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 Table of Contents  
ORIGINAL ARTICLE
Year : 2018  |  Volume : 2  |  Issue : 4  |  Page : 66-72

Assessment of knowledge, attitude, and practice of hand hygiene among medical and health profession students at King Saud Bin Abdulaziz University for Health Sciences in Saudi Arabia


1 Registered Respiratory Therapist, King Abdulaziz Medical City; Health Systems and Quality Management Division, College of Public Health and Health Informatics, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
2 Health Systems and Quality Management Division, College of Public Health and Health Informatics, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia

Date of Web Publication29-Apr-2019

Correspondence Address:
Mohammed Bin Humran
King Abdulaziz Medical City, P. O. Box 28618, Riyadh 11447
Saudi Arabia
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/sccj.sccj_6_19

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  Abstract 


Background: In recent years, patients' safety has become high priority for health-care organizations. It has been documented that poor knowledge and compliance of health-care providers toward hand hygiene have contributed to poor patient safety outcomes. College students of health sciences may not receive adequate education and training on hand hygiene best practices. Objectives: To assess the health profession students' knowledge, attitude, and practice toward hand hygiene and to investigate the factors associated with poor hand hygiene knowledge and practice. Methods: This cross-sectional, correlational, descriptive study was conducted at King Saud Bin Abdulaziz University for Health Sciences performing clinical rotations at King Abdulaziz Medical City in Riyadh, Saudi Arabia. A proportional sampling was used to calculate the required proportions that reflect the size of student population form each of the three colleges. A total of 270 students including 140 medical, 83 nursing, and 47 respiratory therapy students who were selected using a simple random sampling method were included in the study. An adapted and validated knowledge, attitude, and practice (KAP) questionnaire was used to assess four domains: general information, knowledge, self-reported compliance to the WHO 5 Moments of Hand Hygiene, and general satisfaction on received education. Results: The overall average of knowledge score was 81.13 points out of 100. The results revealed that the knowledge score of hand hygiene was higher for nursing school (84.22 ± 12.98), followed by medical school (81.71 ± 11.31) and then respiratory therapy program (75.53 ± 11.76). The results also showed that students who took courses covering hand hygiene scored higher in knowledge score (83.28 ± 11.3) as compared to students who did not take such courses (75.16 ± 12.89). In the compliance domain, the results showed that there were no significant differences in compliance of hand hygiene between students in all categories. In terms of overall student satisfaction with hand hygiene education and training, the results showed that nursing students have higher satisfaction score (72.7%) than their counterparts in medical school (48.3%) and respiratory therapy program (49.7%). Conclusion: Hand hygiene knowledge among students was generally good, and the highest was among nursing students and the lowest among respiratory therapy students. The compliance of students toward the WHO 5 Moments of Hand Hygiene did not vary across different colleges. Improved knowledge was found to be associated with improved compliance with hand hygiene best practices. Recommendations: Increasing the academic focus on hand hygiene in both the curriculum and clinical rotations with periodic standardized educational courses and focusing on hands-on workshops could have a positive impact on the knowledge and practice of hand hygiene for current health sciences students and future health-care providers. Future studies are needed to assess the hand hygiene KAP among students in hospital settings using observation of actual practice.

Keywords: Health-care workers, knowledge, attitude, and practice, middle east respiratory syndrome coronavirus, objective structured clinical examination, World Health Organization


How to cite this article:
Humran MB, Alahmary K. Assessment of knowledge, attitude, and practice of hand hygiene among medical and health profession students at King Saud Bin Abdulaziz University for Health Sciences in Saudi Arabia. Saudi Crit Care J 2018;2:66-72

How to cite this URL:
Humran MB, Alahmary K. Assessment of knowledge, attitude, and practice of hand hygiene among medical and health profession students at King Saud Bin Abdulaziz University for Health Sciences in Saudi Arabia. Saudi Crit Care J [serial online] 2018 [cited 2019 Jul 19];2:66-72. Available from: http://www.sccj-sa.org/text.asp?2018/2/4/66/257381




  Introduction Top


In recent years, patients' safety has become high priority for health-care organizations. To achieve the patient safety goal, health-care providers have focused their efforts on strategies for infection prevention and control. Among many different factors, it has been documented that poor knowledge and compliance of health-care providers toward hand hygiene have contributed to poor patient safety outcomes. College students of health sciences may not receive adequate education on the importance of hand hygiene as the first line of defense against infection diseases. They also may not receive sufficient hands-on training on the proper hand hygiene practices before engaging in patient care. Through observations, we found that some students follow their preceptors even when they are not practicing good hand washing or proper use of alcohol-based hand rub. This may reflect on their perception and compliance of hand hygiene as future health professionals.

