European Journal of Cardiovascular Medicine

Healthcare-Associated Infections (HAIs), also known as nosocomial infections, are infections acquired during healthcare delivery that were neither present nor incubating at the time of admission [1, 2]. Globally, HAIs affect hundreds of millions of patients annually and represent a significant public health burden, leading to prolonged hospital stays, increased antimicrobial resistance, substantial economic costs, and, tragically, higher morbidity and mortality [3, 4]. This problem is particularly acute in developing countries, including India, where surveillance is often suboptimal, and patient-to-staff ratios strain resources, leading to reported HAI rates that are often several fold higher than those in developed nations [5, 6].

In the pediatric population, HAIs pose an even greater risk due to the immaturity of the immune system, increased vulnerability to virulent pathogens, and frequent use of invasive procedures [7]. Tertiary care centers like SVPPGIP and Sishu Bhaban in Cuttack, which serve as referral hubs for large parts of Odisha and neighboring states, manage a high volume of complex pediatric cases, making effective infection control paramount [8].

The World Health Organization (WHO) and other major health bodies universally recognize Hand Hygiene (HH) defined as the cleaning of hands by washing with soap and water or by using alcohol-based hand rub (ABHR)—as the single most critical measure for preventing the transmission of pathogens and controlling HAIs [9]. The WHO’s "Five Moments for Hand Hygiene" campaign has successfully driven improvement among healthcare workers [10].

However, the patient themselves represents a constant source of potential auto-inoculation (transferring pathogens from one body site to another) and cross-transmission (to other patients, caregivers, or surfaces) [11]. In a hospital setting, patients frequently touch their faces, medical devices, bedrails, and visitors, creating multiple opportunities for microbial spread [12]. While staff compliance is critical, empowering the patient to participate in their own infection prevention, particularly through effective hand hygiene, adds a crucial layer of defense [13, 14].

The age group of 10 to 12 years is socio-developmentally significant. These school-age children possess the cognitive capacity (Piaget's concrete operational stage) to understand complex sequential tasks, grasp abstract concepts like 'germs' and 'infection transmission,' and are transitioning towards independent self-care [15]. Unlike younger children who are wholly dependent on caregivers, or older adolescents who may exhibit risk-taking behavior, this cohort is receptive to directed health education and behavior modification [16].

Assessing their Knowledge, Attitude, and Practice (KAP) is essential. While high knowledge or a positive attitude is encouraging, research consistently shows a significant "know-do" gap, where awareness does not translate into consistent, correct behavior [17]. Furthermore, the transition of HH practice from the home or school environment to the unfamiliar and potentially stressful hospital setting is an area that requires specific investigation [18].

Given the high patient volume and the necessity of robust infection control in the study setting, this research was designed to provide data specific to patient behavior. The objectives of this study were:

1. To quantitatively assess the level of Knowledge and Attitude regarding hand hygiene among hospitalized children aged 10-12 years at SVPPGIP and Sishu Bhaban.
2. To determine the adequacy of Observed Hand Hygiene Practice (OP), particularly focusing on the correct technique and duration as per WHO guidelines.
3. To identify the socio-demographic and behavioral factors (e.g., parental education, knowledge level) that are significantly associated with adequate Observed Practice.
4. To compare the children's self-reported practice (SRP) with their observed practice (OP) to quantify the magnitude of the reporting bias.

The findings are intended to inform and enhance patient-centered infection control interventions specific to the pediatric wards of these tertiary care centers.

Study Design and Setting

This was an observational, multi-center, cross-sectional study. Data were collected over a three-month period, from January to March 2022. The study sites were the general pediatric wards, including medical and surgical admissions, of the Sriram Chandra Bhanja V.P.P.G. Institute of Pediatrics (SVPPGIP) and Sishu Bhaban in Cuttack, Odisha. These institutions were selected as they represent the highest level of pediatric care in the state, serving a diverse demographic population.

Study Population and Ethical Approval

The target population included all children aged exactly 10 to 12 years who were admitted to the selected wards.

Inclusion Criteria:

• Age 10-12 years.
• Hospitalized for ≥48 hours.
• Medically stable (not in ICU or requiring continuous monitoring).
• Cognitively and physically able to comprehend and respond to the questionnaire.
• Assent obtained from the child and informed consent obtained from the primary legal guardian.

Exclusion Criteria:

• Children with any condition preventing appropriate hand movement (e.g., cast, paralysis).
• Children with known neurological or psychiatric disorders.
• Children with a language barrier that could not be overcome by the bilingual study team.

Sample Size and Sampling: A target sample size of N=250 was chosen based on resource availability and to ensure adequate statistical power for correlation analysis, aiming for N=125 from each institution. A consecutive non-probability convenience sampling method was used, where all eligible children meeting the criteria were recruited until the target sample size was achieved.

