American Journal of Infection Control 44 (2016) 691-704

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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

Special articles (or Research methods)

Evidence-based practices to increase hand hygiene compliance in

health care facilities: An integrated review
Jun Rong Jeffrey Neo BS a,*, Rana Sagha-Zadeh MArch, PhD a, Ole Vielemeyer MD b,
Ella Franklin RN, BSN c
a
Department of Design and Environmental Analysis, Cornell University, Ithaca, NY
b
Division of Infectious Disease, Weill Cornell Medical College, New York, NY
c National Center for Human Factors in Healthcare, MedStar Health, Washington, DC

Background: Hand hygiene (HH) in health care facilities is a key component to reduce pathogen trans-
mission and nosocomial infections. However, most HH interventions (HHI) have not been sustainable.
Aims: This review aims to provide a comprehensive summary of recently published evidence-based HHI
designed to improve HH compliance (HHC) that will enable health care providers to make informed choices
when allocating limited resources to improve HHC and patient safety.
Methods: The Medline electronic database (using PubMed) was used to identify relevant studies. English
language articles that included hand hygiene interventions and related terms combined with health care
environments or related terms were included.
Results: Seventy-three studies that met the inclusion criteria were summarized. Interventions were cat-
egorized as improving awareness with education, facility design, and planning, unit-level protocols and
procedures, hospital-wide programs, and multimodal interventions. Past successful HHIs may not
be as effective when applied to other health care environments. HH education should be interactive
and engaging. Electronic monitoring and reminders should be implemented in phases to ensure cost-
effectiveness. To create hospitalwide programs that engage end users, policy makers should draw expertise
from interdisciplinary fields. Before implementing the various components of multimodal interven-
tions, health care practitioners should identify and examine HH difficulties unique to their organizations.
Conclusions: Future research should seek to achieve the following: replicate successful HHI in other
health care environments, develop reliable HHC monitoring tools, understand caregiver-patient-family
interactions, examine ways (eg, hospital leadership, financial support, and strategies from public health
and infection prevention initiatives) to sustain HHC, and use simulated lab environments to refine study
designs.
© 2016 Association for Professionals in Infection Control and Epidemiology, Inc. Published by Elsevier
Inc. All rights reserved.

BACKGROUND In complex modern health care environments, health

Despite many efforts, health care-associated infections (HAI) con-
tinue to be a threat to hospital patients. Whereas various factors
account for HAIs,1 contact transmission is a key pathway.2 Thus, hand
hygiene (HH) with soap and water or alcohol-based handrub (ABHR)
is regarded as among the most important interventions to prevent
HAI.3 As far as 150 years ago, Ignaz Semmelweis described a sub-
stantial drop in mortality rates with simple HH.4
* Address correspondence to Jun Rong Jeffrey Neo, BS, 2425 Martha Van Rensselaer
Hall, Ithaca, New York 14850.
E-mail address: jn458@cornell.edu (J.R.J. Neo).
Conflicts of Interest: None to report.
care workers (HCWs) are constantly on the move and respond to
stressful and time-sensitive work demands. Thus, sustaining HH com-
pliance (HHC) remains a challenge.5 In fact, public health authorities
have rated HHC among HCWs to be unacceptably poor.6 In one
review, for example, HHC only reached 30%-40% in intensive care
units (ICUs).7,8 According to the World Health Organization (WHO),
several types of microbes (eg, Staphylococcus aureus, Streptococcus
pyogenes, and vancomycin-resistant Enterococcus) can be spread
through the hands of HCWs due to lapses in HH. HCW hands can
be contaminated even after various “clean” procedures (eg, taking
a pulse). Several studies have suggested that contaminated hands
can increase the spread of microbes and HAI, which are a threat to
patients.9 According to the Centers for Disease Control and Preven-
tion (CDC), in 2011, the total number of HAI cases in the United States