Students' clinical rotations may increase the risk of hospital-acquired infection if proper hand hygiene is not followed. The cost and length of stay for admitted patients postinfection became major issues in most educational hospitals, especially when students are involved. It is important to assess the hand hygiene knowledge, attitude, and practice (KAP) among students during clinical rotations. Little is known about hand hygiene knowledge and practice among students from different colleges of health sciences in Saudi Arabia. This study aims to fill this gap.

Aims of the study

  1. To assess the health profession students' KAP toward hand hygiene practices
  2. To compare the KAP among students from different health profession specialties
  3. To investigate the factors associated with poor hand hygiene KAP and compliance among students.



  Literature Review Top


In Saudi Arabia, few reports tackled the World Health Organization (WHO) hand hygiene guidelines among health-care students. Little is known about the knowledge, attitude, and compliance of hand hygiene nationally and worldwide for health-care students from different colleges. The majority of studies conducted in the country involved medical and nursing students. This review concerned about the assessment of KAP of hand hygiene toward health-care students in Saudi Arabia.

A study reviewed the implementation of hand hygiene guidelines according to the WHO project closure at King Abdulaziz Medical City (KAMC). The review identified eight challenges facing health-care professionals to comply with hand hygiene practices. However, the participation of students in the process of hand hygiene was not considered. The study concluded that there is an improvement in changing challenges into projects following recommendations of the WHO draft guidelines on hand hygiene and showed increased compliance rate by 30% over the 5-year plan.[1]

Following international standards for hand hygiene can improve clinical practice. A survey was conducted among students during objective structured clinical examination following the WHO “5 Moments for Hand Hygiene,” where both surgeons and students are blind for the purpose to avoid biases. The results showed that 51.7% of male and 62.5% of female students have knowledge about hand hygiene, but 29% of the total identified the 5 moments of hand hygiene. The results revealed no significant differences between both genders. The measured average compliance rate was 17% for all students without major differences in both genders too.[2]

Knowledge of hand hygiene practices may be associated with the level of education and training. In a study involved medical students to assess their knowledge and attitude toward standard precautions, 251 participants from both genders enrolled into a pretest self-administrative questions distributed anonymously. This cross-sectional study has provided two parts: one to measure the students' knowledge including hand hygiene and the second one to evaluate the curriculum of education materials in the university. The results revealed low knowledge score, but considered acceptable level among all the participated students. On the other hand, the curriculum of training was insufficient in providing adequate knowledge and skills concerning standard precautions. The study showed that increase in the knowledge positively correlates with the year level and negatively associated with the amount of previous training on standard precautions. Hand hygiene was the highest score in all year levels across all domains.[3]

On the other hand, it is important to educate students about the significance of infectious disease and the need to follow precautions to minimize the spread of infections. A study surveyed health college students and health-care workers regarding knowledge of hepatitis B and C virus (HBV and HCV) infections. The study involved equal participants with 300 from each with a total of 600 participants. The study included different domains and hand hygiene was one of them. Students showed poor knowledge toward blood-borne infections, with only 35% of them identified sources of infections. However, the students' attitude toward routine testing for HBV and HCV was positive. The recommendation of this study is to upgrade the curricula to educate students regarding infection prevention because they will become staff after graduation.[4]

In addition, college-based training may play an important role in improving practices of hand hygiene. In a mixed methods study conducted in nursing college during internship with 33 participants to assess knowledge, practice, and attitude regarding infection control and its measures, students were enrolled in three parts of assessments. In addition to a questionnaire, an observational checklist was documented to assess the performance before and after reviewing protocols and guidelines concerning infection control. The results of this study concluded that prior training of nursing internship students had helped enhancing knowledge, attitude, and performance regarding infection control including hand hygiene.[5]

