Assessment of Hand Hygiene Knowledge, Attitude, and Practice Among Health Sciences Students in Herat, Afghanistan: A Cross-Sectional Study [Letter]

Dear editor

The reviewers have assessed the paper “Assessment of Hand Hygiene Knowledge, Attitude, and Practice Among Health Sciences Students in Herat, Afghanistan” by Ejaz et al.¹ This study provides valuable insight into hand hygiene (HH) awareness among future healthcare professionals in a challenging, resource-limited setting. The authors deserve recognition for addressing a critical public health issue within the context of Afghanistan.

The use of convenience sampling limits the generalisability of the findings. Since the participants may not fully represent the broader student population, the results should be interpreted with caution. The paper does not report how many students were approached versus how many took part. The absence of this information makes determining the potential for nonresponse bias challenging.

The research is based only on self-reported data, which probably led to the relatively high HH adherence rate of 92.85%. There is a chance of social preference bias, which makes it hard to know how right these answers are without observational or objective measures.

While the authors used a previously validated questionnaire, it was originally piloted among healthcare workers, not students. The validation population (30 healthcare workers) differs slightly from the study population (students)—this could impact the transferability of psychometrics. There are possible response bias due to the self-administered format.

Also, important validation steps like construct validity testing (eg, factor analysis) were not performed. KAP (Knowledge, Attitude, and Practice) scores were categorised using the sample’s median rather than international benchmarks, such as WHO standards. This makes it difficult to compare results with other studies globally.

The study does not mention any efforts to adapt the questionnaire to Afghanistan’s multilingual context. This could affect how well participants understood the questions, possibly influencing the results.

The study used a subjective measure of SES. More objective methods—like income ranges or asset ownership—would improve classification accuracy. While overall scores were high, important gaps in understanding were found. Only 3.3% of students knew that gloves should be used regardless of visible infection, and over half (57.8%) thought HH is only needed during official hospital work. These results show a significant gap between knowledge and real-world application. Possible confounding factors (eg, prior HH training, institution type) are not discussed or adjusted for.

In conclusion, Ejaz et al’s work makes a meaningful contribution to infection prevention literature in a low-resource setting. With some methodological refinements, future studies can offer even deeper and more actionable insights.