American Journal of Infection Control 45 (2017) 1043-5

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American Journal of Infection Control American Journal of

Infection Control

j o u r n a l h o m e p a g e : w w w. a j i c j o u r n a l . o r g

Brief Report

Knowledge, attitudes, and practices regarding environmental cleaning

among environmental service workers in Chinese hospitals
Kaiwen Ni MPH a, Bingbing Chen MM b, Hui Jin MS b, Qingxin Kong MS b,
Xiaoping Ni MB b, Hong Xu MM b,c,*
a
School of Public Health, The University of Hong Kong, Hong Kong, China
b
Department of Disinfection Surveillance and Vector Control, Hangzhou Center for Disease Control and Prevention, Hangzhou, Zhejiang, China
c Field Epidemiology Training Program of Zhejiang Province, Hangzhou, China

Key Words: We conducted a study using a face-to-face survey to assess knowledge, attitudes, and practices of envi-
Environmental cleaning ronmental service workers (ESWs) concerning routine cleaning and disinfection at 3 tertiary hospitals
Infection control in China. There were 115 (89.1%) respondents who agreed that environmental cleaning can contribute
Health care–associated infections
to keep patients safe, whereas 63 (48.8%) reported they were very willing to make cleaning practices better.
Occupational safety
Only 15 (11.6%) ESWs agreed they were in risk of nosocomial infections during daily cleaning. Our find-
ings suggest that the level of ESWs’ knowledge regarding cleaning practices was passable, but the awareness
of occupational safety and health was weak. There is a need to introduce sustained education and train-
ing aimed at ESWs.
© 2017 Association for Professionals in Infection Control and Epidemiology, Inc. Published by Elsevier
Inc. All rights reserved.

Health care–associated infections remain a leading cause of public METHODS

health problems, including prolonged stay in hospitals and addi-
tional mortality.1,2 Scientific evidence demonstrated that nosocomial
pathogens, such as methicillin-resistant Staphylococcus aureus, Clos-
tridium difficile, and vancomycin-resistant Enterococcus spp, can
survive on environmental surfaces for days to months,3,4 which in-
creases the risk of cross-transmission.
Environmental service workers (ESWs) are responsible for routine
cleaning-disinfection in patient rooms and communal areas, build-
ing a clean and safe health care environment. However, cleaning
practices by ESWs are often suboptimal, partly because of the lack
of feedback and training.5,6 ESWs’ attitudes and beliefs about their
job may impact their intent to clean and in turn the effectiveness
of their efforts.7 However, the role of environmental cleaning has
not received the same level of consideration as other infection control
strategies within hospitals in China. Our study aimed to assess the
level of knowledge, attitudes, and practices among ESWs regard-
ing environmental cleaning in Chinese hospitals.
Study design
This cross-sectional study was conducted in March 2015 at 3 ter-
tiary hospitals (hospitals A, B, and C) in Zhejiang Province, China.
Hospitals ranged in size from 1,000-3,200 beds. Cleaning and dis-
infection services in these hospitals were performed by 3 different
outsourcing companies. Trained interviewers selected subjects to
include ESWs who were responsible for different areas in hospi-
tals (outpatient area, general wards, and intensive care units). In each
area, no less than 30% of ESWs were invited to participate in face-
to-face surveys as a convenience sample. Verbally informed consent
was obtained from respondents, and survey results were kept
confidential.
Survey questionnaire

The questionnaire was designed by the authors. It consisted of

* Address correspondence to Hong Xu, MM, Department of Disinfection
Surveillance and Vector Control, Hangzhou Center for Disease Control and Prevention,
Mingshi Rd, Jianqiao Town, Jianggan District, Hangzhou, Zhejiang Province 310021,
China.
E-mail address: xuhong-123456@hotmail.com (H. Xu).
Funding/support: Supported by a grant from the Hangzhou Science and Tech-
nology Bureau (No. 20130733Q32).
Conflicts of interest: None to report.
5 sections: demographic information, knowledge regarding health
care–associated infections and occupational exposure, cleaning pro-
cedures, hand hygiene compliance, and attitudes toward
environmental cleaning. Correct general knowledge answers re-
ceived 1 point, whereas wrong knowledge answers received 0 points.
When ESWs agreed they had the knowledge of injury handling mea-
sures or standardized handwashing steps, interviewers further asked