Assessing the quality of the curriculum is also an important strategy to improve hand hygiene practices. A study was conducted to assess nursing students' knowledge of infection control and standard precautions and attitude regarding the curriculum design as a main source of information. The total score for knowledge was 38.71 out of 53 where only 44 students achieved scores above 40. The result considered this score as acceptable related to the knowledge and hand hygiene was the highest scores among all domains tested with 90.6% of students. The study revealed that attitude regarding infection control and standard precautions has high percentage and students satisfied with their current curriculum. Moreover, the study expressed that the knowledge was significantly correlated with the levels of academic years and previous training had increased the awareness of infection control and standard precautions. The study recommended more of training and courses during their education and before graduation.[6]

Study design

This is a cross-sectional, correlational, descriptive study using a survey design. The study was conducted at King Saud Bin Abdulaziz University for Health Sciences (KSAU-HS) performing clinical rotations at KAMC in Riyadh (KAMC-RD), Saudi Arabia.

Sampling

We surveyed students from college of medicine, nursing college, and respiratory therapy program during their regular classes. Based on previous studies using the same questionnaire, we have calculated the sample size using a two-tailed test with alpha level of 0.05, a study power of 0.8, and an effect size (Cohen's d) of 0.33. The sample size calculation showed that a sample size of 286 is required to achieve an adequately powered study. Because the number of students from each college (study population) varied, we used proportional sampling to calculate the required proportions that reflect the size of student population form each college. Proportions were calculated using the following formula:

Required proportional sampling = the total number of students in each college/the total number of all students in the three colleges (489).

The calculations resulted in the following proportions:

  • College of medicine was 287/498 = 0.59
  • Nursing was 152/498 = 0.31
  • Respiratory therapy was 50/489 = 0.10.


The selected proportional random sampling from the college of medicine included 0.59 × 286 = 169 students, nursing 0.31 × 286 = 89 students, and respiratory therapy 0.10 × 286 = 29 students.

We utilized a simple random sampling to choose the required number of students from each college using Microsoft Office Excel 2010 (v14.0) for Windows. However, we decided to include all nursing and respiratory therapy students because they were less in number compared to medical students. There were 353 questionnaires distributed to the selected students. A total of 270 completed questionnaires were returned with a response rate of 76.5%.

Procedures for data collection

A list of randomly selected students were used with hard copies of the questionnaire, wrapped, put in sealed labeled envelopes according to each college. These envelopes were handed to the office of students' affairs in each college and distributed to students at the beginning of each class and received by the office. The follow-ups were conducted biweekly to assure the completion of questionnaires, and the completed questionnaires were collected from their coordinators. The data were collected over 4 weeks from September 14, 2015, to October 14, 2015.

The ethical aspects and procedures of the study had obtained the approval from King Abdullah International Medical Research Center with file number 6832/2015.

Data collection tools

The study used an adapted and validated KAP questionnaire utilizing the Perception Survey for Health-Care Workers (WHO, 2009), the Hand Hygiene Knowledge Questionnaire for Health-Care Workers (WHO, 2009), and the WHO My 5 Moments for Hand Hygiene.[7],[8],[9] The questionnaire has been shown to be valid and reliable by distributing 25 copies to different levels of students, to test readability and understandability, returned back without further adjustments. Reliability analysis (Cronbach's alpha) for the total knowledge, compliance, and satisfaction (18 items) was 0.441 and reliability coefficients for each domain were 0.104, 0.547, and 0.736, respectively. The questionnaire aims to assess four domains as follows:

  1. General information including gender, age, college, year at the college, and received courses/training regarding hand hygiene
  2. Knowledge (ten items) consisted of true or false questions
  3. Self-reported compliance to the WHO 5 Moments of Hand Hygiene (5 items) with yes or no answers
  4. General satisfaction (three items) on hand hygiene courses, training, and clinical rotations composed of five subscales: dissatisfied, somewhat dissatisfied, neutral, somewhat satisfied, and satisfied.


