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Review
Hand hygiene-related clinical trials reported since
2010: a systematic review
L. Kingston
a,*
, N.H. O’Connell
b,c
, C.P. Dunne
c
a
Department of Nursing and Midwifery, University of Limerick, Limerick, Ireland
b
Department of Clinical Microbiology, University Hospital Limerick, Limerick, Ireland
c
Graduate Entry Medical School and Centre for Interventions in Infection, Inflammation & Immunity (4i),
University of Limerick, Limerick, Ireland
ARTICLE INFO
Article history:
Received 11 September 2015
Accepted 19 November 2015
Available online 17 December
2015
Keywords:
Compliance
Hand hygiene
Hand hygiene opportunity
Multimodal approach
SUMMARY
Considerable emphasis is currently placed on reducing healthcare-associated infection
through improving hand hygiene compliance among healthcare professionals. There is also
increasing discussion in the lay media of perceived poor hand hygiene compliance among
healthcare staff. Our aim was to report the outcomes of a systematic search for peer-
reviewed, published studies eespecially clinical trials ethat focused on hand hygiene
compliance among healthcare professionals. Literature published between December
2009, after publication of the World Health Organization (WHO) hand hygiene guidelines,
and February 2014, which was indexed in PubMed and CINAHL on the topic of hand hygiene
compliance, was searched. Following examination of relevance and methodology of the 57
publications initially retrieved, 16 clinical trials were finally included in the review. The
majority of studies were conducted in the USA and Europe. The intensive care unit
emerged as the predominant focus of studies followed by facilities for care of the elderly.
The category of healthcare worker most often the focus of the research was the nurse,
followed by the healthcare assistant and the doctor. The unit of analysis reported for hand
hygiene compliance was ‘hand hygiene opportunity’; four studies adopted the ‘my five
moments for hand hygiene’ framework, as set out in the WHO guidelines, whereas other
papers focused on unique multimodal strategies of varying design. We concluded that
adopting a multimodal approach to hand hygiene improvement intervention strategies,
whether guided by the WHO framework or by another tested multimodal framework, re-
sults in moderate improvements in hand hygiene compliance.
ª2015 The Healthcare Infection Society. Published by Elsevier Ltd. All rights reserved.
Introduction
Healthcare-associated infections (HCAIs), also termed
nosocomial infections, are complications of healthcare that
lead to increased patient morbidity and mortality.
1
HCAIs lead
to increased healthcare costs for patients, their insurers and
hospitals, due to unanticipated duration of hospital stay and
associated treatment. There is also a psychological burden
placed on patients, their carers, and their families, in addition
to opportunity costs arising from patients and their carers’
inability to work, attend school, etc., while hospital capacity
impacts the efficiency of healthcare.
2,3
In the USA, it is estimated that HCAI affects about two
million patients annually, of whom w90,000 die.
4
The overall
annual cost of HCAI in the USA has been estimated to range
* Corresponding author. Address: Department of Nursing and
Midwifery, University of Limerick, Castletroy, Limerick, Ireland.
Tel.: þ353 (0)61 202818.
E-mail address: liz.kingston@ul.ie (L. Kingston).
Available online at www.sciencedirect.com
Journal of Hospital Infection
journal homepage: www.elsevierhealth.com/journals/jhin
http://dx.doi.org/10.1016/j.jhin.2015.11.012
0195-6701/ª2015 The Healthcare Infection Society. Published by Elsevier Ltd. All rights reserved.
Journal of Hospital Infection 92 (2016) 309e320

from US$28 to 45 billion.
4
Similarly, in the EU, the European
Centre for Disease Prevention and Control (ECDC) advises that
w4.1 million patients in acute care facilities acquire an HCAI
annually, with the number of deaths directly related to HCAI
estimated to be at least 37,000.
5
Whereas the prevalence of at least one HCAI, methicillin-
resistant Staphylococcus aureus (MRSA) related HCAIs, is sta-
bilizing or decreasing in some European countries, other HCAIs
are increasing (e.g. Escherichia coli and Klebsiella pneu-
monia).
6
Monitoring of HCAI, including pan-European surveil-
lance, has been expanded to encompass long-term care
facilities (LTCFs) in addition to hospitals.
7
Consequently, more
comprehensive data are emerging across Europe and in Ireland,
where a recent national median HCAI prevalence of 4.2% in
LTCFs was reported.
8
This is comparable with a national overall
HCAI prevalence of 5.2% in acute care facilities.
9
HCAIs, however, are preventable and hand hygiene is widely
regarded as the most effective preventive measure for
healthcare workers (HCWs).
10,11
Naikoba and Hayward con-
ducted a systematic literature review to establish the effec-
tiveness of interventions aimed at improving hand hygiene
compliance.
12
On reviewing 21 studies, they concluded that a
multifaceted approach to hand hygiene which includes edu-
cation, reminders and feedback was most effective in
increasing hand hygiene compliance and improving rates of
hospital-acquired infections.
12
In the intervening years, this
multifaceted or multimodal approach to hand hygiene appears
to have been adopted and advocated in the hand hygiene
policies and campaigns of multiple countries; for example, by
the USA, Canada, the UK, and Ireland.
13e16
Several reviews have superseded that of Naikoba and Hay-
ward, which is limited to examining the literature between
1986 and 1999.
12
For example, Erasmus et al. systematically
reviewed studies on compliance with hand hygiene guidelines
in hospital care, assessing the prevalence and correlates of
compliance and non-compliance.
