to cited text no. 5
World Health Organization. WHO Guidelines on Hand Hygiene in Health Care. First Global Patient Safety Challenge Clean Care is Safer Care; 2009. Available form: https://apps.who.int/iris/bitstream/handle/10665/44102/9789241597906_eng.pdf;jsessionid=CC34CB8C29DD743C84DFECF16B85A3A9?sequence=1. [Last Accessed on 2020 Sep 27].  Back to cited text no. 6
Mermel LA. Ban the handshake in winter? Infect Control Hosp Epidemiol 2019;40:699-700.  Back to cited text no. 7
World Health Organization. Tools for Evaluation and Feedback. World Health Organization; 2011. Available from: http://www.who.int/gpsc/5may/tools/evaluation_feedback/en/. [Last accessed on 2017 Nov 13].  Back to cited text no. 8
World Health Organization. Process of Translation and Adaptation of Instruments. WHO. World Health Organization; 2010. Available from: http://www.who.int/substance_abuse/research_tools/translation/en/. [Last accessed on 2017 Nov 10].  Back to cited text no. 9
Holt G. Asking questions, analysing answers: Relative importance revisited. Constct Innov 2014;14:2-16.  Back to cited text no. 10
Semmelweis IP. Encyclopedia Britannica. Vol. 20. Chicago: Encyclopedia Britannica, Inc.; 1965. p. 318.  Back to cited text no. 11
Patarakul K, Tan-Khum A, Kanha S, Padungpean D, Jaichaiyapum OO. Cross-sectional survey of hand-hygiene compliance and attitudes of health care workers and visitors in the intensive care units at King Chulalongkorn Memorial Hospital. J Med Assoc Thai 2005;88:S287-93.  Back to cited text no. 12
Sklansky M, Nadkarni N, Ramirez-Avila L. Banning the handshake from the health care setting. JAMA 2014;311:2477-8.  Back to cited text no. 13
Ciofi degli Atti ML, Tozzi AE, Ciliento G, Pomponi M, Rinaldi S, Raponi M. Healthcare workers' and parents' perceptions of measures for improving adherence to hand-hygiene. BMC Public Health 2011;11:466.  Back to cited text no. 14
Ghareeb PA, Bourlai T, Dutton W, McClellan WT. Reducing pathogen transmission in a hospital setting. Handshake verses fist bump: A pilot study. J Hosp Infect 2013;85:321-3.  Back to cited text no. 15
Fred HL. Banning the handshake from healthcare settings is not the solution to poor hand hygiene. Tex Heart Inst J 2015;42:510-1.  Back to cited text no. 16
Pung R, Chiew CJ, Young BE, Chin S, Chen MI, Clapham HE, et al. Investigation of three clusters of COVID-19 in Singapore: Implications for surveillance and response measures. Lancet 2020;395:1039-46.  Back to cited text no. 17
Bellissimo-Rodrigues F, Pires D, Zingg W, Pittet D. Role of parents in the promotion of hand hygiene in the paediatric setting: A systematic literature review. J Hosp Infect 2016;93:159-63.  Back to cited text no. 18


  [Table 1], [Table 2], [Table 3]


    Similar in PUBMED
   Search Pubmed for
   Search in Google Scholar for
 Related articles
    Access Statistics
    Email Alert *
    Add to My List *
* Registration required (free)  

  In this article
Article Tables

 Article Access Statistics
    PDF Downloaded49    
    Comments [Add]    

Recommend this journal