Posted in Infection control research

WHO’s Multi-modal Hand Hygiene Strategy

In 2009, the WHO published its hand hygiene promotion strategy. It was a multi-modal strategy and consisted of five modes. These were as follows;

WHO’s multi-modal hand hygiene strategy

  • System change,
  • Training and education,
  • Evaluation and feedback,
  • Reminders in the workplace,
  • and institutional safety climate.

Moreover, the WHO published a guide and toolkit to facilitate the implementation of those strategies. I summarized it below.

Component 1: System change

Contrary to my expectation, it is not about a systems change per se; rather, it refers to availability and accessibility to products that are required handwashing: alcohol-based hand rub at the point of care; access to a safe, continuous water supply, soap, and towels.

Component 2: Training and education

This refers to the training and education on the “my 5 moments for hand hygiene” which is depicted below. However, this should include the exact hand hygiene technique too.

My 5 moments for hand hygiene
Component 3: Evaluation and feedback

Under the evaluation and feedback, the strategy begins with monitoring hand hygiene practices and infrastructure, along with related perceptions and knowledge among health-care workers. The implementation of this component alone surely requires a research unit because monitoring hand hygiene practices are not easy and could be marred with biases including the Hawthorne effect.

Component 5: Sending reminders at the workplace

Yes, reminders help to promote the practice; however, regular changes to the messages are necessary since “message fatigue” surely will settle in with time. I am not sure why this “activity” takes such a prominent place in the multi-modal strategy.

Component 6: Institutional safety climate

I believe this is the most crucial strategy in any behavior change effort since it is the immediate environment we live in that ensures sustainability. However, the challenge is how to create it. The toolkit is not clear about its road map in this regard.

The 2015 expert review: An important milestone

Due to the absence of significant improvements, a European expert group updated the previous recommendations based on the evidence that surfaced between 2009 and 2012. Their recommendations were based on a systematic review which included 92 studies published between 1996 and 2012. The Lancet published its report in 2015. Their focus was mainly directed on hospital organization and management structure under which they identified ten key components.

Of those ten components, I am here highlighting the critical issues that need to be emphasized in the current context according to my opinion.

Number of beds per infection control nurse ratio

Traditionally, this ratio has been static during the past 30 years: 1 nurse to 250 hospital beds. The experts were of the view in this paper that it should be reduced to 1 nurse to 100 beds in acute care settings and 1 nurse to 150-250 beds in long-term care settings.

Limitation of the infection control teams

The experts seem to be very clear on this; that the presence of effective infection control teams, although essential, inadequate to achieve infection control goals. Furthermore, it also depends on;

  • Hospital organization
  • Bed occupancy
  • Staffing
  • Workload

In fact, this is common sense too. How can one adhere to complete hand hygiene procedures whenever they are pressured by a fewer number of staff members and a higher workload? It all depends, in turn, on the hospital organization and management.

Easy access to materials and the presence of ergonomics experts

Surprisingly, the hospital authorities seem to have overlooked this dimension altogether according to the paper.

Education and training

Quite correctly, they recognize that education and training should be accompanied by relevant leadership engagement and environmental modification. They go further by underlying that whatever the training should include interventions with strong “behavioral component aimed at removing barriers and helping the learners to manage their workload without compromising the quality”. We all know this is not an easy task.

More importantly, they too seem not to be having a clear road map either. The study authors claim that positive organizational culture can “only” emerge with a genuine interest in “leaders”. According to my thinking, this is unlikely to happen without a “paradigm shift” of thinking.

Paulo’s “critical consciousness”

This is where Paulo Freire’s “critical consciousness” should come into play. What is being used in education and training programs so far is the traditional “banking” model in which the teacher/trainer “deposits” the knowledge on the learner and the learners are expected to practice those without question.

I will write about it later.

2017 update: new WHO recommendations

In 2017, Julie Storr and her colleagues updated the previous report with new evidence. According to them, these recommendations were for acute care settings although its core components could be applicable to any healthcare setting, potentially including long-term care settings too. It included eight components, unlike the previous five components.

It seems that the WHO has yet to develop its new implementation strategy and tools.

Posted in Infection control research

Education alone does not improve hand hygiene

Does education alone improve handwashing compliance among healthcare workers in a hospital setting?

According to the study that I discuss below, the short answer to the above question appears to be no.