17
Factors included occupa-
tion, knowledge, attitude, time of day, patient’s risk of
infection, feedback, and effects of varying hand hygiene so-
lutions. This was the first review to distinguish between
compliance both before and after patient contact, but it is
perhaps constrained by the inclusion of studies published
before the World Health Organization (WHO) guidelines on
hand hygiene.
1
In a Cochrane review, Gould et al. evaluated 39 of the 96
studies reviewed by Erasmus et al., while focusing on in-
terventions to improve hand hygiene compliance in patient
care.
17,18
The authors concluded that interventions should
focus on the urgent need to offer solution-focused guidance in
this field of practice.
19
Huis et al. conducted a systematic review of hand hygiene
improvement strategies from a behaviourist approach.
19
In
order to provide conceptual clarity, Huis et al. explored
frequently used hand hygiene improvement strategies and
related determinants of behaviour that included: knowledge;
awareness; action control; facilitation; social influence; atti-
tude; self-efficacy and intention.
19
The authors found that
those studies using a combination of various determinants of
behavioural change (including social influence, self-efficacy,
attitude and intention) may result in better outcomes.
19
A frequent discussion point in the above publications relates
to methodological weaknesses in many of the studies
reviewed.
12,17e19
WHO has subsequently published guidelines
on hand hygiene since the last review was published, and so we
believe that an updated collation of the literature is war-
ranted, with a focus on clinical trials with robust methodo-
logical design published in the last five years.
1
Methods
Scope
The scope included literature published between December
2009 and February 2014, which is indexed in PubMed and
CINAHL, on the topic of hand hygiene compliance among
healthcare professionals.
Systematic approach to finding appropriate literature
Searches were performed in PubMed and CINAHL in February
2014 for full articles published on the topic of hand hygiene
compliance. The study methodology leading to publication
within the scope of this review was clinical trials. Papers that
were not published in English were excluded. Only full original
research papers and reviews were included, that is: editorial
opinions, letters to the editor, and other ‘opinion’-based
publications were not included.
Search methodology
Title and abstract fields were searched for publications
containing the words: hand hygiene, handwashing, compli-
ance. Boolean operators were used to combine search com-
ponents. For example, the PubMed search was: (hand hygiene)
OR (hand washing) AND compliance (hand hygiene [Title/Ab-
stract]) AND compliance [Title/Abstract]. The CINAHL search
was: (hand hygiene) OR (hand washing) AND compliance. The
combined yield was 57 articles (Figure 1). This number is
relatively low but may be attributable to limiting the search to
clinical trials only.
Critical appraisal and synthesis
Two reviewers (L.K. and C.D.) independently reviewed the
search results, titles, and abstracts. Consensus on eligibility for
inclusion was agreed and where discrepancies arose these were
resolved by discussion. These potentially eligible articles were
retrieved and read, resulting in the final selection of eligible
studies. Those articles retrieved by the search but deemed
ineligible for further analysis, as they did not report on hand
hygiene compliance, are listed in Table I.
20e55
Studies that met the following criteria were included:
empirical studies conducted in study settings that included
acute, non-acute, long-term care of the elderly and primary
care; samples from countries with developed and developing
economies; compliance with hand hygiene measured either by
observation or electronic counters; results of hand hygiene
compliance rates published; published in the English language.
Studies set in domestic or school settings were excluded. One
study where compliance was measured by self-reporting was
excluded.
Of the 57 papers identified by the search, 16 studies were
deemed eligible. Data were extracted by examining study
characteristics using the following headings: country of origin,
L. Kingston et al. / Journal of Hospital Infection 92 (2016) 309e320310

study objectives, study setting, target population, study
design, interventions and finally study outcomes. A lack of
homogeneity of the studies selected was identified on extrac-
tion of study characteristics and so formal meta-analysis was
not possible; however, further analysis was achieved by
manually collating data and compiling results in tables.
Results
Geographical location
Hand hygiene compliance research is of global interest and
results of this review reflect the diversity of countries con-
ducting research on this topic. Of the 16 reported studies, the
majority were carried out in Europe and the USA. Six of the
studies were carried out in EU Member States; two in The
Netherlands, two in France, one in Spain, and one in the UK.
The five studies conducted in the USA were across various
States, in Washington, Virginia, New Hampshire, Ohio, and
Texas.
56e66
Two studies were conducted in resource-limited
countries, one in Brazil, and the other was across 19
resource-limited countries in Latin America, South America,
Asia, the Middle East and Europe.
67,68
One Australian study was
reviewed, and two studies were conducted in Hong Kong.
69e71
Clinical setting
Studies were conducted in a variety of clinical settings,
some across multiple clinical settings and indeed across mul-
tiple geographical locations, leading to a total of 299 indi-
vidual clinical settings where studies were conducted
(Table II).Intensivecareunit(ICU)settingsweremostpopu-
lar, accounting for the largest number of settings within which
studies were conducted (N¼135). This included adult, step-
down, paediatric, and neonatal ICUs. Care-of-the-elderly
settings accounted for the second most popular clinical
setting (N¼93) and this included acute and long-term care-
of-the-elderly clinical settings. Ward settings (N¼59)
included medical, surgical, paediatric, and burns wards.