0196-6553/© 2016 Association for Professionals in Infection Control and Epidemiology, Inc. Published by Elsevier Inc. All rights reserved.
http://dx.doi.org/10.1016/j.ajic.2015.11.034
692 J.R.J. Neo et al. / American Journal of Infection Control 44 (2016) 691-704
alone was estimated to be 721,800 and cost the US health care system
$35 billion.10 In 2000, Pitiet et al11 noted that “HHC level does not
rely on individual factors alone, and [that] the same can be said for
its promotion.” For example, besides personal variables, environ-
ment conditions, social norms, and organizational policies are some
factors that may affect HHC.
HH is defined as the act of handwashing with soap and water or
disinfection with an antiseptic agent.6,7 Accordingly, HHC refers to the
extent to which HH behavior matches or conforms to recommen-
dations or guidelines.12,13 An HH intervention (HHI) is defined as a
hand sanitization program implemented by an organization to in-
crease HHC. It can range in design from simple (eg, increased availability
of cleaning agents) to complex (eg, multimodal intervention [MMI]
program involving education, facility design, and performance feed-
back). In addition, HHI could also be studied to reduce HAI.14
Given that the behavior change process is multifaceted and
complex, an HHI that targets only a specific user or area often fail
to yield positive results.11 Although some evidence-based HHIs have
been developed, sustaining HHC among HCWs remains difficult, ul-
timately threatening health care quality and safety.15 That being said,
several government agencies have provided guideline and/or tools
to improve HHC in health care systems. In 2002, the CDC pro-
duced guidelines for HH in health-care settings.16 The guideline
provides HCWs with a data review for handwashing and hand an-
tisepsis in health care environments. The review also provides in-
depth recommendations to improve HHC and reduce pathogenic
microorganism transmissions in health care environments.16 In 2005,
the Institute for Healthcare Improvement, in collaboration with the
CDC, the Association for Professionals in Infection Control and Epi-
demiology, and the Society of Healthcare Epidemiology of America
produced “How-to Guide: Improving Hand Hygiene.”17 The guide
includes a description of the case for improving HH and use of gloves
among HCWs, recommended evidence-based HH that will result in
improved HH, steps to improve HHC in health care organizations,
and measurement support tools.17 According to The Joint Commis-
sion, HH is the most critical intervention for preventing HAI. The
Joint Commission provides resources that include HH solutions avail-
able from the Center for Transforming Healthcare, and a monograph
on measuring hand hygiene adherence, among others.18
Recently, with increased public awareness and robust research
activity in this area, a growing number of articles and reviews have
been published. The latter mostly focus on documenting and sum-
marizing various kinds of HHI. In 2008, Backman, Zoutman, and
Marck14 reviewed 35 publications that examined the effectiveness
of various HHIs and called for more rigorous studies to provide ev-
idence on the influence of specific HHIs on HAI prevention.
More recently, Marra and Edmond19 discussed new technolo-
gies to monitor HHC among HCWs. They concluded that before
making significant investments, more analyses are needed to assess
the effectiveness of these HH technologies. As new technologies to
Table 1
Inclusion and exclusion criteria
Inclusion
Date of publication January 1, 2002-September 30, 2015
Location or context Health care environments (eg, entire facility, intensive care unit, inpatient units,
long-term care facility) in developed countries
Intervention Various forms of hand hygiene interventions
Outcome Measurements of improvement in hand hygiene compliance
Study design Experimental: Randomized controlled trial and nonrandomized controlled trial
Observational: Pre- and postintervention design with a control group and pre- and
postintervention design without a control group
monitor HHC are constantly developed, interdisciplinary teams need
to collaborate in the planning phase.
Our review provides a comprehensive summary of recently pub-
lished HHIs aimed at improving HHC, paying special attention to
capture and discuss the full breadth of HHI types. It also provides
a useful framework to enable health care providers to make in-
formed choices when allocating limited resources to improve HHC
and patient safety.
METHODS
Search strategy
The electronic database Medline (using PubMed) was used. A
search included articles in English with the MESH headings:
handwash*, hand hygiene, intervention*, program*, technique*, tech-
nology*, protocol*, compliance*, and observance. These words were
combined with 1 of the following terms: hospital*, and healthcare
environment*. An asterisk is used as a truncation symbol that allow
us to search the “root” of a word to find all its different endings.
For example, technology* finds technologies, technological, and the
like. Table A1 provides the full list of search terms. Of the 151 ar-