Data analysis

The data were entered, and the variables were coded using IBM Statistical Package for the Social Sciences Version 22, tabulated, and analyzed using proportion and percentage for categorical variables and mean and standard deviation for numerical variables in descriptive data. We utilized independent samples t-test for interval level data, Chi-squared test for comparison between groups, analysis of variance (ANOVA) test to identify differences between and within the groups, and multiple regression analysis to possibly predict knowledge and compliance of hand hygiene among different independent variables. The level of significance (P value) was set at <0.05.


  Results Top


Descriptive results

132 (48.9%) male and 138 (51.1%) female students participated in the study and their age ranged from 19 to 30 years. [Table 1] shows the characteristics of participated students. There were 140 (52%) medical, 83 (31%) nursing, and 47 (17%) respiratory therapy students.
Table 1: Characteristics of the medical, nursing, and respiratory therapy students participated in the study

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Bivariate results

A t-test compared knowledge score between male and female students, year in the college, colleges, and prior courses and training of hand hygiene using Tukey's HSD test for normal distribution. The knowledge scale was transformed to range from 0 to 100. The results showed that there were no significant differences in hand hygiene knowledge between both genders, year in the college, and training (P > 0.05). However, there is a statistical significance in knowledge between students from different colleges and between students who took courses covering hand hygiene and those who did not (P ≤ 0.05). The knowledge scores were higher for nursing school (84.22 ± 12.98), followed by medical school (81.71 ± 11.31) and respiratory therapy program (75.53 ± 11.76). The results also showed that students who took courses covering hand hygiene scored higher in knowledge score (83.28 ± 11.3) as compared to students did not take such courses (75.16 ± 12.89). In this domain, the average knowledge score was 81.13 ± 11.91 [Table 2]. Chi-squared test for nonnormal distribution of data was performed to compare compliance of hand hygiene between male and female students, year in the college, colleges, and prior courses and training. The results showed that there were no significant differences in compliance of hand hygiene between students in all categories (P > 0.05) [Table 3].
Table 2: Comparison of knowledge scores per gender, year in the college, college, course, and training

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Table 3: Comparison of compliance scores according to student characteristics

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The satisfaction scale of hand hygiene courses, training, and clinical rotation composed of 5 subscales: dissatisfied, somewhat dissatisfied, neutral, somewhat satisfied, and satisfied and also ranged from 0 to 100. ANOVA test was conducted to compare student's total satisfaction of hand hygiene education and training between students from different colleges. [Table 4] shows that there is a significant difference across colleges [F (2, 267) = 27.54, P < 0.05]. It shows that nursing students, in average, have higher satisfaction score (72.7) than their counterparts in medical school (48.3) and respiratory therapy program (49.7).
Table 4: General satisfaction among the three colleges

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Multivariate analysis

Regression analysis was conducted to test the association between hand hygiene knowledge, as the dependent variable, and gender, colleges, and hand hygiene teaching [Table 5]. [Table 5] shows that there is a significant association between the college and knowledge score. Nursing and medical students scored 5.98 and 4.45 points, respectively, higher than respiratory therapy students (P < 0.05). The results also showed that there is a significant association between courses in the curriculum and knowledge score. Students who took courses covering hand hygiene scored approximately 6 points higher than those who did not (P < 0.05). On the other hand, gender was not associated with knowledge score (P > 0.05), and the results showed that male students are more knowledgeable (+0.852) than female students. The final model in the same table explained about 10% of variation in the knowledge of hand hygiene (R2 = 0.099). Additional regression analysis tested whether higher knowledge of hand hygiene predicts better compliance rate, adjusting for differences between male and female students and differences across colleges. The results showed a significant association between knowledge and compliance even after the adjustment for covariates [Table 6]. The adjusted results showed that, for each one point increase in the knowledge score, there is a 0.27 point increase in the compliance rate (P ≤ 0.001). The results also showed that male students are more compliant (+3.5 points) than female students; however, it was not significant. Furthermore, it appears that nursing students scored higher in compliance than medical and respiratory therapy students, but again this was not statistically significant (P > 0.05). The final model explained about 6% of the variation in compliance of hand hygiene (R2 = 0.057).
Table 5: Predictors of hand hygiene knowledge score

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Table 6: Predictors of hand hygiene compliance rate

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  Discussion Top


Hand hygiene is the first effective basic action to prevent infection among populations inside and outside of hospitals. The preparations to simplest infection prevention must take place for health-care students during their colleges before joining health-care organizations as future health-care workers. This study was conducted just around the time period when the outbreak of Middle East respiratory syndrome coronavirus (MERS-CoV) took place in National Guard Hospital in Riyadh. It is undoubtedly that the time has come to seriously revise and improve the education and practice of hand hygiene for current and future health-care professionals. The timing of the current study was perfect to assess the KAP of hand hygiene among senior students from different colleges of health sciences, who soon will take care of patients as the new generation of healthcare professionals.