Following review of titles
and abstracts to exclude those
outside of the scope, N = 21
Following review of full-text
papers to exclude those
outside of the scope, N = 14
Following review of full-text
papers to exclude those
outside of the scope, N = 2
Following review of titles
and abstracts to exclude those
outside of the scope, N = 8
Following exclusion of
duplicates, N = 24
Final number of papers
reviewed, N = 16
PubMed search:
hand hygiene, handwashing,
compliance, N = 41
CINAHL search:
hand hygiene, handwashing,
compliance, N = 16
Initial search
Scope
Exclusions
Final publications
Figure 1. Study selection methodology.
L. Kingston et al. / Journal of Hospital Infection 92 (2016) 309e320 311

Eleven primary healthcare centres were included (N¼11),
and finally one study was performed across the whole orga-
nization (N¼1).
Some studies were conducted across multiple clinical set-
tings, for example Huis et al. studied the ICU setting, medical,
surgical, and paediatric wards (Table II).
56
Similarly, Fuller
et al. studied the adult ICU setting as well as acute care-of-the-
elderly wards.
61
Some studies were conducted across multiple
geographical sites, for example Martin-Madrazo et al. used 11
primary healthcare centres, and Chami et al. examined 47
long-term care-of-the-elderly facilities.
59,60
It is unknown
exactly what clinical settings or how many clinical settings
within the organization were involved in the Henderson et al.
study, as the focus was on the organization as a whole.
62
Healthcare worker category
The presentation of data in the reported studies relating to
the categories of HCWs participating in the studies lacks
uniformity, and so analysis is challenging. Moreover the lack of
agreed global HCW job titles and professional roles makes it
difficult to compare studies in a consistent way. Of the 16
studies reviewed, only six quantified the total number of
participating HCWs, with five of these six identifying the
various HCW categories participating (Table III).
Nurses, doctors, and healthcare assistants were the cat-
egories of HCWs most involved in hand hygiene compliance
studies. The largest participant sample size (N¼4221) was
attributed to Linam et al.
65
This sample represented predom-
inately nurses, doctors and healthcare assistants or care at-
tendants, but also included were a broad range of other HCWs
including respiratory therapists, physical therapists, occupa-
tional therapists, speech pathologists, dieticians, child life
specialists, radiology technicians, and chaplains. Huis et al.
recruited 2733 participants and all were nurses.
56
The largest
group in the Ho et al. study were healthcare assistants (health
workers and personal-care assistants) (N¼499) followed by
nurses (N¼130) and others, namely physiotherapists and
Table I
Summary of excluded studies
Study Year Study focus Study source
Aeillo et al.
20
2012 Influenza in young adults PubMed
Ashraf et al.
21
2010 Self-reporting hand hygiene compliance PubMed
Bearman et al.
22
2010 Glove use PubMed
Birnbach et al.
23
2010 Hospital design PubMed
Chittleborough et al.
24
2010 Primary school setting CINAHL
Chow et al.
25
2012 Comparing hand hygiene protocols CINAHL
Darawad et al.
26
2012 Hand hygiene survey PubMed
Diaz-Agero et al.
27
2011 Preoperative nosocomial infections PubMed
Erasmus et al.
28
2011 Study protocol PubMed
Eveillard et al.
29
2011 Glove use PubMed
Eveillard et al.
30
2012 Glove use PubMed
Fisher et al.
31
2013 Validating automated device CINAHL
Fuller et al.
32
2010 Assessment of blinding observers in an RCT CINAHL
Fuller et al.
33
2011 Glove use PubMed
Harris et al.
34
2013 Glove and gown use PubMed
Huis et al.
35
2011 Study protocol PubMed
Huis et al.
36
2013 Cost analysis PubMed
Huis et al.
37
2013 Process evaluation PubMed
Kampf et al.
38
2010 Testing hand hygiene products PubMed
Kutting et al.
39
2010 Skin protection PubMed
Larson et al.
40
2010 Domestic setting PubMed
Nevo et al.
41
2010 Efficacy of hand hygiene triggers PubMed
Pandejpong et al.
42
2012 Pre-school setting CINAHL
Perez et al.
43
2012 University setting PubMed
Reardon et al.
44
2013 Glove use PubMed
Rello et al.
45
2013 Prevention of VAP PubMed
Rock et al.
46
2013 Hand hygiene before glove use CINAHL
Shaw et al.
47
2011 Trial on botulinum CINAHL
Simmerman et al.
48
2011 Domestic setting PubMed
Stebbins et al.
49
2010 Primary school setting PubMed
Stuart et al.
50
2011 Prevalence of antimicrobial-resistant organisms PubMed
Suchomel et al.
51
2012 Testing hand hygiene products CINAHL
Suess et al.
52
2012 Domestic setting PubMed
Williams et al.
53
2011 Skin irritation PubMed
Yardley et al.
54
2011 Domestic setting CINAHL
Yawson and Hesse
55
2013 Hand hygiene survey PubMed
RCT, randomized controlled trial; VAP, ventilator-associated pneumonia.
L. Kingston et al. / Journal of Hospital Infection 92 (2016) 309e320312

occupational therapists (N¼39).
70
No doctors participated in
that study.
Although the sample size was smaller (N¼198) in a study by
Martin-Madrazo et al., a wide range of healthcare professionals
took part including nurses (N¼85) and doctors (N¼91), of
whom 22 were paediatricians and 69 were general practi-
tioners, and others (N¼22) including midwives, care assis-
tants, dental hygienists and odontostomatologists.
60
Category
of HCW was a variable not addressed by Bearman et al.,
although we know that 32 HCWs enrolled in the study and 25
completed the study.
63
However, once again it is challenging to
extract any further quantifiable information on the breakdown
of participants by profession.
