Healthcare-associated infections (HAIs) are the most frequent adverse events among hospitalized patients and a major global problem for patient safety [1] . It is estimated that over 1.4 million people suffer from hospital-acquired infections, and the risk of contracting them is two to twenty times higher in developing countries [2] . In sub-Saharan Africa, the prevalence of HAIs ranges from 1.6% to 28.7% [3] [4] . About 50% of these infections are transmitted by the hands of healthcare providers in the course of their work [5] .

The World Health Organization (WHO) recommends five indications for hand hygiene (HH) in healthcare settings and encourages providers to regularly clean their hands in the performance of their duties. However, HH membership among providers remains low, with an average of 40% worldwide [5] .

In addition to the physical and moral consequences they have for patients and their families, healthcare-associated infections are the basis for longer hospital stays, excess costs, high resistance of microorganisms to antibiotics, and high mortality rates. They therefore place a high financial burden on health systems [6] [7] .

The high burden of healthcare-associated infections is due to the lack of standardized infection prevention and control (IPC) programs [7] . Many healthcare facilities (HCF) are not equipped with handwashing facilities; an estimated 7% of healthcare facilities in sub-Saharan Africa and 2% worldwide are completely devoid of them [4] . There is thus a gap between the desired quality of hand hygiene as recommended through the IPC standard and that applied in healthcare facilities [8] .

During the COVID-19 pandemic, HH has garnered unprecedented attention and has become the central pillar of national COVID-19 prevention strategies. However, it should not be just a temporary public health measure in times of crisis, but a daily vital attitude contributing to health and economic resilience [9] .

The results of two studies conducted in Malawi and in Kisangani also showed low adherence to the practice of hand hygiene among hospital health providers, at 22% and 39%, respectively [6] [10] . Even a recent study in Togo on staff’s knowledge reported: 31.1% of practitioners did not wash their hands on arrival and departure in services; 62.2% did not wash their hands before treatment [11] . A recent qualitative study carried out in Ethiopia identified three main categories of barriers to hand hygiene practice: barriers related to individuals (including three sub-categories: lack of knowledge and skill, improper attitude, and poor attention and negligence of healthcare workers); leadership barriers (including two sub-categories: lack of dedicated staff and low attention of leaders); and institutional barriers (including three sub-categories: inappropriate infrastructure and lack of resources, shortage of water, and high workload and staff turnover) [12] .

Despite its justified interest and contribution to improving the quality of care, HH is still poorly known and poorly implemented within healthcare facilities [13] . Its implementation therefore requires that IPC teams be functional, that the indications and practical modalities on hygiene promotion are defined, that administrative measures be applicable in the healthcare facilities, that workload is respected, and that providers are trained and made aware of the value and need to apply hand hygiene in healthcare settings. This can only be successful if there is in-depth information on the knowledge and practices of providers in the field of hand hygiene.

The Democratic Republic of Congo (DRC), and particularly the province of Lualaba, should be no exception to this general observation, especially since healthcare facilities operate in a context with limited resources. However, the existing data on claimants’ behavior towards HH do not provide in-depth information on the explanatory factors for this [6] [14] . Thus, this study was conducted to determine the factors associated with low adherence to HH practice among providers of healthcare facilities in Lualaba province, their characteristics, and their knowledge of HH in order to contribute to the implementation of interventions for the control of infections carried by the hands.

A total of 384 interviews were completed out of the 400 expected, giving a response rate of 96.0%. Thus, 1996 HH actions were identified out of 5266 opportunities, representing an overall compliance rate of 37.9%. Table 1 summarizes HH compliance levels among care providers.

Midwives/birth attendants had the highest rate of HH adherence (44.4%), followed by laboratory technicians (41.1%), nurses (39.2%), and doctors (37.1%). However, hand-rubbing using the hydroalcoholic solution was used more often for HH (29.3%) than hand washing (8.6%). Table 2 describes the characteristics of health care facilities, providers, and general knowledge of hand hygiene in the Province of Lualaba.

Of these interviews, 143 (37.2%) took place at the Mwangeji second-level HCF; 128 (33.3%) at the Gécamines Staff Hospital in Kolwezi; 49 (12.8%) at the second-level HCF in Kanzenze; 39 (10.2%) at the Dipeta second-level HCF; and 25 (6.5%) at the Mupanja second-level HCF.

The majority of providers interviewed (38.5%) were nurses, followed by physicians (28.1%). In relation to the origin of the water used for hand hygiene, in 54.9% it came from boreholes, and in 43.8% the source was the national water distribution company (REGIDESO). Hydroalcoholic solution (HAS) was not widely available, with 24.7% of healthcare providers reporting that they did not have access to it.

