Medical students constitute an important group within the healthcare workforce and havethe potential to transmit infections to vulnerable patients as they frequently come into contact with patients during clinical examinations, ward postings and in operating theatres (1, 2). Contaminated hands of healthcare practitioners represent a significant modeof transmission of pathogens within the health care setting (3,4). Poor compliance with hand hygiene protocols exacerbates the threat to patient safety. This could lead to a significant rise in the prevalence of healthcare-associated infections (HAIs)resulting in increased morbidity, mortality, prolonged hospital stays, and escalating healthcare costs (5, 6,7). Hand hygiene is recognized by the Centre for Disease Control and Prevention (CDC) and the World Health Organization (WHO) as the single most effective measure for preventing the transmission of infections in healthcare settings (1,4). Appropriate hand hygiene is estimated toprevent up to half of all avoidable healthcare-associated infections, making it the most effective and cost-efficient strategy for reducing pathogen transmission (8,9). Medical students begin interacting directly with patients during their clinical postings.Hand hygiene practices acquired during this period are likely to persist throughout their professional careers. Improving awareness regarding appropriate hand hygiene practices among medical students is therefore essential for strengthening infection prevention and promoting patient safety and it provides an opportunity to identify knowledge gaps and implement educational interventions before they enter independent clinical practice(10). The present study was undertaken to assess the awareness of undergraduate medical students regarding hand hygiene during their clinical postings, to evaluate their self-reported practices, and to identify gaps in knowledge and adherence to WHO recommendations. By highlighting these gaps, this study aims to recommend targeted interventions that can improve compliance with hand hygiene protocols and strengthen infection prevention practices among future healthcare professionals. METHODOLOGY This was a cross-sectional questionnaire-based study conducted among undergraduate medical students attending clinical postings at a Medical College, Andhra Pradesh, India. The study was conducted after obtaining approval from the Institutional Ethics Committee(IEC:06). First-year undergraduate medical students and those who had not attended clinical postings for three consecutive days before data collection were excluded from the study. A total of 150 undergraduate medical students attending clinical postings and are willing to participate were included in the study. Before administering the questionnaire, all participants were explained the purpose of the studyand provided assurance regarding the confidentiality of their responses. Data was collected using a validated, structured questionnaire prepared by reviewing questionnaires of validated surveys that were previously done and modifiedto suit the local healthcare setting (11,12,13). The questionnaire comprised two sections: the first assessed participants' awareness regarding hand hygiene, while the second evaluated their self-reported hand hygiene practices. Responses were recorded in a Yes/No format, along with selected multiple-choice questions assessing knowledge of hand hygiene techniques, indications, and duration.

This was a cross-sectional questionnaire-based study conducted among undergraduate medical students attending clinical postings at a Medical College, Andhra Pradesh, India. The study was conducted after obtaining approval from the Institutional Ethics Committee(IEC:06). First-year undergraduate medical students and those who had not attended clinical postings for three consecutive days before data collection were excluded from the study. A total of 150 undergraduate medical students attending clinical postings and are willing to participate were included in the study. Before administering the questionnaire, all participants were explained the purpose of the studyand provided assurance regarding the confidentiality of their responses. Data was collected using a validated, structured questionnaire prepared by reviewing questionnaires of validated surveys that were previously done and modifiedto suit the local healthcare setting (11,12,13). The questionnaire comprised two sections: the first assessed participants' awareness regarding hand hygiene, while the second evaluated their self-reported hand hygiene practices. Responses were recorded in a Yes/No format, along with selected multiple-choice questions assessing knowledge of hand hygiene techniques, indications, and duration