ticles retrieved, 73 articles met the inclusion criteria.
Two reviewers (JN and RZ) independently evaluated the 151 re-
trieved articles. Following the initial round of independent reviews,
the reviewers (JN and RZ) discussed the rationale as to why some
articles were included or excluded from the review, based on the
inclusion and exclusion criteria.
Inclusion and exclusion criteria
The findings were analyzed based on targeted participant groups
(HCW, physicians, registered nurses, nursing students, families and
visitors, and patients), health care settings (eg, ICU, inpatient unit,
entire facility, and long-term-care facility), intervention types (im-
proving awareness with education, facility design and planning [FDP],
unit-level protocols and procedures, institution-wide programs, and
MMI), study rigor (P value, study design, and comments on study
design), and effectiveness and sustainability of HHC. They are re-
ported in Table 1.
Study rigor
Several past studies related to HHC considered a P value < .05
to be significant.20-22 In this review, a P value < .05 would be con-
sidered to be a clinically significant increase in HHC, following past
studies with similar assumptions.23 The study design (pre- and
postintervention with/without control group or nonrandomized/
randomized controlled trial) for each study was also included in the
results table (Table A2).
Exclusion
Before January 1, 2002, after October 1, 2015
All other settings (eg, education spaces, workspaces, public
spaces)
Antibiotics or therapeutic drugs
Precautionary isolation measures
Any other studies that do not measure improvement in
hand hygiene compliance
Any other publications (eg, commentary, outbreak reports)
 J.R.J. Neo et al. / American Journal of Infection Control 44 (2016) 691-704
SEARCH RESULTS
Seventy-three of 151 studies were retrieved from MEDLINE and
met the inclusion criteria.
Participant groups
The results table (Table A2) shows the list of HHI classified ac-
cording to study participants: 51 (70%) HCW (not otherwise
specified); 17 (23%) registered nurses, nursing assistants, and stu-
dents; 5 (7%) families and visitors; 3 (4%) physicians; and 1 (1%)
patients. As some studies examined different participant groups in
the same study, the sum of studies is >73, and thus the total per-
centages are >100%.
Health care settings
The results table (Table A2) shows a list of HHIs sorted accord-
ing to the general facility type where HHI was conducted: 16 (22%)
entire facility, 28 (38%) ICU, 27 (37%) non-ICU inpatient units, 5 (7%)
long-term facility, and 4 (5%) reported data from other locations.
Intervention types
Five key categories of HHI emerged: improving awareness with
education (knowledge transfer, evaluation, mentoring, and feed-
back), FDP, unit-level protocols and procedures, institution-wide
programs, and MMIs.
Intervention 1: Improving awareness with education (knowledge
transfer, evaluation, mentoring, and feedback)
A host of interventions emerged that involved knowledge trans-
fer and knowledge retention for HHC for HCWs, families, visitors,
and/or patients. Educational interventions included knowledge trans-
fer via hands-on or online training; problem-based education;
education with gaming technology, conferences, newsletters, bro-
chures, videos, posters, visual cues with inputs from staff, and simple
visual illustrations to families and visitors; verbal reminders; voice
messages; electronic alerts and displays; e-mail; screen savers; signs;
prominent visual cues; and getting patients to remind HCWs on HHC;
monitoring using cameras to record HH; electronic monitoring; eval-
uation using performance feedback; and use of fluorescent gel to
evaluate HH technique; and engaging student mentors in monitor-
ing students’ HH.
Thirty-three of 34 studies found improved HHC between 4%31 and
70%.52 Several studies indicated that unit-level education interven-
tions are effective. Education that engages users appears more effective.
Some interventions are enhanced by technology and/or games.
Intervention 2: FDP
A group of HHI involved interventions at the FDP and manage-
ment level. FDP interventions included installation of new ABHR
dispensers in the units in strategic locations, repositioning of ex-
isting ABHR, and increasing sink numbers. FDP can be effective in
improving HH. Seven of the 8 studies found improved HHC of
14%61-60%.60
Intervention 3: Unit-level protocols and procedures
A group of studies included unit-level operational interven-
tions that have to do with procedures, practices, and protocols. Unit-
level protocols and procedures included enforcements, protocols,
standard operating procedures, guidelines, and Six Sigma pro-
cesses to identify, implement, and sustain changes in the areas of
HH, infection control, and isolation, decontamination, and clean-
ing of clinical instruments. Unit-level protocols and procedures with
693
direct relevance to HH are effective to improve HH. Six of the 7
studies found improved HHC between 16%71 and 59%.70
Intervention 4: Institution-wide programs