Other studies provided information on hand hygiene op-
portunities (HHOs) observed based on the category of HCW. In
those cases, the categorization of HCW is known but the
numbers are not. Rosenthal et al. recruited nurses, doctors,
and ancillary staff, and although data are provided relating to
the numbers of HHOs observed in each category of HCW, no
data are provided on actual numbers of participants.
68
Despite
this, univariate analysis of variables associated with poor hand
hygiene was performed and the independent variable ‘pro-
fession of HCW’ was analysed, thus indicating the importance
of this variable to the study results.
68
The primary outcomes of the study by Koff et al. were in-
dividual and group hourly electronically recorded and observed
hand hygiene compliance rates.
64
Nurses, doctors and respi-
ratory therapists were recruited but exact numbers of each
were not reported. Similarly, Marra et al. investigated positive
deviance training to all HCWs in a step-down unit, including
nurses, doctors, physical therapists, speech pathologists and
nutritionists, but they did not record numbers of partici-
pants.
67
Positive deviance is defined as ‘the observation that in
every community there are certain individuals or groups whose
uncommon behaviours and strategies enable them to find
better solutions to problems than their peers, while having
access to the same resources and facing similar or worse
challenges’.
72
Hitoto et al. make little reference to categories
of HCWs except in reference to opportunities for hand hygiene
observed.
58
Of the 1326 HHOs observed, 88% concerned nurses
and nurse assistants. Elsewhere a reference is made to medical
staff, so it may be reasonable to assume that doctors were also
involved.
Hand hygiene opportunities
In line with WHO guidelines, the unit of analysis reported
was the HHO.
1
An HHO is a moment in time when hand hygiene
should be carried out.
1
These opportunities were observed
either by direct observation of participants or, in the case of
two studies, by electronic recording devices.
64,67
Ten of the 16
studies provided quantified data on these opportunities and
these data, alongside the settings within which observations
occurred, are provided in Table IV. There was large variation in
respect of the number of observations recorded in the various
studies. In total, 719,876 HHOs were recorded, ranging from
1173 HHOs in an adult ICU setting to 506,111 in two step-down
ICU settings, the latter being recorded by electronic devices
worn by the participants.
67
The mean number for HHOs was
65,443. Whereas most studies provide data on the HHOs
observed in each clinical setting, Huis et al. provided an overall
number and did not provide a breakdown of HHO data by
clinical site.
56
One study provided an approximation of HHOs
per month, enabling a calculation to be made based on the
duration of the study.
62
Also five studies did not provide any
HHO data.
59e61,64,66
Hand hygiene compliance interventions
The interventions reported in these studies were predomi-
nately multimodal, focusing on more than one hand hygiene
intervention, with the exception of three studies
(Table V).
61,63,66
Two of these studies focused on the same
single intervention, i.e. education, while the other focused on
performance feedback.
61,63,66
In two studies, just two
Table II
Clinical settings
Type of clinical
setting
No. of clinical
settings
Study
Adult ICU (N¼113) 80 Rosenthal et al.
68
11 Fuller et al.
61
13 Huis et al.
56
4 Hitoto et al.
58
2 Bingham et al.
66
1 Marshall et al.
69
1 Koff et al.
64
1 Bearman et al.
63
Step-down ICU
(N¼2)
2 Marra et al.
67
Neonatal ICU
(N¼11)
10 Rosenthal et al.
68
1 van den Hoogan
et al.
57
Paediatric ICU
(N¼9)
9 Rosenthal et al.
68
Sub-total: ICU
settings
135
Long term care of
the elderly
(N¼71)
47 Chami et al.
59
18 Ho et al.
70
6 Yeung et al.
71
Acute care-of-the-
elderly wards
(N¼22)
22 Fuller et al.
61
Sub-total: care
of elderly
settings
93
Medical and/or
surgical ward
(N¼47)
45 Huis et al.
56
2 Bingham et al.
66
Paediatric ward
(N¼11)
9 Huis et al.
56
2 Linam et al.
65
Burns unit (N¼1) 1 Bingham et al.
66
Sub-total: ward
settings
59
Primary
healthcare
centre (N¼11)
11 Martin-Madrazo
et al.
60
Whole
organization
(N¼1)
1 Henderson et al.
62
Total 299
ICU, intensive care unit.
L. Kingston et al. / Journal of Hospital Infection 92 (2016) 309e320 313

interventions are described, with both focusing on the same
two interventions, i.e. education and performance
feedback.
64,69
Bingham et al. implemented a single hand-hygiene inter-
vention, whereby hand hygiene education was implemented in
a pre-test/post-test design focused on reducing the probability
of ventilator-associated pneumonia.
66
Other interventions
included oral care and head-of-bed elevation and are not
relevant to this review.
66
Bearman et al. also focused on hand
hygiene education.
63
They conducted a four-month random-
ized blinded prospective crossover trial and provided hand
hygiene education as part of this larger study to determine the
effectiveness of antimicrobial scrubs on hand and clothing
bacterial burden.
63
Both of the aforementioned studies
included hand hygiene reporting as part of studies that pre-
dominantly focused on achieving other outcomes.
63,66
The
third study with a single intervention focused on personalized
written feedback in the form of an action plan in attempting to
achieve improved hand hygiene compliance.
61
Marshall et al. and Koff et al. both described two in-
terventions.
64,69
Both combined education on hand hygiene
and performance feedback as the foci of their interventions.
