1. Introduction

        Healthcare-associated infections (HAIs) remain a significant global health concern, contributing to patient morbidity and mortality with increasing healthcare costs. In high-income nations such as the United States, estimates suggest that HAIs affect between 1.7 and 23.6 per 100 hospital admissions, resulting in considerable morbidity, mortality, and economic costs, approximated at over $28 billion annually and about 80,000 deaths. [1] Conversely, developing countries face a disproportionately higher burden, with prevalence rates reaching up to 25%, compared to 5-10% in developed nations. [2] Factors contributing to this disparity include shortages of trained personnel, limited access to appropriate infection control infrastructure, and insufficient implementation of preventive protocols. In contexts like Myanmar, where health systems are resource-constrained, these issues are compounded, emphasizing the urgent need for targeted interventions to mitigate the prevalence of HAIs and improve patient safety.

Hand hygiene (HH) is recognized worldwide as a fundamental and cost-effective measure to prevent HAIs. It serves as a critical barrier against the transmission of pathogenic microorganisms such as methicillin-resistant Staphylococcus aureus (MRSA), Klebsiella spp., Clostridium difficile, and other Gram-negative bacteria that can colonize healthcare workers' hands and facilitate cross-infection. [3,4] Despite the well-established efficacy of proper HH, compliance rates often remain disappointingly low, particularly in resource-limited settings where infrastructural deficiencies and behavioral factors hinder routine practice. Hand hygiene adherence rates among healthcare workers vary between 40% and 89% globally, with even lower compliance in certain settings. [5,6] Research demonstrates that consistent adherence to hand hygiene protocols significantly reduces the incidence of HAIs, shortens hospital stays, and decreases mortality rates, underscoring its vital role in patient safety and infection control strategies. [7] Nonetheless, multiple barriers, including workload pressures, lack of availability of hand hygiene supplies, and cultural attitudes, impede optimal compliance among healthcare workers (HCWs). [8,9,10]

The World Health Organization (WHO) introduced the "Five Moments for Hand Hygiene" framework in 2009 to standardize and promote optimal hand hygiene practices among HCWs. These five critical moments include: (1) before patient contact, (2) before aseptic procedures, (3) after exposure to body fluids, (4) after patient contact, and (5) after contact with patient surroundings. [11] Studies across different healthcare settings reveal that compliance with these five moments varies considerably, with notably lower adherence before patient contact and aseptic tasks compared to after exposure to body fluids. This discrepancy often stems from perceived lower risk or time constraints during routine interactions. The availability and strategic placement of alcohol-based hand rubs (ABHR) have been shown to significantly improve compliance, as they are more accessible and less time-consuming than traditional handwashing with soap and water. [12] The WHO emphasizes that continuous education, monitoring, and feedback are crucial components of promoting sustained adherence to the five moments, thereby reducing HAIs. [13]

The COVID-19 pandemic brought renewed global attention to hand hygiene as a critical measure for controlling infectious disease transmission. Despite widespread awareness campaigns and reinforced guidelines, compliance with HH protocols during the pandemic has been inconsistent, especially in resource-limited settings. For instance, in Nigeria, a study reported a compliance rate of approximately 31%, which is below the threshold necessary for effective infection prevention. [1] Similar observations have been made in other regions, indicating persistent gaps between knowledge and actual practice. [14] The pandemic highlighted that infrastructural inadequacies, such as limited availability of hand sanitizers and sinks, along with increased workload and stress, hinder sustained adherence. Moreover, behavioral factors like complacency or underestimation of risk continue to influence practice. While the pandemic underscored the importance of HH, it also exposed vulnerabilities in health systems' capacity to uphold rigorous infection control standards during crises. Efforts to improve compliance during this period included enhanced training, increased supply of sanitizers, and institutional campaigns, but challenges remain in translating awareness into consistent behavior change.