In the present study, the participation of male and female students is almost equal and the highest responders among medical students, as this had been noticed in some studies.[2],[3] The results showed that nursing students had the highest proportion in receiving courses and training in their curriculum and the lowest was among medical students. This suggests that medical school and respiratory therapy program are having less attention toward hand hygiene courses or training in their curriculum. Few students reported that they did not receive courses and training on hand hygiene in their curriculum and may suggest that they recently joined the colleges, transferred from different professions, or absences during classes.

Students in the current study showed a very good knowledge about hand hygiene best practices. This finding was supported by other researchers that the domain of knowledge in hand hygiene among health-care students was in acceptable levels.[2],[3],[5],[6] There were no gender differences in the knowledge score and is consistent with a previous research.[2] In addition, there were no differences in knowledge scores between different levels in each college. In the medical school, the 6th year students scored lower knowledge score than the 5th year students. This study is inconsistent with a previous study conducted in Saudi Arabia, where the knowledge correlated with year at the college.[3] This finding may indicate that cumulative knowledge of hand hygiene is worsening as students approach graduation. This may be explained by a shift in focus on advanced knowledge and application of skills on the expense of standard preventive practice such as hand hygiene. The findings of this study showed that nursing and medicine students are more knowledgeable than respiratory therapists toward hand hygiene. This may be a result of more curriculum focus on hand hygiene in the nursing and medical schools as compared to respiratory therapy program. This also suggests that the existing short course on hand hygiene in respiratory therapy program curriculum is not sufficient. This study showed no differences in hand hygiene knowledge between male and female students and is consistent with previous studies conducted in Saudi Arabia.[2],[3] The present study revealed that there is a positive correlation between taking courses covering hand hygiene and the overall knowledge score. It appears that teaching courses of hand hygiene during the curriculum is the main source of information for students. This finding is similar to other studies conducted for medical and nursing students.[2],[5],[6] In this study, prior training on hand hygiene did not improve the knowledge of students. This may be related to not providing hands-on workshops in the curriculum or hand hygiene practicum in the hospital settings. Similar results were found in some studies conducted on medical and nursing students.[3],[4],[6] A study conducted on nursing students at Hafr-Al Batin revealed that there was a significant improvement in the knowledge regarding infection control including hand hygiene after implementing training program.[5] Recommendations by other researchers indicated that mentors and role models can improve the knowledge, attitude, and practice for students if performed in the right manner.[2],[3],[4],[5]

The self-reported compliance score to the WHO 5 Moments of Hand Hygiene in this study was above 90 out of 100. This study revealed that the higher knowledge predicting better compliance with hand hygiene. Furthermore, this study showed that nursing and medical students reported better compliance for hand hygiene than respiratory therapy students and may explain that they have better knowledge, reflecting more focus on their curriculum. It appears that nursing and medical students are conducting more of training in their curriculum than respiratory therapy students and may suggest the existence of designated clinical preceptors. A previous study conducted in Najran University involved students from different health colleges showed that poor compliance with standard isolation precautions is related to poor knowledge.[4] Another study conducted on nursing students revealed that postimplementation of hand hygiene guidelines resulted in significant improvement enhancing practices.[5]

The WHO's indications for hand hygiene covered during classes need to be reflected in students' attitude and practices. Students need to know and practice when to start performing hand hygiene in the patient zone, surroundings, and critical areas. Most of the studies conducted in Saudi Arabia employed the WHO's approach and suggested to follow hand hygiene concepts.[2],[3],[5],[6]

In this study, nursing students were generally satisfied with the provided courses, training, and clinical rotation covered in their curriculum, reflecting a positive attitude toward hand hygiene. On the other hand, medical and respiratory therapy students reported low satisfaction with delivered courses, training, and clinical rotation in their colleges. This may be because nurses are more concerned about close contact with patients and continuous monitoring, suggesting more concentration on training and education in their curriculum regarding hand hygiene. These findings suggest that the focus on hand hygiene in the medical and respiratory therapy curricula and clinical rotation may not be adequate. This may have led to not meeting students' expectations regarding hand hygiene education and training.