The former introduced hand hygiene compliance as one of
many measures taken to strengthen a study that focused on
reducing MRSA acquisition and provided regular compliance-
monitoring feedback to participants.
69
The latter designed a
beforeeafter study to evaluate the impact of a focused hand
hygiene programme on the incidence of catheter-related
bloodstream infections and ventilator-associated pneumo-
nias.
64
The programme involved education and performance
feedback, and the participants wore an electronic hand hy-
giene device to record compliance.
64
Ten other studies addressed multimodal interventions
ranging from three to six interventions.
56,57,59,60,62,65,67,68,70,71
Van den Hoogen et al. evaluated the effect of a multimodal
hand hygiene intervention programme in a neonatal intensive
care unit.
57
The programme comprised observation of hand
hygiene practices, a knowledge questionnaire followed by
immediate feedback and discussion, surveillance cultures
feedback, education using video-based resources, and re-
minders using posters and cartoons displayed prominently.
57
In
addition to focusing on hand hygiene education and the use of
reminder materials, e.g. posters, others also addressed the
issue of alcohol-based hand rub (ABHR) availability, supply
and/or consumption.
59,60,71
Table III
Healthcare workers: categories and sample sizes
Study Nurse Physician Healthcare assistant Other Total sample size
Linam et al.
65
2192 597 971 461 4221
Huis et al.
56
2733 0 0 0 2733
Ho et al.
70
(missing data reported) 130 0 499 39 810
Martin-Madrazo et al.
60
85 91 0 22 198
Yeung et al.
71
26 0 150 4 180
Bearman et al.
63
ee e e 32
Marshall et al.
69
ee e e e
Henderson et al.
62
Yes (e) Yes (e)eYes (e)e
Bingham et al.
66
Yes (e) Yes (e)eYes (e)e
Rosenthal et al.
68
Yes (e) Yes (e) Yes (e) Yes (e)e
Marra et al.
67
Yes (e) Yes (e) No Yes (e)e
Koff et al.
64
Yes (e) Yes (e) No Yes (e)e
Hitoto et al.
58
Yes (e) Yes (e) Yes (e)No e
Fuller et al.
61
Yes (e) Yes (e) Yes (e) Yes (e)e
Chami et al.
59
Yes (e) Yes (e)No No e
van den Hoogen et al.
57
Yes (e) Yes (e) No Yes (e)e
‘Yes (e)’: sample included this category of healthcare worker but the sample size was not reported.
Table IV
Hand hygiene opportunities
Study Clinical setting
type (no.)
No. of HHOs
observed or
recorded
Marra et al.
67
Step-down ICU (2) 506,111 (ERD)
Rosenthal et al.
68
Adult ICU (80) 149,727
Neonatal ICU (10)
Paediatric ICU (9)
Henderson et al.
62
Academic medical
centre (1)
24,000
Ho et al.
70
Long-term care
elderly (18)
11,669
Huis et al.
56
Medical/surgical
wards (45)
10,785
Adult ICU (13)
Paediatric wards (9)
Marshall et al.
69
Adult ICU (1) 6179
Linam et al.
65
Paediatric wards (2) 4029
Yeung et al.
71
Long-term care
elderly (6)
3300
van den
Hoogen et al.
57
Neonatal ICU (1) 1577
Hitoto et al.
58
Adult ICU (4) 1326
Bearman et al.
63
Adult ICU (1) 1173
Total 719,876
Range 1173e506,111
Mean 65,443
HHO, hand hygiene opportunity; ICU, intensive care unit; ERD, elec-
tronic recording device.
L. Kingston et al. / Journal of Hospital Infection 92 (2016) 309e320314

Four studies addressed the issue of leadership and the need
for strong leadership in promoting a culture of compliance with
evidence-based hand hygiene practices.
56,65,67,68
Each
described different leadership strategies adopted in order to
pursue the goal of improved compliance with hand hygiene
practices. Rosenthal et al. addressed leadership by ensuring
that hospital administrators of participating hospitals agreed
and committed to the study, supported the need for additional
resources and attended feedback meetings.
68
Marra et al.
adopted a positive deviance strategy for improving hand hy-
giene compliance, where the leadership was enhanced by HCW
peers (called positive deviants) who acted as role models for
best practice.
67
Both Linam et al. and Huis et al. address
leadership in conjunction with a team approach.
56,65
Described as a quality improvement initiative, Linam et al.
incorporated a leadership and team approach to developing
and testing a multimodal intervention approach to improving
hand hygiene compliance among HCWs.
65
Leadership teams
were established comprising frontline staff and infection con-
trol staff whose role was to provide committed unit leadership
and to serve as role models and educators. They sought to in-
fluence the culture of the units in order that hand hygiene
compliance would become the social norm.
65
In a cluster-
randomized trial, Huis et al. also addressed social influence
in groups by adopting a team-and-leaders-directed strategy
which was tested alongside an evidence-based strategy that
excluded a team-and-leaders approach.
56
Unlike Linam et al.,
who developed their own conceptual model, Huis et al. drew
on existing theories of leadership (Ovretveit), team effective-
ness (Shortell et al.; West), social influence theory (Mittman
et al.) and social learning theory (Bandura), and based the
strategy on gaining the active commitment of ward manage-
ment, settings targets within teams and role-modelling by
leaders at ward level.