Barriers to effective hand hygiene practice are multifaceted, encompassing infrastructural, organizational, and individual factors. A significant infrastructural barrier is the limited access to adequate hand hygiene facilities, such as sinks, hand sanitizers, and a reliable water supply, particularly in rural or underfunded healthcare settings. [15] Studies indicate that poorly positioned wash stations and shortages of alcohol-based hand rubs contribute to non-compliance. [16] Organizational challenges include high patient-to-staff ratios, excessive workloads, and insufficient staffing, which reduce the time HCWs can dedicate to HH during routine care. Behavioral barriers, such as lack of knowledge, negative attitudes, and under-appreciation of the risks associated with poor HH, also play a critical role. [8] Moreover, the absence of regular training, monitoring, and feedback mechanisms further diminishes adherence rates. Healthcare workers often lack role models or adequate reinforcement, which hampers the development of a safety culture. Physical environment design, such as the placement of sinks and dispensers, also influences compliance levels. Addressing these barriers requires a multifaceted approach that includes infrastructural improvements, ongoing education, behavioral interventions, and organizational policy changes to foster a culture of safety and accountability. [17]

Medical students, particularly those in their internship or house officer phase, occupy a crucial position in the healthcare system, often serving as the first point of contact for patients and being directly involved in numerous clinical procedures. Their behaviors and perceptions regarding hand hygiene are critical because they form the foundational habits for their professional practices in the long term. Ensuring they possess adequate knowledge, positive attitudes, and consistent hand hygiene practice is essential to foster a culture of safety and professionalism in healthcare services. [18]

Most existing literature predominantly focuses on developed countries or specific healthcare settings, leaving a research gap regarding developing nations. [19] This study aims to assess the knowledge, attitudes, and practices of hand hygiene among house officers at Nay-Pyi-Taw General Hospital, aiming to enhance hand hygiene adherence, reduce HAIs, and foster a sustainable culture of infection prevention among future healthcare professionals in Myanmar.

2. Materials and Methods

2.1. Study Design and Setting

This research adopted a descriptive cross-sectional survey design at Nay-Pyi-Taw General Hospital, a 1000-bedded tertiary care facility, over three months, from February to April 2025.

2.2. Study Population

The population comprised house officers who were undergoing internship training at the hospital during the study period. House officers, also known as medical interns or first-year postgraduate trainees, are medical graduates who have completed their undergraduate medical education and are undergoing a one-year compulsory rotating internship in various clinical departments. They function as junior doctors under supervision, directly involved in patient care, clinical procedures, and ward responsibilities.

Inclusion criteria were: (1) current internship status, (2) active participation in clinical duties, and (3) consent to participate. Exclusion criteria included those on leave or unavailable during data collection.

2.3. Sampling and Sample Size

A total enumeration sampling method was used, encompassing all eligible house officers during the data collection period. The total number of eligible house officers during the study period was 68. Of these, 65 participated, yielding a response rate of 95.6%. Three individuals were excluded due to being on leave during data collection (n=2) or declining to participate (n=1). The final sample of 65 participants was deemed sufficient to achieve the study objectives and ensure representation across various demographics.

2.4. Data Collection

Prior to data collection, the purpose of the study was explained to participants, and informed consent was obtained. Participants completed the questionnaires anonymously and voluntarily. Data were gathered through structured self-administered questionnaires, developed in alignment with WHO standards for hand hygiene assessment. Completed questionnaires were collected immediately to prevent data loss and to ensure confidentiality.

The questionnaire was divided into four sections:

- Section A: Socio-demographic data (age, gender, marital status, university, workload)

- Section B: Knowledge assessment (8 true/false questions)

- Section C: Attitude assessment (10 statements rated on a 5-point Likert scale)

- Section D: Practice assessment (12 statements rated on a 5-point Likert scale)

2.5. Questionnaire Development and Validation

The questionnaire was developed based on WHO hand hygiene guidelines and validated instruments used in previous studies [20,21]. Content validity was established through review by three experts in infectious disease control and public health. A pilot study was conducted with 15 house officers at a different hospital to assess clarity, comprehensibility, and internal consistency. Cronbach's alpha coefficients were 0.78 for the knowledge section, 0.82 for the attitude section, and 0.85 for the practice section, indicating acceptable internal consistency. Minor modifications were made to the question wording based on pilot feedback. The full questionnaire is provided as Supplementary Material.