Based on the study findings, there is a need to increase the academic focus on hand hygiene in both the curriculum and clinical rotation across all colleges of health sciences. Inclusion of educational courses and periodic training for students within the curriculum at different levels may improve the knowledge and compliance regarding hand hygiene. Standardizing courses and training sessions among all students across all colleges conducted by infection prevention and control practitioners may have a positive impact on students' knowledge and practices. Providing hands-on or workshops on hand hygiene in the academic level would prepare students to handle patients in the future. Revising the colleges' curriculum to enhance hand hygiene practices among students will improve their knowledge. Assigning the role model or best mentors will facilitate the educational purposes of hand hygiene and infection prevention and control as well. Further qualitative studies are needed to assess the KAP during students' clinical rotations supervised by qualified mentors.

The strengths of this study are this is the first local study conducted on students from three different health-care colleges studying at KSAU-HS affiliated with KAMC-RD. To the best of our knowledge, this is the first study worldwide to assess the KAP of hand hygiene among respiratory therapy students and can be considered as a base for future studies. In addition, this study shows very good response rate compared with other studies conducted on two or more health-care professions. Moreover, this study utilized a reliable questionnaire with Cronbach's alpha of 0.441.

However, the study findings should be viewed in light of some limitations. This is a cross-sectional survey, which, by design, does not take into account the possible changes in knowledge and compliance of the same cohort of students across time. In addition, this study was conducted on a single university campus. Therefore, the results may not be generalizable to other academic institutions, especially those universities without hospitals within or adjunct to their campuses.


  Conclusion Top


Hand hygiene is the first line in preventing infection in hospitals and in the general community. Hand hygiene knowledge among students was generally good. It was highest among nursing students and lowest among respiratory therapy students. Courses covering hand hygiene did increase knowledge scores across all colleges. On the other hand, compliance did not vary across different colleges. Improved knowledge was found to be associated with improved compliance with hand hygiene best practices. The most recent outbreak of MERS-CoV is a stark reminder to health-care educational institutions and providers about the significance of hand hygiene and other protective and preventive measures against killer viruses and pathogens. It is now more than ever that the issue of hand hygiene is taken seriously not only in hospitals but also in educational settings and within the larger community.

Acknowledgments

We would like to acknowledge the Department of Students' Affairs, College of Medicine; the Department of Students' Affairs and Research Unit, Nursing College; and Chairman and Director of Respiratory Therapy Program, College of Applied Medical Sciences.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

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Amin TT, Al Noaim KI, Bu Saad MA, Al Malhm TA, Al Mulhim AA, Al Awas MA. Standard precautions and infection control, medical students' knowledge and behavior at a Saudi University: The need for change. Glob J Health Sci 2013;5:114-25.  Back to cited text no. 3
    
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Alqahtani JM, Abu-Eshy SA, Mahfouz AA, El-Mekki AA, Asaad AM. Seroprevalence of hepatitis B and C virus infections among health students and health care workers in the Najran region, southwestern Saudi Arabia: The need for national guidelines for health students. BMC Public Health 2014;14:577.  Back to cited text no. 4
    
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Ghalya M, Ibrahim Y. Knowledge, attitudes and sources of information among nursing students toward infection control and standard precautions. Life Sci J 2014;11:249-60.  Back to cited text no. 6
    
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Tavolacci MP, Ladner J, Bailly L, Merle V, Pitrou I, Czernichow P, et al. Prevention of nosocomial infection and standard precautions: Knowledge and source of information among healthcare students. Infect Control Hosp Epidemiol 2008;29:642-7.  Back to cited text no. 7
    
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Amin T, Al Wehedy A. Healthcare providers' knowledge of standard precautions at the primary healthcare level in Saudi Arabia. Healthc Infect 2009;14:65.  Back to cited text no. 8
    
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    Tables

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



 

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