Data Collection Instruments

Data were collected by two trained research assistants using a standardized tool translated into the local language (Odia) and back-translated to ensure validity. The tool comprised two main parts:

Structured KAP Questionnaire

This was administered via a face-to-face interview with the child in a private setting.

• Socio-demographics:Age, gender, duration of stay, and Parental Education Level (categorized: Primary School or Less, Secondary School, Higher Secondary School, Graduate/Post-Graduate).
• Knowledge (10 items):Assessed understanding of 'when' (critical moments) and 'how' (duration, use of soap/ABHR) to wash hands. Score Range: 0-10.
• Attitude (5 items):Assessed beliefs about the importance of HH using a 5-point Likert scale (Strongly Disagree to Strongly Agree).
• Self-Reported Practice (SRP):Assessed the frequency of HH at key moments using a 3-point scale (Always, Sometimes, Never).

Observed Practice (OP) Checklist

This was a separate, standardized checklist used for direct, covert observation to minimize the Hawthorne effect.

• Moment of Observation:Hand hygiene performed before eating the main hospital meal was selected as the critical observation point.
• Technique Assessment:The observer used a checklist based on the WHO's 7 steps for handwashing (e.g., Palm to Palm, Back of Hands, Interlacing, Rotational rubbing of thumbs, Fingertips, Wrists).
• Duration Assessment:Measured the time taken for the entire procedure from water on to water off/drying.

Definition of Scores and Outcomes

• Good Knowledge:Total score of ≥7 out of 10 (≥70%).
• Positive Attitude:An average Likert score of ≥4.0 across all attitude items.
• Adequate Observed Practice (OP):Defined by meeting two specific criteria:

1. Technique:Adherence to ≥5 of the 7 WHO steps.
2. Duration:Washing hands for a duration of ≥20 seconds.

Data Management and Statistical Analysis

Data were double-entered into a customized database using Microsoft Excel to ensure accuracy and consistency. Statistical analysis was performed using IBM SPSS Statistics version 26.0.

• Descriptive Analysis:Frequencies, percentages, means (xˉ), and standard deviations (SD) were calculated for all variables.
• Inferential Analysis:The Chi-square test (χ2) was the primary test used to explore the association between categorical independent variables (demographics, Knowledge/Attitude classifications) and the primary dependent outcome variable, Adequate Observed Practice (OP).
• The level of significance was set at p<0.05.

A total of 250 eligible children were enrolled in the study, N=125 from each site. The sample was slightly male-predominant (55.2% male, 44.8% female). The mean age was 11.3±0.9 years. The majority of parents had a Secondary School education or lower (62.0%).

The mean Knowledge score was 7.2±1.8 (out of 10). While 58% demonstrated good overall knowledge, the most frequently missed knowledge points related to the correct duration (≥20 seconds) and the difference between routine and antiseptic HH. The attitude towards HH was strongly positive, with virtually all children recognizing its importance in preventing illness.

Direct observation revealed a striking contrast with the high KAP scores. Only 70 children (28%) met the criteria for Adequate Observed Practice (OP) (i.e., ≥5 steps and ≥20 seconds).

Analysis of technique showed that the steps most frequently omitted were:

1. Rotational rubbing of thumbs (68% omission rate).
2. Rotational rubbing, backwards and forwards with clasped fingers (for fingertips) (55% omission rate).

The mean duration of hand washing observed was 14.5±3.1 seconds, significantly short of the recommended 20 seconds.

Table 2. Cross-tabulation of Knowledge and Attitude classifications against the Observed Practice outcome.

Note:  p-values indicate statistical significance (p<0.05).

A statistically significant association was found between Good Knowledge and Adequate Observed Practice(p=0.001). Children who knew more about HH were more likely, though still not guaranteed, to perform it correctly. Importantly, Attitude was not significantly associated with adequate practice (p=0.432), confirming that motivation does not automatically lead to skill application.

Table 3. Influence of the primary caregiver's formal education level on the child's hand hygiene practice.

The Chi-square test demonstrated a statistically significant association between Parental Education Level and the child's Observed Practice (p=0.012). Children whose parents had completed Higher Secondary School or a higher degree had significantly higher rates of Adequate Observed Practice (45.5% and 37.5%, respectively) compared to those whose parents had Primary School education or less (11.1%).

The analysis of self-reported practice (SRP) against observed practice (OP) revealed a severe over-reporting bias. For the critical moment of "Before Eating," 76.0% of children reported that they Always wash their hands, yet only 28.0%were observed to perform the procedure adequately. This 48.0% discrepancy highlights the social desirability bias inherent in self-report and strongly validates the necessity of direct observation.