2.6. Variables and Measurement

- Independent variables: Socio-demographic factors (age, gender, marital status, university, workload)

- Dependent variables: Levels of knowledge, attitude, and practice regarding hand hygiene

2.7. Scoring System

- Knowledge: Each correct answer scored as 1; the total score ranged from 0 to 8. Correct responses were classified as "correct," and incorrect or "don't know" responses as "incorrect."

- Attitude: Responses scored from 1 (Strongly Disagree) to 5 (Strongly Agree); total attitude score ranged from 10 to 50.

- Practice: Responses scored similarly; total practice score ranged from 12 to 60.

2.8. Statistical Analysis

Data from questionnaires were coded and checked for accuracy and completeness. Data were entered into SPSS version 26.0 for analysis. Descriptive statistics, including frequencies, percentages, mean, standard deviation, median, and interquartile ranges (IQR), were used to summarize demographic data and KAP scores.

Assumption checking: Prior to parametric testing, assumptions of normality were assessed using the Shapiro-Wilk test, and homogeneity of variances was assessed using Levene's test. For groups with sample sizes <30, normality was assessed using Q-Q plots and the Shapiro-Wilk test. The assumption of homogeneity of variances was met for most comparisons (p>0.05), except for comparisons involving the married group (n=4), where the assumption was violated.

Group comparisons: An independent samples t-test was conducted to compare means between two groups, where assumptions were met. For comparisons involving groups with violated assumptions, the non-parametric Mann-Whitney U test was used as a robust alternative. One-way analysis of variance (ANOVA) was used to compare means across three or more groups where assumptions were met. For university comparisons, the Kruskal-Wallis test was employed as a non-parametric alternative due to unequal group sizes and potential variance heterogeneity.

Multiple comparisons: To control for Type I error inflation due to multiple comparisons, the False Discovery Rate (FDR) correction using the Benjamini-Hochberg procedure was applied to all post-hoc comparisons. Adjusted p-values (q-values) were reported alongside raw p-values.

Effect sizes: Cohen's d was calculated for t-test comparisons, and eta-squared (η²) was calculated for ANOVA comparisons to quantify the magnitude of observed effects. For significant ANOVA results, post-hoc pairwise comparisons with FDR correction were performed.

Missing data: Complete case analysis was employed, as there were no missing data for any of the questionnaire items. All 65 participants provided fully completed questionnaires.

For all tests conducted in this study, a p-value <0.05 was considered statistically significant. Effect sizes were interpreted according to Cohen's conventions (small: d=0.2, medium: d=0.5, large: d=0.8 for t-tests; small: η²=0.01, medium: η²=0.06, large: η²=0.14 for ANOVA).

2.9. Ethical Considerations

Ethical approval for this study was obtained from the Ethics Review Committee of Nay-Pyi-Taw General Hospital. Permission to conduct the research was also granted by the hospital administration. Written informed consent was obtained from all participants after providing comprehensive information about the study objectives, voluntary participation, anonymity, and confidentiality of responses. Participants were assured that their decision to participate or not would not affect their training or professional standing. Data were anonymized and stored securely, accessible only to the research team.

3. Results

3.1. Socio-demographic Characteristics of Participants

Table 1 describes the socio-demographic status of participants.

3.2. Knowledge of Hand Hygiene

Assessment of knowledge was based on eight true/false questions aligned with WHO standards. Table 2 summarizes the responses regarding key aspects of hand hygiene knowledge. Table 3. compares the mean scores of knowledge across demographic characteristics and institutions.

3.3. Attitudes Towards Hand Hygiene

Attitudes were evaluated through ten items rated on a 5-point Likert scale, with higher scores indicating more positive perceptions. Table 4 presents the frequency distribution of attitude responses. Table 5. compares the mean scores of attitudes across demographic characteristics and institution,

3.4. Hand Hygiene Practices

Practices were assessed through twelve questions, each rated on a 5-point scale. The mean practice score was 55.2 (SD=5.78) out of 60, indicating high self-reported compliance. Table 6 describes the frequency distribution of hand hygiene practices among participants. Table 7. compares the mean scores of practices across demographic characteristics and institution. Table 8. describes post-hoc pairwise comparisons for university (with FDR correction).