However, this study has adopted a before-after intervention design without a control group. The more accurate interpretation should be that education/feedback intervention alone is inadequate to improve handwashing compliance significantly.

Setting Two ICUs and one general medical ward in a US hospital
Target audienceAll healthcare workers
Study design Before-after intervention /observational study
Intervention Six in-service education/feedback intervention per each
Main outcome measure Direct observation of handwashing randomized for the
time of the day and bed location
Findings No statistically significant change in handwashing rates
Conclusion The introduction of education/feedback was not associated with significant higher rates of handwashing compliance.
Journal referenceApril 10, 2000, JAMA NETWORK;
Accessfree access to the full article

This was only one component of a bigger study in which alcohol-based hand sanitizer was introduced. It came out with a statistically significant improvement in compliance. I discussed it in another post.

Furthermore, a systematic review of 19 systematic reviews of hand hygiene compliance found that the interventions that address social influence, attitudes, self-efficacy, and intentions improve compliance significantly. In other words, the interventions should be grounded on behavior change theories.

Posted in #covid-19 Infection control research

Alcohol sanitizers and hand hygiene compliance

Hand hygiene has become nowadays one of the most heard behavioral activities. It is one of the most effective actions we should do to prevent the spread of the COVID 19 virus. Therefore alcohol hand sanitizers are an essential commodity.

The healthcare workers are not an exception.

However, adherence to cleaning hands with 70 percent alcohol hand sanitizers by healthcare workers requires promotion.

Simply, alcohol hand sanitizers should be made accessible at hand whenever necessary, most of the time at bedside of patients in hospitals.

Does alcohol-based hand rub sanitizers, when accessible, improve hand hygiene compliance among healthcare workers?

The answer is yes.

Setting Two ICUs and one general medical ward in a US hospital
Target audienceAll healthcare workers
Study design Six-month observational study
Intervention One sanitizer per 4 bedsides initially and then one per
each bedside was introduced.
Main outcome measure Direct observation of handwashing randomized for the
time of the day and bed location
Findings The compliance rates improved from 19% to 41% with
1 dispenser per 4 beds and from 23% to 48%
with 1 dispenser for each bed.
Conclusion The introduction of sanitizers is associated with higher
rates of handwashing compliance.
Journal referenceApril 10, 2000, JAMA NETWORK;
Accessfree access to the full article

However, the finding is from an observational study.

hand washing
Posted in Infection control research

Research on health workers’ hand hygiene compliance promotion:1

During this unprecedented COVID 19 pandemic, healthcare workers are one of the most vulnerable high-risk groups who have been contracting the virus, second only to the seniors living in long-term care facilities.

In this background, I looked at the existing evidence about one crucial aspect in the prevention and control of spreading the virus: healthcare workers’ hand hygiene.

During my exploration, I found a systematic review of systematic reviews published in 2018.

A systematic review of systematic reviews – 2018

As anyone can guess, there has been a large number of research available in the world for someone to conduct a systematic review of systematic reviews.

This review has looked at 19 systematic reviews published between 2001 to 2017. Of these, 13 reviews included hospital-based primary studies. In addition to the hospitals, the rest has looked at studies from long-term and other care facilities. Before going further, I would like to highlight that only study, according to their review criteria, had low-risk of bias.


They have found that;

  • the interventions that targeted social influence, attitudes, self-efficacy, and intention were associated with greater effectiveness.
  • no clear association between the delivery method of the intervention and its effectiveness.

The interventions targeting social influence, attitudes, self-efficacy, and intention were associated with greater effectiveness

Price, L., MacDonald, J., Gozdzielewska, L., Howe, T., Flowers, P., Shepherd, L., . . . Reilly, J. (2018). Interventions to improve healthcare workers’ hand hygiene compliance: A systematic review of systematic reviews. Infection Control & Hospital Epidemiology, 39(12), 1449-1456. doi:10.1017/ice.2018.262:


It seems clear that the interventions work. However, there are several caveats; no adequate evidence about the nature of the content, delivery method, and monitoring strategies.


Future research should rigorously apply behavior change theories; the interventions should be long-term and adopt strong study designs with clearly defined outcomes.

Those who are interested to read the full report, here is the link:’_hand_hygiene_compliance_A_systematic_review_of_systematic_reviews