0196-6553/© 2017 Association for Professionals in Infection Control and Epidemiology, Inc. Published by Elsevier Inc. All rights reserved.
http://dx.doi.org/10.1016/j.ajic.2017.02.029
1044 K. Ni et al. / American Journal of Infection Control 45 (2017) 1043-5

them to perform the corresponding processes. For instance, if the
performance of 6-step handwashing was entirely correct, the ESW
received 2 points; ESWs who could perform 2-5 steps for hand
hygiene received 1 point. A pilot test was conducted on a conve-
nience sample of 18 ESWs to assess the clarity and feasibility of the
process. The questionnaire was put into use after several revi-
sions, with approximately 12 minutes required for each one.
Statistical analysis
Quantitative data following normal distribution were analyzed
using mean and SD, whereas 1-way analysis of variance was used
to determine intergroup differences (data of age). Median, interquartile
range, and Kruskal-Wallis H test were performed when analyzing
data following skewed distribution (data of service year). Categor-
ical data, such as sex and education level, were examined using χ2
test or Fisher exact test. Correlation coefficients were calculated ac-
cording to age, education level, service year, and knowledge score.
All analyses were performed with R version 3.2.3 (R Foundation for
Statistical Computing, Vienna, Austria), and statistical significance
was defined by P < .05. The study was approved by the Research Ethics
Board at Hangzhou Center for Disease Control and Prevention.
RESULTS
A total of 129 ESWs were invited in this survey, with a 100% re-
sponse rate. Most respondents were women (72.9%), and the mean
age was 51.6 years (range, 32-65). Of the respondents, only 5 (3.9%)
received senior secondary education, whereas 78 (60.5%) were un-
educated or received primary education. The median number of
service years was 4 (range, 2 days-23 years). All ESWs received
preservice training focusing on cleaning procedures, except for 1
ESW who did not receive any training. There were statistically sig-
nificant differences in sex, education level, and service year between
hospitals (all P = .001). Table 1 shows more detailed demographic
information from survey respondents in each hospital.
Most respondents (89.1%) agreed that environmental cleaning
can contribute to keep patient safety, and 48.8% reported they were
very willing to make cleaning practices better. Regarding occupa-
tional safety and health, only 15 (11.6%) respondents agreed they
were susceptible to nosocomial infections during daily cleaning in
patient rooms, whereas 85 (65.9%) reported there was no risk of
acquiring infections. Of the respondents, 38% agreed that ESWs may
get infections from needlestick injuries with blood. In addition, less
than two-thirds of respondents had the corresponding knowledge
of injury-handling measures (Table 2).
There was no statistically significant difference in means of
knowledge scores between hospitals (F = 0.73, P = .49). A positive
correlation can be found between service year and knowledge score
(Spearman correlation = 0.22, P = .01). However, knowledge score did
not show statistical significance of correlations with age and edu-
cation level (Spearman correlation = −0.14, P = .11 and Spearman
correlation = 0.01, P = .93, respectively).
DISCUSSION
Outsourcing of environmental cleaning services has been widely
adopted in Chinese hospitals, but the impact of outsourcing on staff-
ing levels and the performance of cleaning practices is still unknown.
Toffolutti et al8 demonstrated that contracted ESWs were associ-
ated with increased methicillin-resistant S aureus incidence; however,
the burden of economic cost was lower in hospitals. A survey of
ESWs’ knowledge and opinions found no correlation between a
worker’s years of experience and total correct answers.9 In our study,
however, a positive correlation was found between ESWs’ service
year and knowledge score.
The level of ESWs’ knowledge regarding cleaning procedures
was passable, but their cleaning compliance had not been regular-
ly assessed in this study. Adenosine triphosphate bioluminescence
assay may be a useful indicator of environmental contamination
to assess cleaning efficacy. Previous studies have shown that clean-
ing practice interventions based on adenosine triphosphate surface

