It consisted of all personnel working in wards: medical doctors (MD), medical assistants (MA), midwives (MW), birth attendants (BA), nurses (Nrs), and orderlies (O).

Included in the study were health workers, who provided care and had direct contact with patients and were present in the inpatient departments during the study period.

Not included in the study: health workers who were absent or refused to complete the questionnaire.

We conducted a prospective, cross-sectional descriptive study with extensive sampling. (The sample is no longer returned to the population after selection).

The information collected focused on knowledge, attitudes and practices related to HH. This survey was conducted using a questionnaire and observation grid.

The questionnaire: A series of standardized questions were administered to selected caregivers to explore their knowledge and perceptions of HH. This questionnaire consisted of two parts: identification of the respondent, his knowledge and attitudes about HH (See appendix for the questionnaire). Staff had to answer the questions in writing, after explanation and informed consent the questionnaire was administered to the selected. The questionnaire was tested and corrected before administration. This questionnaire came from several sources, the assembly of which constituted the questionnaire.

The observation grid: it was used to assess the type and quality of the technique used for HDM practice. Health workers were noted by us by observing them in their practice.

The main variables studied were:

- Level of knowledge of health care personnel on hand hygiene.

- Attitude of nursing staff on hand hygiene.

- The practice of hand hygiene performed by nursing staff.

The data collected were processed using Epi Info software version 7.2.5.0. and manually. Text entry and processing was possible using Microsoft Word Office 2013.

The study had received management approval from RHC Dapaong prior to commencing the investigation.

After a clear explanation of the benefits of the study, consent was obtained before the questionnaire was administered. The confidentiality of the information collected was guaranteed. The dignity and freedom of the respondents were respected throughout the investigation.

Male personnel accounted for 57.8% with a sex ratio of 1.4. The mean age of was 39 years ± 6.27 years (ranged 25 to 50 years). The surveyed staff consisted of five (5.6%) medical doctors, 10 (11.1%) medical assistants, 32 (35.6%) nurses, 10 (11.1%) Midwives, 8 (8.9%) birth attendants, and 25 (27.8%) orderlies.

When surveyed regarding HH purpose, staff provided the following answers: protection of both caregivers and patients, and protection of caregivers in 94.4%, and 5.6% respectively. None reported the protection of the patients as HH purpose. In relation to hand washing (HW) requirement, all personnel reported the need of soap and water. Regarding the number of HW types, 85.5% reported a correct answer (Table 1).

When they were surveyed on the timing of hand washing, the following responses were given as reported in Table 2: upon arrival and departure from care facilities (68.9%), at departure only (26.7%) and on arrival only (4.4%).

The difference between simple hand washing (SHW) and Hygienic Hand Washing (HHW), which was based on type of soap and washing duration was known by 73.3% of caregivers (Table 3). Whereas the HHW as correct type of HW to perform after a septic care, and the SHW as correct HW to perform after a non-septic care were known by 54.4% and 62.2% of staff respectively (Table 3).

*SHW: Simple Hand Washing; ^&HHW: Hygienic or Sanitary Hand Washing; ^#SrHW: Surgical Hand Washing.

The antiseptic soap was known by 69 caregivers (76.7%) to be the recommended soap for SHW, while none knew the duration of hand massage (Table 4).

The correct amount of antiseptics (≥5 ml) required for hand sanitation was known by 19 caregivers (21.1%), and all of them knew at least one hand antiseptic (Table 5).

Forty-six caregivers (51.1%) thought wearing gloves can replace hand washing (Table 6).

During the survey, the personnel used to wash hands before and after care in respectively 34 (37.8%) and 61 cases (67.8%), while 63 caregivers (70.0%) removed jewels except wedding ring, and 25 (28.8%) always used antiseptics (Table 7). A correct flushing direction and soap plating during HW were observed in 31 cases (34.4%), and 8 (8.9%) respectively (Table 8). None of surveyed personnel dried his hands after washing or closed the faucet with the hand towel.

We did not take samples from the hands of the nursing staff in order to assess the quality of HH. The study was done during Covid-19, which is a real bias on the results.

• Sample size

The small size included sample was related to the investigation design and the consent of staff. It would be related to the fact that some health workers were afraid of being exposed as setting a bad example during COVID-19.

• Age of the personnel

The mean age of respondents was 39 years ± 6.27 years, with extremes of 25 and 50 years. This result is a reflection of the mostly young health workers constituting valid arms for the RHC-Dapaong.

• Category of staff

Among those surveyed non-medical staff accounted for 94.4%. This workforce is inherent in all health facilities and depending on hospital activities requiring more paramedics.

• Purpose of the HH

The goal of hand hygiene was not known by 5.6% of the respondents. A category in our sample had not received training on HH. Objective recalled by [10] . This staff exposes patients to the risk of infection. DRAME G. [1] in his study in Mali reported a rate of 21.1% not knowing the objective. These staff need training on HH.

All respondents (100%) were aware that the HW consists of washing their hands with soap and water. Indeed, all health personnel had had training on hand hygiene in health facilities in Togo, particularly at RH of Dapaong. The definition recalled by [11] .

For DIALLO A it was 98.3% [5] . This knowledge remains to be encouraged, it serves as a basis for practice.