Some studies introduced HHI that required policy implemen-
tations at the institutional level by administrators. Institution-
wide programs included infection control programs, patient safety
programs, and enforcement of the CDC HH guideline. Programs that
engage users are effective to enforce HHC. Two of 3 studies found
improved HHC of 20%73 and 43%.74
Intervention 5: MMIs
If the HHI consists of various interventions, it was categorized
into intervention 5. MMIs included education delivered via knowl-
edge transfer (problem-based and task-oriented training, WHO 5
moments of HH, health talks, videos, and posters), reminders (in-
structions), monitoring (mentoring), and evaluation (performance
feedback); FDP by installing new ABHR, ABHR racks, and pull reels
in the units in strategic locations, and repositioning of existing ABHR
dispensers; leadership engagement and commitment, leader-
directed strategies, HH initiatives championed by physicians and
nurses, guiding nurses in a welcoming manner, adopting an open
communication approach, role modeling, and social influence; and
protocols and procedures using regular HH audit, HAI surveil-
lance, clinical improvements, enhanced minimal handling protocol,
clustering of nursing care, compliance assessments, and financial
incentives. For example, Harbarth et al80 combined knowledge trans-
fer, FDP and leadership, role models, and empowerment in their MMI.
Study rigor
Among studies that reported the P value, 59 out of 63 pro-
duced a statistically significant increase in HHC (P < .05) and 4 did
not.26,65,69,85 Ten studies did not report the P value.36,38-40,42,47,74,79,89,94
As for study design, 37 (51%) pre- and postinterventions without
a control group, 21 (29%) pre- and postinterventions with a control
group, 9 (12%) nonrandomized controlled trials, and 6 (8%) ran-
domized controlled trials.
DISCUSSION
This integrated review identified, classified, and summarized re-
cently published multidisciplinary evidence-based HHIs to increase
HHC. Studies were analyzed based on targeted participant groups,
health care settings, intervention types, study rigor, effectiveness,
and sustainability of HHC.
Selected publications examined HHIs across various partici-
pant groups: families, visitors, patients, and all types of HCW.
Although 70% of the studies were conducted among HCWs, signifi-
cantly more studies were conducted on nurses than on physicians.
Five types of HHI to improve HHC in health care environments
were identified: improving awareness with education (knowledge
transfer, evaluation, mentoring, and feedback), influencing HH with
FDP, use of unit-level protocols and procedures, and effects seen with
institution-wide programs. A fair number of studies targeted >1
intervention type (ie, MMI).
Health care settings
HH studies were examined across 5 facility types ranging from
specialized units to entire facilities. However, study locations were
unequally distributed, with 38% of HH studies conducted in ICUs
alone, contrasted with only 7% of studies in long-term-care facili-
ties. Because many infection control programs have an incentive to
694 J.R.J. Neo et al. / American Journal of Infection Control 44 (2016) 691-704
reduce HAI and pathogen transmission with improved HH, data are
routinely collected only from ICUs but not hospitalwide. Only
16 (22%) studies took place within the entire health care facility.
Ten (14%) out of 73 studies reported the inability to generalize
their findings to other health care facilities as a research
limitation.21,22,30,42,48,50,57,58,66,68 HH behaviors can differ vastly de-
pending on the health care setting, and there is no 1-size-fits-all
solution to improve HH across every health care delivery system.
Thus, to determine the generalizability of successful HHI, future re-
search needs to replicate results in other health care facility
types,24,34,69,80,88 and allow other researchers to apply the design of
successful HH studies onto other facility types by providing de-
tailed descriptions of the HHI and the health care facility type
examined.82 Given the relatively higher HAI and mortality rates in
ICUs, such acute care units may benefit most from HH research
advancements.63,83,89 Also, there is a need to understand the effect
of the social context, social networking, and positive deviance on
HH behavior.11
Intervention 1: Improving awareness with education (knowledge
transfer, evaluation, mentoring, and feedback)
Several studies combined knowledge transfer, monitoring, and
evaluation and feedback at the unit or institutional level. Most train-
ing programs were effective for all occupants.
Interactive HH training needs to target the right audience. Train-
ing that provided HCWs with constant interactive engagements and
learning opportunities produced greater improvements.47,54 In Zingg
et al,26 the 4-phase training program may be overly informative and
cognitively demanding. Thus, training should not exert excessive cog-
nitive load on HCW in addition to their hectic work schedule. Training
should be fun, engaging, and should fit well into the daily workflow.54