A total of 150 undergraduate medical students participated in the present study. Awareness regarding Hand Hygiene: Of the 150 participants, 80%(n=120) had undergone formal training for hand hygiene, 95%(n=142)were aware about health care associated infections,97%(n=145) recognized that hand hygiene is an effective way to prevent cross infections.Regarding the method of hand hygiene 5% (n=8) correctly identified that hand rub is effective in removing germs than hand was in clean hands whereas 95%(n=142) didnot.For visibly soiled hands 92%(n=138) correctly reported that hand washing should be performed. Regarding the agents used for hand hygiene 75%(112)correctly identified that both alcohol-based hand rubs and antimicrobial soaps can be used for hand hygiene.83%(n=124)participants preferred hand wash following exposure to blood or body fluids.55%(n=82) participants selected duration of hand rub as 20seconds,65%(n=97)participants selected the duration of hand wash as 60 seconds.67%(n=100)participants identified unclean hands of health care professionals as the source of transmission of Health care associated infections. Practices regarding Hand hygiene: Among the 150undergraduate medical students 69%(n=103) mentioned that hand hygiene to be performed before taking blood pressure,88%(n=132),95%(n=142)and 86%(n=129)preferred hand rub before giving injections, before palpating abdomen and before touching another patient respectively.87%(n=130)participants reported that hand hygiene to be performed after removing gloves and 94%(n=141) stated that all accessories are to be removed before performing hand hygiene. A majority 85%(n=127) acknowledged that excessive use of hand rub can cause dryness.93%(n=139) reported performing hand hygiene after touching hospital surfaces and 66%(n=98)preferred hand wash for that 70%(n=105) mentioned that they will not turn off the faucet with washed hands after performing hand hygiene.79%(n=119) mentioned that they prefer hand hygiene after coughing or sneezing. TABLE1.AWARENESS REGARDING HAND HYGIENE AMONG UNDERGRADUATE MEDICAL STUDENTS 1 QUESTION NUMBER (n) PERCENTAGE (%) FOR HAND HYGIENE, FOLLOWING PRACTICES CAN BE USED A.ALCOHOL BASED SOLUTIONS 15 10 B. ANTIMICROBIALS BASED SOAPS OR LIQUIDS 21 14 C.BOTH 112 75 D.NONE OF THE ABOVE 2 1 2 HAND HYGIENE TO BE FOLLOWED AFTER CONTACTING BLOOD OR BODY FLUIDS? A.HAND WASH 124 83 B.HAND RUB 26 17 3 DURATION OF HAND RUB A.10 SEC 14 9 B.20 SEC 82 55 C.40 SEC 26 17 D.60 SEC 29 19 4 DURATION OF HAND WASH A.30 SEC 32 21 B.40 SEC 15 10 C.50 SEC 6 4 D.60 SEC 97 65 5. WHAT ARE THE SOURCES OF TRANSMISSION OF HEALTHCARE ASSOCIATED INFECTIONS? A.UNCLEAN HANDS OF HEALTHCARE PROFESSIONALS 100 67 B.SHARING OF UNCLEAN OBJECTS 6 4 C.CONTAMINATED SURFACES 39 26 D.CIRCULATING HOSPITAL AIR 5 3 TABLE2.PRACTICE OF UNDERGRADUATE MEDICAL STUDENTS REGARDING HAND HYGIENE PRACTICES 1 QUESTION NUMBER (n) PERCENTAGE (%) WHAT IS THE PRIMARY PURPOSE OF HAND HYGIENE? TO REDUCE THE MICROBES ON THE HANDS 139 93 TO KEEP NAILS CLEAN 5 3 TO MAINTAIN SKIN INTEGRITY 6 4 2 WHICH PRACTICE DO YOU PREFER AFTER SNEEZING OR COUGHING HAND HYGIENE 119 79 TISSUE 31 21 3 WHICH HAND HYGIENE WOULD YOU PREFER AFTER TOUCHING HOSPITAL SURFACES? HAND RUB 52 34 HAND WASH 98 66

Hand hygiene is considered as the most effective and economical intervention to prevent transmission of Health care associated infections. As undergraduate medical students are increasingly involved in contact with patients during clinical postings their awareness and adherence to hand hygiene practices play an important role in ensuring patient safety. The present study evaluated the awareness and self-reported hand hygiene practices among undergraduate medical students attending clinical postings. In the present study 80% of undergraduate medical students have undergone formal training for hand hygiene and 95% of participants have an idea regarding health care associated infections. These findings are comparable with those reported by Nair et al., in which79%of medical and nursing students reported having received formal hand hygiene training (12). Although this indicates a satisfactory level of awareness among majority of participants it is noteworthy that 20% had not received any formal training and 5% had no idea regarding