56,73e77
Hand hygiene compliance outcomes
Hand hygiene compliance was measured either by direct
observation or by electronic recording. The observation was
based on whether or not the HCW complied with best-practice
relating to an HHO. Most studies reported compliance as a
percentage rate and identified a baseline before the study. Ten
studies have supplied data on compliance, of which eight
provide both baseline data and post-intervention data
(Table VI).
56,57,60,64,65,68,70,71
The baseline compliance rate
varied considerably, with some organizations starting from a
very low baseline, e.g. 8.1% and 20e23%.
56,60
Eight studies identified baseline compliance rates in either
one or two intervention arms and in a control arm. This allows a
mean baseline (before interventions) compliance rate respec-
tive to each study to be calculated. The mean baseline (before
interventions) compliance rates varied considerably in the
eight studies that provided such data, ranging from 8.1% to
69.5%.
60,65
The overall mean baseline compliance rate before
interventions, when all studies were combined, was 34.1%.
Overall compliance rates improved as a result of the in-
terventions, with some studies showing greater and more sus-
tained improvements than others. Yeung et al. reported only
slight improvement, from 25.8% to 33.3%.
71
Moderate to sig-
nificant improvements were also reported. Martin-Madrazo
et al. reported that the intervention group increased their
compliance by 21.6% compared with an improvement of 3.6% in
the control group at six months.
60
Koff et al. reported signifi-
cant improvements from a mean of 53% during the control
period to a mean of 75% during the study period.
64
Similarly,
Rosenthal et al. reported that overall compliance increased
from 48.4% to 71.4%.
68
Van den Hoogen et al. described an
improvement in compliance from 23% in the baseline assess-
ment to 50% in the second assessment.
57
Table V
Hand hygiene compliance interventions: type and number
Study Education Reminder
materials
a
ABHR (supply and
consumption
monitoring)
Performance
feedback
Leadership and
management support
Team
approach
Total no. of
interventions
Huis et al.
56
Yes Yes Yes Yes Yes Yes 6
Linam et al.
65
Yes Yes Yes Yes Yes 5
Marra et al.
67
Yes Yes Yes Yes Yes 5
Ho et al.
70
Yes Yes Yes Yes 4
Henderson et al.
62
Yes Yes Yes Yes 4
Rosenthal et al.
68
Yes Yes Yes Yes Yes 4
van den Hoogen et al.
57
Yes Yes Yes 3
Chami et al.
59
Yes Yes Yes 3
Yeung et al.
71
Yes Yes Yes 3
Martin-Madrazo et al.
60
Yes Yes Yes 3
Marshall et al.
69
Yes Yes 2
Koff et al.
64
Yes Yes 2
Bingham et al.
66
Yes 1
Bearman et al.
63
Yes 1
Fuller et al.
61
Yes 1
ABHR, alcohol-based hand rub.
No hand hygiene intervention reported by Hitoto et al.
58
a
E.g. posters and videos.
L. Kingston et al. / Journal of Hospital Infection 92 (2016) 309e320 315

The calculated mean compliance rates in the intervention
groups after intervention allow an overall mean improved
compliance rate to be calculated in the intervention groups at
56.98%. This suggests an improvement of 22.88% from the
calculated mean baseline compliance rate of 34.1%.
Discussion
This review describes clinical trials conducted since 2010
that have reported hand hygiene compliance in the context of
reducing healthcare-associated infections. The methodolog-
ical weaknesses in many previous studies have been dis-
cussed.
12,17e19
We are now reviewing an updated collation of
the literature with a focus on clinical trials with robust meth-
odological design published in the last five years.
For clarification purposes, it is noted that the hand hygiene
data in many of the studies reviewed is reported as part of a
larger study. Examples of other outcomes examined include
HCAI rates, the impact of screening, and the impact of active
surveillance and contact precautions.
58,59,62,64,66,69
Geographical location
Healthcare-associated infections are a global patient safety
concern. The geographical location of the studies reported
suggests that hand hygiene compliance research is conducted
predominately in Europe and the USA. We identified two
studies from Asia, both conducted in Hong Kong, and two other
studies from resource-limited countries, suggesting that
further studies are needed in these locations.
Clinical setting
The clinical setting in which hand hygiene compliance is
monitored and reported is examined in this review and the
results provide some interesting insight into the clinical set-
tings selected. From the available data it emerges that the ICU
is the predominant focus; when step-down, neonatal and
paediatric ICUs are included, a total of 135 ICU settings were
the foci of attention. Care-of-the-elderly facilities accounted
for 93 study settings, whereas the other settings combined e
medical, surgical, paediatric, and burns wards eaccounted for
59 settings. Finally, one study examined 11 primary healthcare
settings and one study provided no information on the clinical
settings within the organization studied.
60,62
Acute care settings, especially ICUs, have been the focus of
research studies for many years and justifiably so given the
prevalence of HCAI in intensive care settings. The most recent
ECDC point prevalence survey examining the prevalence of
HCAI in 1000 European hospitals in 30 counties is informative in
this regard.
5
The prevalence of HCAI was the highest among
patients admitted to ICUs, where 19.5% of patients had at least
one HCAI.
5
The ECDC estimates that w5.7% of patients, or one
in 18 patients, or 80,000 patients in European hospitals, have
HCAI on any given day. The survey confirms that HCAI remains a
major public health and patient safety issue across acute care
facilities in Europe.
However, the expansion of research in recent years to
encompass care-of-the-elderly facilities is welcome. The in-
clusion of acute care-of-the-elderly settings and long-term
care-of-the-elderly settings reported in this review reflects
Table VI
Hand hygiene compliance outcomes
Study Reported hand hygiene compliance outcomes Mean compliance (%)
before intervention
Mean compliance (%)
after intervention
(in intervention group)
Net effect on
intervention group
van den Hoogen et al.