Also, an HHI focused on 1 of the WHO 5 moments of HH im-
proved HHC by 9.1% among nurses but −14% among physicians.78
In this study, nurses received more HH training on proper hand-
washing technique as part of the standard training activities between
observation periods.78 Each nurse was encouraged to participate at
least once during the training.78 However, physicians did not receive
the same level of reinforcement and learning opportunities on good
HH, and that may be why the WHO intervention produced posi-
tive improvements among nurses, but not physicians.78
Evaluation, monitoring, and feedback can be enhanced with
technology.34-41 Several studies indicated that unit-level educa-
tion, campaigns, evaluation, mentoring, and feedback in hospitals
are effective.34,36-39,41,43,46,47 Some technological interventions were
enhanced by gaming.54 An HHI focused on HH e-mail, bulletins,
posters, and verbal reminders improved HHC by 11% after 1 month.31
However, HHC returned to baseline after 3 months. Findings from
this study support past evidence that HHC tends to return to base-
line unless sustained with continued audit and reinforcement.31 Thus,
HHI involving technology and gaming may improve HHC over sus-
tained durations because these HHIs may provide continued audit
and reinforcement.34,36-39,41,43,46,47,54
Routine actions like HH can often be overlooked by busy HCWs,
and technology-assisted evaluation, monitoring, and performance
feedback might be a powerful reminder.76 Although this type of HHI
generally produces greater improvements in HHC, it often costs more
(due to the need for installation, operations, and maintenance) and
may not detect all HH opportunities.36,37,39
Automated HH monitoring systems34-40 would ideally improve
monitoring capabilities at reduced costs and resolve some of
the current monitoring problems. However, their widespread
application remains limited. Such technology should be applied
to areas where HHC appear most crucial such as in neonatal ICUs.
The relatively high cost of automated monitoring may require im-
plementation in phases.
Accurate and meaningful HH evaluation, monitoring, and feed-
back remain critical for patient care and safety.40,41 Future research
should determine optimal locations for important visual remind-
ers such as signs to prevent users’ “information saturation.”42,45,46
In addition, it should focus on a better understanding of human be-
havior in various contexts or health care environments, and draw
expertise from the fields of psychology, human factors, and ergo-
nomics to improve and sustain proper HH behavior through better
monitoring systems11 that incorporate HH opportunities as defined
by WHO Healthcare Infection Control Practices Advisory Commit-
tee as the denominator.96
Intervention 2: FDP
FDP, environmental psychology, behavioral economics, human
factors, and ergonomics are important for the proper design of HH
products, processes, and physical environments to improve HHC.
Such interventions have been used to study issues such as patient
safety, handoffs, and patient–caregiver communications. Yet, without
an understanding of the processes involved and barriers due to
human behavior, simply having more HH products available in more
places would likely not improve and sustain HHC.65 For example,
a study65 that examined the influence of increased sink numbers
on HHC confirmed that the availability of sinks alone does not
improve HHC among HCWs. Thus, instead of just providing HH re-
sources, additional HHIs or MMIs may be required.65 More research
should be devoted to understanding human behavior when it comes
to HHC, and apply novel interventions from nonclinical fields to
reduce infection transfer.65 The Systems Engineering Initiative for
Patient Safety model, a framework for understanding the influ-
ence of work system design on safety and organizational outcomes,
may support the integration of these external disciplines within
future HHIs.97
Optimizing research resources will allow for examining more
targeted HHIs in health care environments.64 Simulated lab envi-
ronments may allow researchers to refine their study designs and
HHIs before applying these HHIs into actual health care
environments.64 Because busy work schedules and perceptions of
HH, among other issues, are often limitations, it is particularly im-
portant for study designs and interventions to be refined before
applying them to field settings.64
Intervention 3: Unit-level protocols and procedures
Six studies implemented unit-level protocols and procedures that
considered the unique HH challenges at their hospital and found
that adapting them to their units successfully increased HHC.66-68,70-72
The 1 study that did not produce increased HHC simply added the
requirement of gown use.69 In situations where gown compliance
is good, users may instead have a false assurance that the re-
quired measures for infection control have been taken, thus
undermining the importance of HH.69 This may also indicate the im-
portance of implementing interventions that allow behavior change
to be paired with unit-level protocols and procedures.66,71