healthcare associated infections. This is a matter of concern as these students will be involved in direct patient care during the clinical postings, where inadequate knowledge can facilitate transmission of Health care associated infections and compromise patient safety. In the present study 97% recognised hand hygiene as an effective way to prevent cross infections. These findings are similar to Modi et al., where 96% of undergraduate medical students recognised hand hygiene as effective method to prevent cross infections (14).This high level of awareness is encouraging but continuous reinforcement through practical training is necessary to translate knowledge into clinical practice. 92% of the participants correctly identified that hand washing can be used for visibly soiled hands,83% correctly mentioned that hand wash to be performed after contact with body fluids whereas 17% mentioned that hand rub to be performed. These findings are in agreement with WHO guidelines on hand hygiene. Similar observations were made by Suchitra and Lakshmi devi et al, who mentioned that although health care workers had good awareness regarding hand hygiene indications, gaps exist in selecting appropriate hand hygiene method in different situations (15). Only 10% of the participants identified alcohol-based hand rub alone as an appropriate method for routine hand hygiene, while 55%correctly identified the recommended duration of hand rubbing and 65% correctly identified the recommended duration of hand washing.Kamble et al.Study also reported that despite overall good knowledge, many undergraduate medical students were unable to correctly answer questions related to the recommended hand hygiene method and duration(16). Although 67% of the participants in the present study correctly recognized contaminated hands of health care workers as the principal route for transmission of Health care associated infections, remaining 33% were unable to identify the most important source of transmission (17). These findings indicate that although the level of awareness is satisfactory, continued emphasis through educational interventions regarding the role of hand hygiene in interrupting the chain of infection is essential during undergraduate medical education. Regarding the self-reported hand hygiene practices majority of participants 89% reported that hand rub to be performed before giving injections, before palpating abdomen (86%),before touching another patient(95%),before measuring blood pressure(69%),hand hygiene to be performed after removing gloves(87%),after touching hospital surface(93%). These findings are in accordance with WHO five moments of hand hygiene (18).Similar findings were reported by Modi et al. Who observed that 91.6% of undergraduate medical students recognised importance of hand hygiene before contact with patient and 88.7% before aseptic procedures (14).Thecomparatively lower compliance before measuring blood pressure observed in the present study suggests that routine non-invasive patient care activities are often underestimated and require greater emphasis during undergraduate clinical training. An encouraging observation is that 94% of the participants reportedremoving hand accessories before performing hand hygiene and 70% reported that they will not turn off the faucet with washed hands after performing hand hygiene. But the remaining participants who did not follow the recommended practices indicate the need for regular practical demonstrations to ensure adherence to standard hand hygiene protocols. Overall, the findings of the present study indicate that undergraduate medical students possess a satisfactory level of awareness regarding the hand hygiene practices but there exists deficiency in application of the WHO recommendations in specific situations (19).Thissuggests that theoretical knowledge alone may not translate into appropriate clinical practice. So, strengthening the undergraduate teaching through simulation sessions, regular refresher training, visual reminders and continuous feedback will likely improve the long-term compliance with the recommended hand hygiene practices (20). Such interventions will strengthen infection prevention control practices and contribute to improved patient safety (21).The limitations of the present study include its single centre designso the generalizability of the findings is limited, and use of self-reported questionnaire instead of direct observation of hand hygiene practices may be influenced by response bias.