4. Discussion

This study examined the knowledge, attitudes, and self-reported hand hygiene practices among house officers at Nay-Pyi-Taw General Hospital. The findings reveal that while knowledge and attitudes are generally favorable, specific gaps exist in technical knowledge, and self-reported compliance may not fully reflect actual practice.

4.1. Knowledge Assessment

All participants demonstrated awareness of hand hygiene's role in infection prevention, consistent with findings from other studies in developing countries. [20,21] This universal awareness likely reflects the emphasis placed on hand hygiene during medical training and the heightened attention due to the COVID-19 pandemic. However, significant knowledge gaps emerged regarding specific technical aspects. Only 9.2% recognized the importance of washing the wrist area, and fewer than half correctly identified the appropriate duration for hand washing (46.2%) or the need to remove accessories (43.1%).

This pattern mirrors findings from Nigeria, where only 30.7% of doctors knew the correct hand washing duration, and fewer understood all hand hygiene indications. [20] Similarly, a study among Iranian residents found that while basic awareness was high, detailed knowledge of proper techniques was lacking. [21] The near-universal awareness but poor technical knowledge suggests that while basic messaging has been effective, detailed procedural education requires reinforcement.

The absence of significant demographic or institutional differences in knowledge scores suggests a shared national curriculum or similar clinical exposure across institutions. This uniformity implies that interventions to improve knowledge should be implemented systematically across all training institutions rather than targeting specific groups. However, the medium effect size for university differences (η²=0.06) suggests that institutional variations, while not statistically significant in this sample, may warrant further investigation in larger studies.

4.2. Attitude Assessment

The majority of house officers exhibited positive attitudes toward hand hygiene, with over 86% acknowledging its importance and supporting public availability of hand gels. This high level of positive attitudes contrasts with findings from Iran, where only 20% of residents answered attitudinal questions correctly [21], but aligns with Nigerian findings showing generally favorable attitudes. [20]

The significant difference in attitude scores based on marital status (p=0.041, r=0.34) is an interesting observation. Married participants demonstrated more positive attitudes, possibly reflecting increased responsibility or exposure to family health concerns. This finding, while based on a small subgroup (n=4), suggests that personal life circumstances may influence healthcare professionals' attitudes toward infection control. The medium effect size (r=0.34) indicates a potentially meaningful relationship, but given the small sample size, this finding should be interpreted cautiously and requires validation in larger studies.

The absence of gender-based differences in our study contrasts with the Nigerian study, where female doctors had significantly better attitudes [20], suggesting that gender-related trends in attitudes may vary by cultural or institutional context. Similarly, the lack of significant age-related differences aligns with findings from Iran, where attitudes were consistently poor across age groups. [21] This suggests that while knowledge may improve with training and experience, attitudes may require more deeply embedded behavioral interventions.

4.3. Practice Assessment

The high self-reported practice scores (mean=55.2/60) indicate that participants perceive themselves as highly compliant with hand hygiene recommendations. Over 95% reported always washing hands after toilet use and handling animals, and over 90% before and after meals. These findings align with the known pattern of higher compliance after "dirty" procedures and lower compliance before "clean" procedures, as documented in WHO guidelines. [11] This pattern suggests that healthcare workers are more likely to perform hand hygiene when they perceive an immediate risk of contamination, compared to situations where the risk is less visible or immediate.

However, lower compliance was reported for routine moments such as after contact with others (56.9% always), after sneezing (56.9%), and before leaving the hospital (64.6%). These moments, which are critical for preventing cross-transmission in healthcare settings, represent areas where targeted interventions could yield significant improvements. The fact that 40% of participants were neutral about changing their practice based on newer health policy suggests potential complacency or lack of awareness about evolving guidelines.