Intervention 4: Institution-wide programs
The 2 studies that improved HHC through an institution-wide
program also engaged participants.73,74 They implemented pro-
grams that incorporated unique issues and challenges for their
respective hospitals.73,74 Rossenthal et al74 described a program
(Measure to Achieve Patient Safety) at the University of California,
Los Angeles, Medical Center to allow undergraduate student
 J.R.J. Neo et al. / American Journal of Infection Control 44 (2016) 691-704
volunteers to conduct HH observations in the hospital. In the study
by Ebnöther et al,73 the infection control program required addi-
tional staff for infection control.
A study that examined the influence of enforcement of the CDC
HH guideline did not improve HHC.72 The authors suggested that
widely disseminated policies, procedures, and programs, and pro-
vision of HH resources alone might be insufficient to improve HHC
in clinical environments.72 Thus, practitioners should seek to explore
MMIs that incorporate additional input from staff before imple-
menting these HH programs.72 Effective administrative policies
should be adapted to HH issues and challenges unique to each health
care environment and be paired with physical, operational, and cul-
tural HHIs to create and sustain behavior change.72 It is important
to engage users during the policy-making process.72 We also propose
that future HH research apply implementation science competen-
cies to create generalizable knowledge that can be applied to various
types of health care environment.
Intervention 5: MMIs
In recent years, MMIs have been widely studied and later adopted
routinely by health care organizations to improve HHC. However,
due to low-quality study design, previous research examining the
influence of MMIs on HHC are largely inconclusive.98
Of the 73 selected manuscripts, 21 (29%) examined the influ-
ence of MMIs on HHC and included the following components:
education (knowledge transfer, evaluation, monitoring, and
feedback); FDP; leadership, role modeling, and empowerment; and
unit-level protocols and procedures.
Education was a component in each of the 21 MMI studies, sug-
gesting the importance of education for improved HH. Future
research may examine how improving awareness with education
can enhance the overall effectiveness of MMIs.
Granted, the HHIs were implemented in various health care fa-
cilities across various participant groups. Thus, it is difficult to make
relative comparisons between percentage improvements. Because
there was a wide range of improvements, the relevance and effi-
cacy of existing MMI components should be questioned. Although
MMIs are commonly used to improve HHC, it is important for health
care practitioners to enforce implementation of these MMI com-
ponents in a selective and prudent manner.85 For example, in Whitby
et al,85 the Liquid-soap Substitution and the Geneva Program failed
to increase HHC. An HHI with past success (eg, in a neonatal ICU)
may not have the same results in other health care environments.85
Thus, it is important to consider past successful MMIs in totality
before implementing them.85
The mixed results generated from recent MMIs suggest that new
and innovative components should be examined in future MMI
studies.89 In Won et al,89 financial rewards or penalties were applied
to the nursing staff based on HH levels. A percentage of total neo-
natal ICU profit was given to nurses as a monthly bonus. HCWs who
performed HH incorrectly had points deducted.89 Bonuses were cal-
culated by dividing each nurse’s points by the total points of all
nurses in the neonatal ICU that month.67 Also, strong leadership,
role modeling, and empowerment emerged as a new category, ex-
clusive to the MMI, but only as 1 component.76-79,88
In summary, MMIs may address the issue of poor HHC on a global
level (eg, HH education and products). Understanding the role of
individual MMI components would ensure optimal manpower and
resource allocations.
Study rigor
Only 6 (8%) studies were randomized controlled trials. The lack
of randomized controlled trials in HH studies could be due to various
695
reasons (eg, clinical equipoises). However, for some types of HH
studies (eg, the use of mock-up architectural simulation to study
HH behaviors and preferences), study design in the form of ran-
domized controlled trials would be possible and should be looked
into for future HH research.
Sustainability of HHC
Besides increasing HHC, sustaining HHC in health care environ-
ments remains a key challenge. HHI needs to be continually
reinforced.43 In an observational trial by Raskind et al,48 results
support past evidence that, without ongoing audit and continual
reinforcement, HHC tends to return to baseline.
Frequent performance feedback and focused training pro-
grams might produce sustained HHC.83,95 Fifty-two out of 73 (71%)
current studies have short follow-up without effective measures of
sustained HHC.86 Future studies should incorporate follow-up
studies83 or have longer durations.86 There is a critical need to provide
measurement and feedback over a sustained duration.74,89 However,
