1.0 INTRODUCTION

1.1 BACKGROUNG INFOERMATION
Infectious diseases are caused by pathogenic microorganism such as bacteria, viruses, parasites or fungi and the disease can be spread directly or indirectly, from one person to another[8]. Among these modes of transmission, person-to-person contact via the hands is a common mode of transmission of bacterial infection. Serious disease causing pathogens commonly found in school settings includes Streptococcus pyogenes, Streptococcus pneumoniae, Staphylococcus epidermidis, and Community-Associated Methicillin-Resistant Staphylococcus[8][9].

According to the WHO, hand hygiene is defined as a behavior of cleaning the hands with soap and water and by hand-rubbing using hand sanitizer without water[10]. Hand-washing is an inexpensive and effective way to prevent infection and control disease, it has long being recognized to be a convenient, effective and also cost effective means of preventing communicable diseases. Research is clear that proper hygiene is the key to reducing occurrence of infectious diseases in many different types of communities, including the healthcare settings, daycare centers, and grade schools[10][14]. A casual link between hand hygiene and rates of infectious disease illness has been established. Poor hand hygiene was significantly linked to higher incidence of infectious diseases, medical visits and absence from classes or work. Absenteeism related to communicable disease also affects educational institutions such as re-teaching absent students. People who are not regular hand washers have been shown to have an increased incidence of viral illness that can lead to inevitable bed rest.

In 2002, it was established that a high level of proper hand hygiene may make the difference between a successful recovery and a health care–associated infection, which account for 1.7 million infections and 99,000 associated deaths each year in American hospitals alone (Center for Disease Control and Prevention [CDC], 2002). Globally >3.5 million children younger then 5 years mainly concentrated in developing countries die from diarrhea and acute lower respiratory infections[15][17]. The transmission of communicable disease is responsible for >165million lost school days per school year among students up to twelfth grade worldwide. Closed environments and low levels of hand-washing contribute to disease transmission on university campuses which is similar to that in hospitals. The CDC (2018) and the WHO have published simple-to-follow hand-washing guidelines. However, incorrect hand-washing practices and low compliance are prevalent even among health care worker[15][17]. Approximately 2.4 million deaths can b prevented annually by good hand hygiene practice, reliable sanitation and drinking water.

1.2 PROBLEM STATEMENT.
Promotion of improved hand hygiene has been recognized as a cornerstone of infectious disease control and an important public health measure. [1] While innumerable studies posit that proper hand hygiene is the key to reduce occurrence of infectious diseases in different types of communities, college/university students have been found to inadequately wash their hands, which increases their chances of contracting infectious diseases. Improper hand hygiene is an important contributing factor to contracting infectious diseases among university students [1][2]. However, incorrect hand washing practices and low compliance are prevalent even among health care workers [3][4]. Several studies addressed hand hygiene among different population, however hand hygiene practices among university students are very limited. Although the morbidity and mortality associated with respiratory and gastrointestinal illness among university students are relatively low, these infectious may contribute to absenteeism along with the sickness presenteeism, which can ultimately affect academic performance and efficiency, and can also be associated with viral gastroenteritis, and upper respiratory tracts infections. Whether the university students have adequate knowledge on the effect of hand hygiene practices against infectious diseases is an interesting question that needs to be assessed in this research study [5]. A meta-analysis on 30 hand hygiene studies found that improvements in hand washing reduced the incidence of upper respiratory tract infections by 21% and gastrointestinal illnesses by 31% [1]. It is also indicated that hand-washing with soap could reduce the risk of diarrheal diseases by 42%–47%, and hand-washing promotion has been projected to save millions of lives [1][2]. Approximately 2.4 million deaths can be prevented annually by good hygiene practices, reliable sanitation, and drinking clean water [6[17].

1.3 RESEARCH QUESTION
This study addresses the following research question,
What are the levels of knowledge, attitudes and practices of hand hygiene among undergraduate medical students during their clinical phase at CUHAS?

1.4 OBJECTIVES
1.4.1 The broad objective of this research
Is to assess the knowledge, attitude and practices of hand hygiene among Medical students during their clinical phase at a CUHAS.
1.4.2 The specific objectives are
• To assess the levels of knowledge of hand hygiene among undergraduate medical students at CUHAS BUGANDO during their clinical phase.
• To assess the attitudes regarding hand hygiene among undergraduate medical students at CUHAS BUGANDO during their clinical phase.
• To assess the self-reported hand hygiene practices among undergraduate medical students at CUHAS BUGANDO during their clinical phase.

1.5 STUDY RATIONALE
Although some of the extensive research has been conducted to investigate the hand hygiene knowledge, beliefs, and practices of health care providers and daycare centers and elementary schools, there are very few previous studies addressing hand hygiene practice on university campuses. This research study would be very useful in identifying gaps in knowledge, poor attitudes and substandard practices to enhance the development of appropriate strategies to promote hand hygiene for university students in the future.