The discrepancy between self-reported and observed compliance is a well-documented phenomenon in hand hygiene research. Omuemu et al. (2013) found a stark contrast between self-reported good practice (48.2%) and actual observed compliance (16.7%) among Nigerian doctors. [20] Similarly, in Iran, none of the residents adhered fully to WHO guidelines during morning visits, with only 3.1% following the standard eight steps of hand washing. [21] This gap between perceived and actual practice highlights a critical challenge: awareness and positive attitudes do not automatically translate into consistent behavior, particularly when faced with real-world pressures such as high workload, time constraints, and forgetfulness. [8,9,10]

4.4. Demographic and Institutional Differences in Practice

Significant differences in practice scores were observed across universities (p=0.016, η²=0.24), with graduates from the University of Medicine Taunggyi and the University of Medicine (1) scoring higher than those from the University of Medicine (2) and the University of Medicine Magway. Post-hoc analysis with FDR correction identified significant differences between UM2 and Taunggyi (q=0.047) and between Magway and Taunggyi (q=0.025). These institutional differences may reflect variations in training emphasis, clinical exposure, or institutional culture regarding infection control.

The large effect size (η²=0.24) suggests that university affiliation explains a substantial proportion of variance in practice scores. This underscores the importance of standardizing hand hygiene training across all medical schools in Myanmar. Factors that may contribute to these differences include variations in curriculum content, quality of clinical supervision, availability of hand hygiene facilities during training, and institutional culture regarding infection prevention. Understanding these institutional factors could inform targeted interventions to improve practices at lower-performing institutions.

Married participants reported perfect practice scores (mean=60.0, SD=0.0), significantly higher than single participants (mean=55.13, SD=5.72; p<0.001, r=0.46). While this finding is striking, it must be interpreted with extreme caution given the very small sample size (n=4). The medium-to-large effect size (r=0.46) suggests a potentially meaningful relationship, but larger studies are needed to confirm whether marital status genuinely influences hand hygiene practices or whether this finding represents sampling bias. It is plausible that married individuals, who may have family responsibilities, develop more disciplined personal hygiene habits that extend to their professional practice. Alternatively, this finding could be explained by other factors such as age or maturity that correlate with marital status.

4.5. Barriers to Optimal Hand Hygiene

Our findings highlight several barriers that impede optimal hand hygiene practice. Technical knowledge gaps, particularly regarding wrist washing, appropriate duration, and removal of accessories, suggest that training programs need to emphasize procedural details more explicitly. The preference for water and soap over hand gels (36.9% preferred water and soap, compared to only 7.7% who strongly preferred hand gels) may indicate issues with gel availability, accessibility, or acceptance. This preference is consistent with findings from Sierra Leone, where healthcare workers expressed concerns about the tolerability and acceptability of alcohol-based hand rubs. [12]

Infrastructural challenges, such as limited access to hand hygiene facilities, have been identified as major barriers in resource-limited settings. [15,16] The fact that 40% of participants were neutral about changing their practice based on newer health policy suggests potential complacency or lack of awareness about evolving guidelines. This finding aligns with research from Liberia, which identified the need for sustainable infrastructure and behavioral interventions to maintain hand hygiene compliance. [17]

High workload (reported by 69.2% as "busy") likely contributes to time constraints that discourage consistent practice during routine patient care, consistent with findings from other studies. [8,9,10] This is particularly concerning given that high workload periods are precisely when the risk of infection transmission is greatest. Healthcare workers in busy settings may prioritize immediate patient care tasks over hand hygiene, perceiving it as an additional burden rather than an integral part of safe care.

4.6. Implications for Practice and Policy

The persistent gap between knowledge and practice observed in this study suggests that effective interventions must go beyond simple education. Multimodal strategies that combine training with infrastructural support, behavioral reinforcement, and organizational culture change are essential. [17] Based on our findings, we propose the following specific recommendations:

1. Targeted training programs that emphasize technical skills (wrist washing, proper duration, accessory removal) alongside theoretical knowledge. These should include practical demonstrations, simulation-based training, and regular refresher courses. Training should address the specific knowledge gaps identified in this study, particularly the low awareness of wrist washing importance (9.2%) and appropriate duration (46.2%).

2. Infrastructure improvements, including strategically placed hand hygiene facilities, adequate supply of alcohol-based hand rubs, and reliable water access. The preference for soap and water over gels (36.9% vs 7.7%) suggests that both options should be available. Facilities should be positioned at points of care to minimize the time and effort required for hand hygiene.