conducting periodic measurement over an extended duration with
effective performance feedback across an entire health care facili-
ty remains challenging.
Son et al47 described a novel approach to measure, monitor, and
increase HHC. WHO guidelines were introduced and incorporated
into the workflow of front-line staff to create a more sustainable
program with peer-based direct observations of HHC throughout
multiple locations within the health care facility.47 HHC improved
from 65%-97% and was sustained for almost 3 years.47 However,
Rosenthal et al74 suggested that peer-based observations might be
inaccurate and impractical due to the hectic work schedule of HCWs.
Third-party remote video auditing with real-time feedback pro-
duced sustained improvements in HHC.41,49
Rupp et al59 found that sustained HHC is strongly related to ABHR
availability. However, Whitby et al85 suggest that the availability of
ABHR alone, without an associated behavior change program, is in-
effective. Behavior change among users is important to sustain HHC.72
Sustained behavior change may require cultural change via a bottom-
up approach.46 HHI needs to be well received43 and engaging.54
Detailed personnel-oriented planning together with a continuous
commitment from opinion leaders and interdisciplinary teams are
essential for sustained HHC.80 An HH campaign should fit the ho-
spital’s culture, and have strong support from senior leadership.88
In Huis et al,87 the 2 hospitals that produced sustained HHC speci-
fied HH as a hospitalwide priority. The third hospital was less explicit
and distinct in addressing the goal of HH as an organizational
priority. 87 Thus, hospital culture might influence HHC and its
sustainability.87
Limitations
The key limitations of this review were that only 1 search engine
(Medline) was used, the search only included studies with the terms
hand hygiene and hand wash due to the large amount of studies avail-
able in this area, and only studies published in English and conducted
in a developed countries were included for better comparison of
the results.
CONCLUSIONS
Our review showed that different HHI types require different fea-
tures to be effective:
1. HHI with past reported success in 1 specific setting may not have
the same positive results when applied to other health care
environments.
696 J.R.J. Neo et al. / American Journal of Infection Control 44 (2016) 691-704
2. Even with improved HHC during the study duration, sustain-
ing HHC over an extended period remains challenging.
3. HH education will likely have minimal benefit unless it is in-
teractive and engaging. Such education must not be overly
informative and cognitively demanding, and must fit well into
the hectic work schedule of HCWs.
4. Phased use of high-cost HH monitoring and electronic remind-
ers may reduce costs.
5. Visual cues and signs are a low-cost form of HHI, suited better
for low-risk health care environments, but are more fre-
quently used with other types of HHI (eg, MMIs).
6. Policy-making processes must address each health care env-
ironment’s unique challenges, engage users, and draw on
expertise from interdisciplinary fields, compared with generic
policies.
7. Health care practitioners should always examine HH issues
unique to their organizations before deciding which MMI com-
ponents to implement.
8. Strong leadership and commitment are needed.
Future research in the field of HH should seek to:
1. Replicate successful HHI strategies in other health care facili-
ty types.
2. Better understand caregiver-patient-family interactions.
3. Examine new ways to sustain HHC over an extended duration.
4. Examine how incorporating HH training into physical environ-
ments, products, procedures, and policies might help sustain
or reinforcement HH behavior improvements.
5. Incorporate new innovative components such as environmen-
tal psychology, behavioral economics, and financial rewards to
better understand and catalyze improved behavioral change in
various contexts and environments to improve HH.
6. Use simulated lab environments to refine study designs and HHI
before actual studies.
7. Apply implementation and dissemination science competen-
cies to future HH research.
8. Evaluate opportunities to apply successful influence and im-
plementation strategies from other public health and infection
prevention initiatives.
9. Develop reliable HHC monitoring tools that incorporate HH op-
portunities as defined by WHO/Healthcare Infection Control
Practices Advisory Committee as the denominator.
10. Study the importance of committed hospital leadership (and
financial support) for sustained improvement in HHC.
From our review, 5 HHI types were found to be effective. The rate
of effectiveness could be increased by systems and MMIs, adapta-
tion of the interventions to unit-level conditions and issues, and
adaptations of novel approaches such as environmental psycholo-
gy, behavioral economics, human factors and ergonomics, and
financial rewards to catalyze behavior change.
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APPENDIX B