Fourteen decimal four percent (14.4%) of respondents did not know that there are 3 types of HW. This is a misunderstanding or oversight. This rate is much lower than that of DRAME G with 72.6% [1] . In this case the infectious risk in DRAMA G [1] was very high. These types were recalled by [12] [13] . In our context, the study was conducted in the midst of the COVID-19 pandemic. This is worrisome because with each type of hand washing, its particular indications. This knowledge should allow a good adaptation of the indications.

24% of respondents did not know the difference between SHW and HHW. The difference was well defined by [14] . This lack of knowledge exposes staff to the risks of contamination of patients and their environment. This lack of knowledge increases the risk of contamination by inappropriate attitude and practice.

All respondents (100%) had no knowledge of friction time during the SHW and therefore did not respect the friction duration. This friction time was recalled by [12] . This lack of staff knowledge increases the poor practice of SHW and a higher risk of contamination by making washing ineffective. Kaba M. [6] reported a rate of 98.6% not knowing the time of friction. This failure is very serious, the time of hand friction contributes to the effectiveness of the SHW. Nursing staff must be trained in hand hygiene.

Out of surveyed staff, 12.2% did not know that it is the single-use hand towel that should be used after rinsing. The use of the hand towel was recalled by [5] probably this result would be related to the lack of hand towels in the services, which makes the staff ignore its importance. For Guemning V. [7] 33.2% of the respondents did not know that the towel was recommended.

Among those surveyed, 31.1% did not know the indications. This was very dangerous with risk of contamination of the patients and the perpetuation of germs on the staff who could contaminate people outside the hospital. The study conducted by DRAME G [1] found a rate of 66.98% not knowing the indications. Hence the need to train or retrain nursing staff on hand washing. This indication was recalled by [5] [12] [15] .

Twenty-three decimal three percent of the respondents did not know the type of soap to use for hand washing. Soap used for hygienic hand washing was recalled by [14] . The staff again needs training on hand hygiene. The hygienic washing was recalled by [12] .

Thirty-seven decimal eight per cent did not know the type of hand washing to be performed after a patient’s care. This type of washing was recalled by [5] . This was yet another misunderstanding of the HW rules.

Forty-one decimal six percent of the respondents did not know the type of hand washing to be performed after a septic act, as recalled by [5] . This result noted the great ignorance of the rules of hand hygiene. It is necessary to organize the training of personnel on HW.

The existence of two types of hand antiseptics was not known by 54.5% of respondents. The existence of both types of antisepsis was by [14] . This lack of knowledge could be explained by the fact that the hospital did not yet have sufficient hydro alcoholic solutions. This finding corroborates that of GUEMNING V. L. [4] who found 54.5% in his study. Staff still need training.

Seventy-eight decimal nine percent of respondents did not know the amount of antisepsis (more than 5 ml). This quantity was recalled by [1] [5] [16] . This result is related to the fact that caregivers make more use of hand washing without the notion of hand antiseptics and therefore ignore good practices. They need to be trained absolutely.

• Jewelry arrangement

Seventy percent of those surveyed did not know that all jewelry and even the wedding ring had to be removed. These provisions were recalled by [12] . This attitude remains a risk factor that can increase the incidence of IAC in care structures. The study conducted by Musangu et al. [8] in the Congo found a similar result (64.6%). Health care workers see jewelry as a precious object. They absolutely need training.

• Nail arrangement

All respondents (100%) recognized the importance of nail trimming. This could be explained by the fact that the hands of caregivers in constant contact with patients could injure them and harbour the germs. This practice should be encouraged to increase the effectiveness of the HW. The nail provisions were also recalled by [12] .

• Hand antiseptics and hand washing

Twenty-seven decimal eight percent (27.8%) of the respondents were unaware that hand antiseptics were optional after hand washing recalled by [5] [14] . This is not a danger in itself.

• Wearing of gloves

Among those surveyed, 51.1% did not know that wearing gloves cannot replace hand washing. This is because health workers use gloves more in their actions instead of washing their hands. They should be aware of the importance of hand washing, it is indicated even before wearing gloves. This attitude is very serious for staff and patients by facilitating the transmission of germs. This rate is lower than that reported by Kaba M. [6] who had found 76.3%. Wearing gloves should never replace hand washing.

Despite adequate knowledge on a variety of hand hygiene measures, other necessary practices are not implemented in the Dapaong Regional Hospital.

Of those surveyed, 62.2% did not wash their hands before treatment. This practice is very dangerous, it constitutes a factor of manual transmission that can increase the incidence of IAC in the structures of care recalled by [12] .

Thirty-two decimal two percent of respondents did not wash their hands after care. This is a very dangerous practice at the origin of the transmission of germs to the sick and to the environment of care structures recalled by [12] .

Ninety-one decimal one percent of the respondents did not spread the soap on their hands and forearms after wetting them. It is a lack of knowledge of the steps of the HW by the caregivers recalled by [5] . This contributes to a decrease in the effectiveness of the gesture, hence the importance of becoming aware.

Of those surveyed, 65.6% did not rinse the hands from the nails to the elbows, a practice recalled by [12] .

This bad practice diminishes the benefit expected from hand washing. It is necessary to train staff in proper washing and rinsing practice in the right direction to optimize the effectiveness of the HW.

None of the respondents dried their hands after washing or closed the tap with the hand towel, a practice recalled by [5] . This bad practice must be corrected by training the care staff.