3. Regular monitoring and feedback using direct observation rather than self-report, with performance data shared constructively with staff to promote accountability. The significant discrepancy between self-reported and observed compliance documented in other studies [20,21] underscores the importance of objective monitoring.

4. Leadership engagement and role modeling from senior physicians to establish a culture where hand hygiene is prioritized and normalized. Healthcare workers often emulate the behavior of senior colleagues, making visible commitment from leadership essential for cultural change.

5. Standardization of training across medical schools to address institutional variations in practice scores. The significant differences observed among universities suggest that some institutions may need additional support to strengthen their infection control training.

6. Integration of hand hygiene into the routine workflow rather than treating it as an additional task. This can be achieved through optimized facility placement, workflow redesign, and the incorporation of hand hygiene into standard operating procedures for clinical care.

7. Addressing workload barriers through adequate staffing, workload management, and the promotion of hand hygiene as an essential patient safety measure rather than an optional extra.

4.7. Strengths and Limitations

This study has several strengths, including its focus on a critical population (house officers at a major tertiary hospital), use of validated WHO-aligned instruments, and comprehensive assessment of KAP domains. The inclusion of statistical effect sizes and FDR correction enhances the robustness of findings. The high response rate (95.6%) minimizes the risk of non-response bias.

However, several limitations warrant consideration. The cross-sectional design limits causal inferences and cannot establish temporal relationships between variables. The small sample size (n=65) and single-center design restrict generalizability to other healthcare settings or professional groups in Myanmar. The small subgroup sizes (particularly married participants, n=4) necessitate cautious interpretation of findings related to these groups. The reliance on self-reported data introduces potential social desirability bias, where participants may overreport compliance. The absence of observational validation means that reported practice levels may not reflect actual behavior, and the documented gap between self-reported and observed compliance in other studies suggests that our findings may overestimate true compliance.

The study did not assess all potential barriers to hand hygiene, such as skin irritation from frequent washing or cultural factors that may influence behavior, which could provide additional insights. The questionnaire, while pilot-tested and validated, may not have captured all relevant aspects of hand hygiene knowledge, attitudes, and practices in the local context. Additionally, the study did not assess the availability and accessibility of hand hygiene facilities, which could provide important contextual information for interpreting practice scores.

Future research should incorporate direct observation of hand hygiene practices to validate self-reported findings, include qualitative methods to explore barriers in depth, and expand to multiple centers across Myanmar to improve generalizability. Longitudinal studies could assess the impact of targeted interventions and track changes in knowledge, attitudes, and practices over time. Studies comparing different training approaches and infrastructural interventions would help identify the most effective strategies for improving hand hygiene compliance in resource-limited settings.

5. Conclusion

This study reveals that house officers at Nay-Pyi-Taw General Hospital generally have satisfactory knowledge and positive attitudes towards hand hygiene, yet notable discrepancies exist between awareness and consistent self-reported practice. While compliance is high in critical situations, lapses occur in routine moments, indicating the need for targeted behavioral interventions. Technical knowledge gaps, particularly regarding wrist washing, appropriate duration, and removal of accessories, require focused educational efforts. Institutional variations in practice scores suggest that training should be standardized across all medical schools in Myanmar.

The results suggest that enhancing practical training, ensuring infrastructural support, promoting a safety culture, and implementing routine monitoring are essential to improve adherence. The high self-reported compliance but documented knowledge gaps indicate that interventions should focus not only on increasing awareness but also on translating knowledge into consistent behavior, addressing workload barriers, and providing adequate facilities.

Future research should incorporate longitudinal and observational methods to better understand behavioral barriers and the impact of educational strategies. Expanding studies to include other healthcare professionals and settings across Myanmar will aid in developing comprehensive, culturally appropriate infection control policies. Strengthening hand hygiene practices through multifaceted approaches is crucial for reducing HAIs and safeguarding patient health in the hospital environment. Given the resource constraints in Myanmar's healthcare system, cost-effective interventions such as targeted training, strategic placement of hand hygiene facilities, and routine feedback should be prioritized.