57
Increased significantly from 23% in the baseline assessment to 50% in the
second assessment
23% 50% 27%
Ho et al.
70
Increased from 27% to 60.6% and 22.2% to 48.6% in two intervention arms 24% 54.60% 30.60%
Yeung et al.
71
Increased slightly but significantly from 25.8% to 33.3% at 7 months post
intervention
25.80% 33.30% 7.50%
Rosenthal et al.
68
Overall compliance increased from 48.4% to 71.4% 48.40% 71.40% 23%
Koff et al.
64
Significantly improved from 44% to 63% (mean 53%) during the control
period to 67e90% (mean 75%) during the study period
53% 75% 22%
Linam et al.
65
Increased from 65% to 91% and from 74% to 92% in the two units 69.50% 91.50% 22%
Martin-Madrazo et al.
60
Baseline compliance rate was 8.1%. HCWs in the intervention group
increased their compliance by 21.6% compared with control group
8.10% 30.56% 22.46%
Huis et al.
56
Increased from baselines of 23% and 20% in the two intervention arms to
46% and 53% in the long run
21.5% 49.5% 28%
Overall mean
compliance rates
34.1% (before
interventions)
56.98% (after
interventions)
22.88% (net
improvement)
HCW, healthcare worker.
L. Kingston et al. / Journal of Hospital Infection 92 (2016) 309e320316

the ageing population and recognizes the importance of con-
ducting robust research into hand hygiene behaviours in these
settings.
59,61,70,71
Data from the ECDC demonstrate the
importance of surveillance in LTCFs. The point prevalence
survey of HCAI in European LTCFs suggests that the crude
prevalence of residents with at least one HCAI in 2013 was
3.4%.
7
From 17 European countries 1181 LTCFs participated in
the survey.
7
It is noteworthy that only one study included in this review
was conducted in a primary healthcare setting despite the
importance of hand hygiene in this setting.
60
Eleven healthcare
settings in Madrid participated in the study. Overall baseline
compliance with hand hygiene procedures was very low at
8.1%, further supporting the argument for conducting research
in this setting. Hand hygiene is important in primary care set-
tings. The move towards more complex and invasive pro-
cedures in primary care, the earlier discharge of patients from
acute care settings, and the advancements in home care all
suggest that hand hygiene compliance and further research is
equally as important in primary care as in acute care settings.
60
International and national guidelines published in more
recent years reflect the increasing awareness of the need to
be equally vigilant in primary care settings.
78,79
The work
of Martin-Madrazo and colleagues demonstrates that signifi-
cant improvements in practice can be achieved in primary
care settings when multimodal hand hygiene improvement
strategies are implemented.
Healthcare worker category
Compliance with hand hygiene is of equal importance
among all HCWs in order to minimize the risk to patients of
acquiring an HCAI. It is important to reflect the categories of
HCWs when reporting studies, as it adds significance to the
results, allowing for greater impact among the professional
groups. Some of the studies in this review may be criticized for
not including reference to the category of HCW involved.
63,69
Other studies define categories, but do not give sample sizes.
It is noteworthy that in some cases hand hygiene is reported as
part of a larger study where other determinants of outcomes
are included.
As nurses, in most cases, form the largest group of health
professionals, it is not surprising that the nursing profession is
well represented in the studies reviewed and accounts for the
large sample sizes.
80
Therefore, in the study with the largest
number of study participants of 4221 it is not unexpected that
nurses formed the largest sample group (N¼2192), followed by
healthcare assistants (N¼971), doctors (N¼597) and others
(N¼461).
65
One study exclusively focused on the nursing
profession (N¼2733) and there is no doubt that the results,
while informative to the nursing profession, might also be of
relevance to other professional groups.
56
Other studies, with
smaller sample sizes than those referred to above, included
more than one category of HCW, allowing the relevant results
to be interpreted by each distinctive professional
group.
60,63,65,70,71
Hand hygiene opportunities
Just two of the included studies reported results relating to
hand hygiene technique.
56,57
However, these are limited to
some, but not all, aspects of correct technique efor example,
wearing jewellery or using an insufficient amount of ABHR.
The technique advocated by WHO is complex and multi-
faceted. It is very likely that many of the aspects of the WHO-
promoted technique, and their correct use, contribute to
prevention of nosocomial infections. We considered this topic
worthy of study in its own right and too large an influencer of
behaviour to be included as only one component of this
review.
Whereas the recognized unit of analysis is HHO, there were
some deviations from this. Two studies recorded data using the
latest cutting-edge technologies. Electronic hand hygiene
counters, worn by participants in one study and placed at ABHR
stations in the other, appear to work by monitoring the
dispensing of the ABHR from the device as opposed to moni-
toring the opportunity for hand hygiene.
64,67
Currently ‘direct
participant observation’ is considered the gold standard in
measuring hand hygiene compliance.
81
However, this can be
time and resource intensive. Furthermore, when interpreting
findings, the Hawthorne effect and the potential for bias must
be considered, when data are collected by direct observa-
tion.
82
Koff et al. report that the electronic device, while novel
at the time of the study, was a reliable system in monitoring
hand hygiene compliance. They also credit the same device
with contributing to the significant improvements in hand hy-
giene compliance reported, from a mean of 53% during the
control period to a mean of 75% during the study period. There
can be no doubt that the design of electronic devices will be
developed further in the future and become more visible in this
field of practice as the technology advances. Consequently,
continued research is required to examine the effectiveness of
electronic counters and their application to this field of
research.