Concerning the existence of a functional IPC team or committee in healthcare facilities (HCFs), less than half of providers (45.8%) acknowledged the existence of an IPC team; in just over one in five establishments (22.4%), administrative measures in the form of negative sanctions/punishments for non-compliance with HH were regularly taken.

Hand hygiene involves the ability to wash hands with soap and water or to rub hands with alcohol-based hand sanitizer (HAS). The results of this work indicate that 261 (68.0%) health providers had not received any training on hand hygiene in the last 3 years. Thus, 28.9% of providers did not know the definition of hand hygiene, and 76.8% were not able to cite the 5 indications of hand hygiene according to the WHO. For 7 out of 10 health care providers (72.7%), the use of gloves in a healthcare setting provides hand hygiene indications; and for 49.0% of them, the practice of hand hygiene should be done only when dirt is evident on the hands. Hand hygiene is an effective way to prevent healthcare-associated infections; however, our results indicate that 14.4% of providers had a poor perception of it. Table 3 and Table 4 summarize factors associated with low adherence to hand hygiene by HCFs’ providers in the Lualaba province.

The analysis of the Chi-Square test looked for an association between low compliance with HH and certain characteristics of HCFs. It appears from this analysis that the absence of administrative measures in the HCFs (p = 0.004), the excessive workload (p = 0.018), the absence of the committee for the control of healthcare-associated infections (p < 0.001), low access to hydroalcoholic solution (p = 0.016), and the nursing profession (p = 0.018) were associated with low compliance with HH in the HCFs visited.

Low adherence to HH was also associated with providers’ low knowledge of the 5 indications for HH (p < 0.001), lack of on-the-job training (p < 0.001), and not perceiving the risk of hand-to-hand transmission of healthcare-associated infections (p = 0.002) ( Table 3 ).

In the multivariate model, the independent variables that had been associated with low compliance with HH in the bivariate analysis were introduced. Thus, only low knowledge of the 5 indications of HH (p < 0.001), lack of training (p = 0.003), low access to hydro-alcoholic solution (p = 0.043), and absence of administrative measures (p = 0.031) were associated with low compliance with HH. Indeed, health care providers with low knowledge of the 5 indications of HH were up to five times more likely not to adhere to HH compared to those with good knowledge (OR = 4.749; 95% CI 2.398 - 9.407; p < 0.001).

Healthcare providers who were not trained in HH were up to 2 times more likely not to adhere to HH (OR = 2.348; 95% CI 1.337 - 4.125; p = 0.003) compared to the others. The inaccessibility of the hydro-alcoholic solution for the providers would double the chance of not performing HH (OR = 1.996; 95% CI 1.021 - 3.902; p = 0.043). Similarly, the absence of administrative measures in favor of HH within the HCFs doubled the chance of not observing HH among healthcare providers (OR = 1.966; 95% CI 1.064 - 3.631; p = 0.031).

Conversely to the above, the permanent availability of water in HCFs (p = 0.012) and the perception of the risk of HAI transmission via hands at any time (p = 0.046) were associated with good adherence to HH. Indeed, the permanent availability of water in HCFs would halve the risk of poor adherence to HH (OR = 0.454; 95% CI 0.255 - 0.846; p = 0.012). Similarly, the perception of the risk of transmission of HAIs by hands at any time (OR = 0.574; 95% CI 0.333 - 0.990; p = 0.046) reduces the risk of poor adherence to HH by almost half.

The results of this study showed that there is an overall low adherence to hand hygiene among healthcare providers in Lualaba province. From this point of view, this result is similar to that reported in Burkina Faso in 2013 [16] , and to those found in Kisangani in 2020 [6] and in the USA in 2022 [17] . However, the rate of compliance with HH found in our work appears to be higher than that reported by Mathai et al. in India [3] , and that found by Nzanga et al. in Malawi [10] . Thus, this result is far higher than that reported in 2011 in a study organized in Ethiopia [18] . Conversely, the HH compliance rate found in this work is lower than those reported by Musu et al. in 2017 [19] and in Saudi Arabia in 2015 [20] . The implementation of interventions to promote HH can improve its compliance rate. Indeed, a study carried out in Nigeria in a Federal Teaching Hospital in the Southeast reported a higher rate of compliance with HH. This was due to the implementation of interventions such as training (provider education), introduction of hand sanitizer, and hand hygiene reminders [21] . In the present study, the Obstetrics and Gynecology department recorded a higher rate of compliance with HH than other HES departments; also, midwives have a higher rate of compliance with HH compared to physicians. These results are similar to those reported in Nigeria in 2014, where the rate of HH adherence was higher among nurses compared to doctors [21] , but do not agree with the Kisangani study [6] . Our result, however, is lower than that found in Bamako in 2016 [22] . The difference observed in this study compared to the other authors is due to the difference in the training programs, the existence of the functional control committee, the promotion and monitoring of hand hygiene in health care facilities, as well as the awareness of the providers.