The present study indicates that though the undergraduate medical students have demonstrated satisfactory level of awareness regarding the hand hygiene practices gaps exist in understanding and application of WHO hand hygiene recommendations. As hand hygiene is fundamental component of infection prevention and control practices integrating hand hygiene training and simulation-basedexercises, performing periodic assessments among undergraduate medical students will help in fostering a strong culture of infection prevention and control practices among future health care professionals

1. World Health Organization. WHO Guidelines on Hand Hygiene in Health Care. Geneva: WHO; 2009. 2. Bhatta DR, Hamal D, Shrestha R, Parajuli R, Baral N, Subramanya SH, et al. Nasal and pharyngeal colonization by bacterial pathogens: A comparative study between preclinical and clinical sciences medical students. Can J Infect Dis Med Microbiol. 2018;2018:7258672. doi:10.1155/2018/7258672. 3. Toney-Butler TJ, Carver N, Gasner A. Hand hygiene [Internet]. StatPearls Publishing; 2023. Available from: https://www.ncbi.nlm.nih.gov/books/NBK470254 (ncbi.nlm.nih.gov in Bing) 4. Boyce JM, Pittet D. Guideline for hand hygiene in health-care settings. MMWR Recomm Rep. 2002;51(RR-16):1–45. 5. Allegranzi B, Pittet D. Role of hand hygiene in healthcare-associated infection prevention. J Hosp Infect. 2009;73(4):305–15. 6. Pittet D. Improving adherence to hand hygiene practice: a multidisciplinary approach. Emerg Infect Dis. 2001;7(2):234–40. 7. National Centre for Disease Control. Procedures and practices for infection prevention and control. Training Session IV. New Delhi: NCDC; 2024. Available from:https://ncdc.mohfw.gov.in/wpcontent/uploads/2024/03/5733625921672916954.pdf (ncdc.mohfw.gov.in in Bing) 8. Mathur P. Hand hygiene: Back to the basics of infection control. Indian J Med Res. 2011;134(5):611–20. 9. Erasmus V, Daha TJ, Brug H, et al. Systematic review of studies on compliance with hand hygiene guidelines in hospital care. Infect Control Hosp Epidemiol. 2010;31(3):283–94. 10. World Health Organization. Hand Hygiene [Internet]. Geneva: WHO; 2022. Available from: https://www.who.int 11. Ariyaratne MHJD, Gunasekara TDCP, Weerasekara MM, et al. Knowledge, attitudes and practices of hand hygiene among final year medical and nursing students at a Sri Lankan university. BMC Med Educ. 2013; 13:15. 12. Nair SS, Hanumantappa R, Hiremath SG, Siraj MA, Raghunath P. Knowledge, attitude and practice of hand hygiene among medical and nursing students at a tertiary health care centre in Raichur. ISRN Prev Med. 2014; 2014:608927. 13. van de Mortel TF, Apostolopoulou E, Petrikkos G. A comparison of the hand hygiene knowledge, beliefs and practices of Greek nursing and medical students. Am J Infect Control. 2010;38(1):75–7. 14. Modi PD, Kumar P, Solanki R, Modi J, Chandramani S, Gill N. Hand hygiene practices among Indian medical undergraduates: A questionnaire-based survey. Cureus. 2017;9(7): e1463. doi:10.7759/cureus.1463. 15. Suchitra JB, Lakshmi Devi N. Impact of education on knowledge, attitudes and practices among various categories of health care workers on nosocomial infections. Indian J Med Microbiol. 2007;25(3):181–7. doi:10.4103/0255-0857.34757. 16. Kamble VS, Biradar SM, Takpere A, Reddy S. Knowledge of hand hygiene practices among students of ESIC medical college, Gulbarga, Karnataka, India. Int J Community Med Public Health. 2017;3(1):94–8. 17. ittet D, Allegranzi B, Sax H, Dharan S, Pessoa-Silva CL, Donaldson L, et al. Evidence-based model for hand transmission during patient care and the role of improved practices. Lancet Infect Dis. 2006;6(10):641–52. 18. Sax H, Allegranzi B, Uçkay I, Larson E, Boyce J, Pittet D. ‘My five moments for hand hygiene’: A user-centred design approach to understand, train, monitor and report hand hygiene. J Hosp Infect. 2007;67(1):9–21. 19. Erasmus V, Daha TJ, Brug H, Richardus JH, Behrendt MD, Vos MC, et al. Systematic review of studies on compliance with hand hygiene guidelines in hospital care. Infect Control Hosp Epidemiol. 2010;31(3):283–94. 20. National Medical Commission. Competency Based Medical Education Curriculum for the Indian Medical Graduate. New Delhi: NMC; 2019. 21. Pittet D. Improving adherence to hand hygiene practice: a multidisciplinary approach. Emerg Infect Dis. 2001;7(2):234–40