Whereas some studies explicitly report using the ‘my five
moments for hand hygiene’ framework for measurement of
HHOs, based on the WHO hand hygiene guidelines, not all
studies report using this approach.
56,58,60,65
It is important to note that whereas a number of studies
do not explicitly address the WHO multimodal strategy
incorporating the ‘my five moments for hand hygiene’
framework, many adopt a multimodal approach using various
unique behavioural approaches. Fuller et al. adopted a
‘feedback intervention’ approach, while Rosenthal et al.
implemented and evaluated the impact of a multidimen-
sional hand hygiene approach designed by the International
Nosocomial Infection Control Consortium (INICC).
61,68
Marra
et al. adopted a ‘positive deviance strategy’ as an alterna-
tive way to produce change, while Linam et al. approached
their research design from a quality improvement
stance.
65,67
Van den Hoogan et al. also reported local hand
hygiene protocols and procedures upon which the study
design is framed.
57
In a number of studies it was not possible to definitively
determine whether or not the ‘my five moments for hand hy-
giene’ framework was used, as explicit information was not
provided on the approach adopted.
62,63,66,69
This suggests that
standardization and conformity to hand hygiene practices and
measures as outlined by the WHO guidelines has not been
uniformly adopted at the time of this review. Clearly, the in-
fluence of the WHO guidelines on hand hygiene and interpre-
tation of the impact of the guidelines is hampered by the low
number of studies (N¼4) explicitly reporting its adoption in
research design.
L. Kingston et al. / Journal of Hospital Infection 92 (2016) 309e320 317

Hand hygiene compliance interventions
Multimodal strategies have emerged as the best approach to
hand hygiene practices, as advocated by WHO.
1
Larson and
colleagues explicitly referred to a multidimensional approach
to hand hygiene in a study published in the USA, and, since
then, increasing evidence has supported this approach.
83
A
multimodal approach involves using a variety of strategies
aimed at addressing barriers to improving compliance with
good hand hygiene practices and achieving behavioural
change.
84
Although evidence supports the implementation of
multimodal strategies and research substantiates the efficacy
of the multimodal approaches, there are challenges associated
with implementing this approach.
81,85e87
Whereas WHO advo-
cates this approach the interpretation and implementation are
varied across sites, leading to challenges of meta-analysis and
comparative review. Results of this review demonstrate that
researchers are focusing on multimodal approaches, with 10 of
the 16 studies adopting this approach by using from three to six
interventions. However, various approaches are taken to single
components of the multimodal approach, for example, edu-
cation. In implementing an education strategy that encom-
passes written materials a wide range of aids is used, from
teaching and practical demonstrations to leaflets and knowl-
edge quizzes to posters and cartoons, to video-based re-
sources, and websites.
56,57,60,67,68,70
With such variability of
interventions, establishing the link to improved outcomes can
be challenging.
88
Hand hygiene compliance outcomes
Analysis of the outcomes of the eight studies that provide
both baseline hand hygiene compliance data and post-
intervention compliance data allow for calculation of an over-
all mean baseline compliance rate of 34.1% before intervention.
All eight studies showed improved compliance following
intervention. Some showed slight improvement of 7.5% net
effect, whereas others reported moderate to significant
improvement of 22%, 23%, 27%, 28%, and 30.6%.
56,57,64,65,68,70,71
Calculation of an overall mean compliance rate after inter-
vention suggests a mean post-intervention compliance rate of
56.98% in the intervention group. Based on these eight studies
the net improvement calculated is 23%.
These reported improvements in outcomes are welcome.
However, notable in this review was the duration of the
studies. Not all studies supplied details of the duration of the
control and intervention period. Of those that did, most studies
were of less than one year’s duration with the control or
baseline period lasting three months and the intervention
period lasting three months.
67,71
Koff et al. reported a two-
year beforeeafter study design.
64
Two longitudinal studies
were reported.
61,68
Rosenthal et al. conducted the study over a
seven-year period whereas Fuller et al. conducted their study
over a three-year period.
61,68
In order to determine sustained
improvement in hand hygiene practices among HCWs, longi-
tudinal studies provide an ideal research design to determine
long-term change in behaviour.
Conclusion
Of the 16 papers reviewed, four research designs were
explicitly guided by the ‘my five moments for hand hygiene’
framework, as set out in the WHO guidelines.
1
Others adopted
locally designed multimodal approaches using various unique
behavioural approaches and althoug there was a lack of uni-
formity in these approaches, positive outcomes were achieved.
This leads us to conclude that adopting a multimodal approach
to hand hygiene improvement intervention strategies, whether
guided by the WHO framework or another tested multimodal
framework, has been shown to achieve slight to moderate
improvements in hand hygiene compliance.
Some especially pertinent areas for additional research
might include knowledge, attitudes and awareness of future
practitioners (e.g. medical and nursing students alongside al-
lied health students and interns, healthcare facility managers,
patients and their carers). Similarly, the adoption of
technology-driven solutions for both delivery of ABHRs and
monitoring of their use, and use of such data for analysis of
patient and healthcare professional movements in the context
of outbreaks, may lead to enhanced compliance, or at least to
better understanding of the challenges involved.
Conflict of interest statement
None declared.
Funding sources
None.
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