The occupational category of nurse was associated with low adherence to HH among providers. This result is different from that found by some studies that have shown low compliance with HH in physicians [10] [21] . This difference is due to a lack of time, a lack of perception of the risk of HAIs, and the speed of care interventions in the group of nurses. It should also be noted that the excessive workload of nurses in healthcare establishments and the lack of training in hand hygiene could explain this low compliance.

The inaccessibility of alcohol-based hand sanitizer (HAS) in the department, the absence of administrative measures, and the absence of an IPC committee in healthcare facilities have been identified as explanatory factors for low compliance with HH. These results are consistent with those found in a study conducted in Ethiopia [23] . The existence of the IPC functional committee is of paramount importance in HCFs for the monitoring of HH practice, the supervision of providers, feedback, the holding of coordination meetings, and the popularization of directives, and the taking of negative or positive administrative measures against health care providers on the application of hand hygiene.

This study reported that the provincial government and technical and financial partners were the main suppliers of consumables (borehole water, hydro-alcoholic gel, and liquid soap) necessary for compliance with HH. However, in the majority of cases, we noted the absence of administrative measures in healthcare institutions. These results are contrary to those found by several authors in the literature [6] [14] [24] .

We found that excessive workload was associated with low adherence to the practice of HH. However, in a study conducted in India, the results showed that the factor associated with low compliance with HH was a lack of time [3] . Several authors have also reported that a lack of time hinders the practice of HH by healthcare providers [24] - [26] .

Through our study, however, we did not find the relevance of the promotion of HH and that of wall posters containing the procedures on HH. Indeed, no association between these practices and low compliance with HH has been demonstrated. These findings are contrary to the findings of Nzanga et al., who reported that the absence of specific hygiene promotion interventions would lead to low compliance with HH by providers [10] . This discrepancy can be explained by the fact that most healthcare facilities in the province of Lualaba are supplied with inputs every quarter (hydro-alcoholic gel and wall posters of HH procedures). With the majority of providers at the bedside, few are trained in HH, and others are negligent and lack conscientiousness.

In terms of on-the-job training for providers, the lack of training was associated with low compliance with HH in Lualaba province. These observations are similar to those found in other studies [20] [23] [27] [28] . This is because capacity building of all professional categories is an ideal way to acquire knowledge of HH, which motivates and improves compliance with HH in healthcare settings.

As for knowledge of HH indications, we reported an association between low knowledge and low compliance with HH, which is similar to the results found in Ethiopia in 2014 [23] . Atif et al. showed that a lack of knowledge on the part of providers about hospital hygiene was a recurring theme in several studies; hence, appropriate IPC training could help address this problem [29] .

The other results of this study indicate that the poor perception of HH as an effective means of infection prevention would multiply the chance of not adhering to it by 2.4. These results are similar to those of a study conducted in the USA, which showed that providers do not consider HH necessary to prevent HAIs and that they also do not perceive the risk of transmission of healthcare-associated infections via the hands [29] . Thus, it is quite evident that when providers are not regularly trained and encouraged, they do not perceive the risk of transmission of healthcare-associated infections through the hands, as is the case in this study.

This study has strengths but also limitations. One of its strengths was that selection biases were minimized by probability sampling of targeted providers and a sufficient sample size. Information bias was also reduced by training investigators in HH observation and by pre-testing tools.

As for the limitations of this work, information bias has not been completely avoided since self-administered questionnaires can lead to response bias [6] [13] . We tried to reduce these biases by triangulating the information collected from the interviews and that from the observations of the practice of HH. The study was carried out in a third of the province’s health-care facilities and was selected on a purposive basis, so the results cannot be generalized to all second-level health-care facilities. However, a representative cross-sectional study is essential to confirm the results of this research in Lualaba province.

The level of knowledge and practices reported on HH compliance in this study indicates that, at present, few providers observe this practice, with regard to the standards laid down by the WHO, and this therefore constitutes an increased risk of healthcare-associated infections in healthcare facilities in Lualaba province.

The lack of administrative measures and the non-existence of the functional committee of the IPC; excessive workload; the lack of in-service training; insufficient knowledge of the 5 indications; and poor risk perception of healthcare-associated infection transmission through the hands were identified as explanatory factors. The application of administrative measures, coupled with provider training, as well as the revitalization of IPC committees in health care institutions, would improve hand hygiene compliance for the benefit of both patients and health providers. The study is therefore a reference document in the implementation of interventions for the control of manufactured infections in healthcare facilities in the province of Lualaba.

We thank the team of the Regional Project for the Strengthening of Disease Surveillance Systems in Central Africa, Fourth Phase (REDISSE IV), for funding this study. We thank the Director of the School of Public Health of Kinshasa (SPHK) and all his staff for making this work possible. We also thank everyone who participated in the data collection.