The Pervasive Gap Between Knowledge and Practice

The core finding of this study is the marked discrepancy between high knowledge/positive attitude and poor actual practice of hand hygiene among hospitalized children in a major Indian pediatric setting. While 58% of the children demonstrated good theoretical knowledge, and 96% agreed that HH is important, less than a third (28%) were observed to perform it correctly and for the adequate duration. This finding is not unique to Cuttack but is a persistent challenge in infection control globally, confirming the existence of the "intention-action gap" where cognitive intent fails to translate into effective motor skill execution [19, 20].

The specific failure points identified—omission of cleaning the thumbs and fingertips, and inadequate duration—are crucial [21]. These steps are technically more demanding than basic palm-to-palm rubbing and are often missed in rushed or poorly learned routines. Since the most common pathogens are transmitted via contact points frequently touched by fingertips, this deficiency represents a major, specific risk factor for self-inoculation and cross-transmission within the ward [22, 23]. The average washing time of 14.5 seconds is substantially below the recommended 20 seconds, indicating that children are rushing the procedure, possibly due to impatience, lack of habit formation, or the absence of immediate monitoring [24].

Our finding of a significant association between Parental Education Level and the child’s Observed Practice is profoundly important in the context of healthcare in India and other developing nations [25]. The child's hospitalization often involves continuous, on-site presence of a primary caregiver who manages the child's daily needs, including meals and toilet visits [26].

Parents with higher educational attainment are generally associated with:

1. Greater Health Literacy:Better ability to understand and assimilate complex health information provided by hospital staff.
2. Increased Reinforcement:Higher propensity to correctly model the behavior and enforce the correct technique upon their children [27].
3. Better Access to Information:Higher education often correlates with better access to, and trust in, public health information sources (e.g., WHO posters, health campaigns) even before hospitalization [28].

This suggests that hand hygiene interventions in this setting must be two-pronged, targeting both the child for skill development and the caregiver for consistent modeling and supervision, with special emphasis on engaging caregivers with lower formal education [29].

The massive 48% difference between self-reported and observed adequate practice (Table 2) validates the decision to use covert observation as the primary measure of practice [30]. The high rate of self-reporting 'Always' washing hands is a classic example of social desirability bias, where the children, aware of the desired behavior, reported compliance rather than actual routine [31]. This disparity underscores the unreliability of self-report questionnaires for measuring adherence to specific technical hygiene steps and advocates for direct observation methods for quality assurance in clinical research.

The current practice in many hospitals relies heavily on visible posters and verbal instructions, which are effective for raising knowledge but fail to instill skill [32]. Based on these results, the SVPPGIP and Sishu Bhaban infection control teams should prioritize interventions focused on motor skill acquisition and habit formation:

1. Skill-Based Training:Replace passive education with interactive sessions using methods like the "Glow Germ"system or fluorescent lotion/dye to visibly demonstrate the missed areas (thumbs, fingertips) [33].
2. Child-Friendly Nudges:Install highly visible, sequential cues (e.g., foot-print stickers leading to the sink, visual step guides at the sink) and ensure easy access to pediatric-height sinks or steps [34].
3. Targeted Caregiver Education:Develop short, focused, culturally-appropriate training modules specifically for caregivers upon admission, emphasizing the seven steps and the 20-second duration, particularly for those with limited literacy [35].

This study's findings must be interpreted in light of its cross-sectional design, which limits the ability to establish causality (e.g., an intervention causing a change in practice). The observation was limited to a single critical moment (before eating), and while efforts were made to keep the observation covert, the mere presence of the research assistant may have subtly influenced behavior (residual Hawthorne effect). Finally, the convenience sampling restricts the direct generalizability, though the results are likely transferable to similar tertiary pediatric settings in India.

This study confirms a significant gap between the high hand hygiene awareness and poor observed practice among 10-12 year old hospitalized children in Cuttack, with only 28% demonstrating adequate technique. The deficiencies are concentrated in the technical steps (thumbs and fingertips) and inadequate duration. Furthermore, the child's practice is significantly influenced by the parent's educational background. Infection control strategies at SVPPGIP and Sishu Bhaban must therefore transition from knowledge dissemination to practical, technique-focused skill training for both the pediatric patient and their primary caregiver to effectively mitigate the risk of patient-initiated HAIs.

A substantial and concerning gap exists between the pediatric patients' awareness and their actual hand hygiene performance. Hospital infection control strategies must shift from passive education to active, skill-based training and robust caregiver engagement to ensure the correct technique and duration are consistently applied, thereby reducing patient-initiated infection risk

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