Table 1
Demographic information from survey respondents in 3 hospitals

Demographics Total (N = 129) Hospital A (n = 47) Hospital B (n = 42) Hospital C (n = 40) P value
Sex
Male 35 (27.1) 4 (9.3) 18 (42.9) 13 (32.5) .001
Female 94 (72.9) 43 (90.7) 24 (57.1) 27 (67.5)
Education level
Illiterate 18 (14.0) 15 (31.9) 3 (7.1) 0 (0.0) .001
Primary school 60 (46.5) 17 (36.2) 20 (47.6) 23 (57.5)
Junior high school 46 (35.7) 15 (31.9) 17 (40.5) 14 (35.0)
Senior high school 5 (3.9) 0 (0.0) 2 (4.8) 3 (7.5)
Age, y 51.6 ± 6.4 50.4 ± 6.3 51.5 ± 5.6 53.1 ± 7.1 .137
Service year 4 (1.0-8.0) 2 (0.9-4.6) 8 (3.0-10.0) 2.5 (0.7-4.0) .001

NOTE. Data are shown as mean ± SD, n (%), median (interquartile range), or as otherwise indicated.

Table 2
Responses to survey questions

Response

Questions Agree-always Uncertain-sometimes Disagree-occasionally

Environmental cleaning can contribute to keep patient safety 115 (89.1) 11 (8.5) 3 (2.3)
I have been taught to use color-coded cleaning tools in different areas 122 (94.6) 1 (0.8) 6 (4.6)
I know one cloth can only be used for one environmental surface in patient rooms 127 (98.4) 0 (0.0) 2 (1.6)
ESWs are susceptible to nosocomial infection in patient rooms during daily cleaning 15 (11.6) 29 (22.5) 85 (65.9)
ESWs may get infections from needlestick injuries with blood 49 (38.0) 51 (39.5) 29 (22.5)
I have the knowledge of injury-handling measures 80 (62.0) 41 (31.8) 8 (6.2)
I have the knowledge of standardized handwashing steps 66 (51.1) 58 (45.0) 5 (3.9)
I wash my hands with soap 107 (82.9) 20 (15.5) 2 (1.6)

NOTE. Values are n (%).

ESW, environmental cleaning worker.
 K. Ni et al. / American Journal of Infection Control 45 (2017) 1043-5
tests were associated with the improvement of environmental
decontamination.10 Therefore, this monitoring method should be
introduced in hospitals, providing direct feedback to ESWs.
Our findings suggest that the awareness of occupational safety
and health among ESWs is weak. Respondents reported that they
were reluctant to use mask and rubber or latex gloves, which were
available at hospitals, because personal protection equipment af-
fected the efficiency of their cleaning practices. However, ESWs are
exposed to biologic and chemical materials, indicating that they may
get infections during cleaning practices. Hand hygiene knowledge
and practice among ESWs were unsatisfactory, but hand hygiene
for ESWs may contribute to reduce the risk of cross-transmission.
Therefore, cleaning supervisors and nurses have the responsibility
to educate ESWs concerning proper use of personal protection equip-
ment, injury handling measures, and the importance of hand hygiene.
A new guideline for environmental cleaning in hospitals, in-
cluding cleaning strategy, cleaning-disinfection procedures, and
monitoring methods, was published in December 2016 in China.
Therefore, these findings have important implications. Consider-
ing the insufficient preservice training by outsourcing companies,
direct feedback and continuing education for ESWs should be per-
formed to improve cleaning practices and reduce incidence of
nosocomial infections in hospitals.
A limitation of the study was that secondary hospitals were not
involved in this survey, which may affect the generalizability of our
findings. Also, data analysis based on self-reported cleaning prac-
tices without assessing actual cleaning compliance may result in
bias in this study. In spite of these limitations, our findings suggest
that the level of ESWs’ knowledge regarding cleaning practices was
passable, but the awareness of occupational safety and health was
1045
weak. Sustained education and training aimed at ESWs may result
in improved environmental cleaning.
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