Table A2
Summary of hand hygiene (HH) interventions and outcomes

Primary Outcome (% improvement

author (y) Design Participants Location Intervention in HH) P value Comments on study design
Improving awareness with education (Knowledge transfer)
Zerr (2005)24 PPWOC HCW Pediatric unit Conferences, employee newsletters, signs 19 <.001 Observer effect
Data collection: Inability to track HHC of individual
HCW
Chen (2007)25 NRCT Families and Pediatric ICU Simple visual illustration to teach HH 26 <.0001 Relatively short study duration
visitors Inability to obtain baseline data for comparison
Zingg (2009)26 PPWOC HCW Medical ICU Education program that taught HH 6 .466 HHC compliance rate did not improve significantly.
(handwashing and hand rubbing technique) Other interventions may be necessary for a facility

J.R.J. Neo et al. / American Journal of Infection Control 44 (2016) 691-704

and catheter care standards with relatively high HHC during preintervention
period
The disparity in study population highlights
limitations of pre–post HHI study in a single facility
Helder PPWOC HCW Neonatal ICU Problem-based HH education 23 <.001 Observer effect
(2010)27
El-Kafrawy PPWOC Families and Neonatal ICU Video showing HH information and standards 21 .002 Inability to capture all HH attempts
(2013)28 visitors
Alemagno PPWOC HCW Children’s hospital Three online training session 26 No data A convenient sample size of volunteer HCWs
(2010)29 Community hospital Only self-assessed HHC. Did not have measures to
validate responses. Did not conduct direct
observations of HHC
Hautemaniere PPWC HCW Teaching hospital 30-min training on good HH practice using 62 <10^-8 Observer effect
(2010)30 florescent gel
Didiodato PPWC RNs, assistants, Community hospital Education program: “Just Clean Your Hands” Before patient contact: 6 <.0001 Relatively small sample size.
(2013)31 students After patient contact: 4 <.0001 Potential confounder: Program may potentially
(sustained) contaminate the control group
Huang (2008)32 PPWOC RN, assistants, Long-term-care facility In-service class (1 h), hands-on training (30 min) 21 <.001 Small sample size and study duration
students
Improving awareness with education (knowledge transfer, evaluation, monitoring, and feedback)
Reich (2015)33 PPWOC Physicians Teaching hospital Physician report cards and comparative rankings 27 (sustained) <.0001 Study was conducted only in 1 ICU without a control
for medical and surgical subspecialty group. The entire sampling method is based on the
reliability of one observer. No specific reliability test
was carried out
Swoboda NRCT HCW Surgical unit Electronic monitoring device and computer 44 <.05 Observer effect
(2004)34 voice prompts Relatively small sample size
Conway PPWOC HCW Inpatient: Childbirth, Electronic monitoring and automated feedback Inpatient units: Hand .008 Relatively small sample size
(2014)35 critical care, joint center, hygiene increased on
medical/surgical, average by 0.17 events/
psychiatry, step-down, patient-hour.
telemetry. Outpatient units: HH
outpatient: computerized performance did not
tomography, emergency, change significantly
endoscopy, lab/
phlebotomy, magnetic
resonance imaging,
mammography

(continued on next page)

699
 700
Table A2
Continued

Primary Outcome (% improvement

author (y) Design Participants Location Intervention in HH) P value Comments on study design
Storey (2014)36 PPWOC HCW Cardiovascular unit Electronic monitoring and automated feedback 45 No data The device could not capture other forms of HHC (eg,
use of soap and water)
Levchenko PPWC HCW Continuing care unit Electronic monitoring and automated feedback 30 .004 The device could not capture other forms of HHC (eg,
(2014)37 use of soap and water)
Venkatesh PPWOC HCW Hematology unit Electronic alerts 34 No data The study was conducted over different periods Thus,
(2008)38 staff population might be different.
The device has occasional sensing issues
The device could not capture the duration of HHC
during patient care and other forms of HHC (eg, use
of soap and water)

J.R.J. Neo et al. / American Journal of Infection Control 44 (2016) 691-704

Levchenko PPWOC RNs, assistants, General/unspecified unit Electronic monitors 53 No data HHC performed with wall-mount soap dispensers
(2011)39 students were not captured
Al Salman PPWC HCW Cardiovascular unit Electronic monitors 15-37 No data Relatively small sample size and short study duration
(2015)40
Armellino PPWOC HCW Medical ICU Cameras to record HH compliance 78 (sustained) .0019 HH data from remote video audit cannot be compared
(2012)41 with HHC rates from human observations
Single study site without a control group
Thomas PPWOC RNs, assistants, Medical, pediatric, surgical, Visual cues produced with input from staff 17 No data Potential confounding variables might be present
(2005)42 students trauma ICU during the move to the new ICU during phase I of
Emergency unit study
McGuckin PPWOC HCW Medical, surgical ICU HH voice message by ICU staff 60 <.001 Did not track if HH product was used by visitors
(2006)43
Pessoa-Silva PPWOC HCW Neonatal unit Posters, focus groups, performance, and 10 (sustained) <.001 Observer effect
(2007)44 infection-rate feedback
D’Egidio PPWC HCW, Hospital entrance Flashing red light attached to ABHR 11 <.0001 Relatively small sample size and short study duration
(2014)45 families, and
visitors
Davis (2010)46 PPWC HCW Surgical unit Bright red tap along corridors leading to ward 38 (sustained) <.0001 Low number of staff entering the ward
entrances, arrowheads pointing at ABHR, and Potential confounder: Other infection control
instructional posters programs may increase HHC
Observer effect
Son (2011)47 PPWOC RNs, assistants, Oncology unit Small-group discussion about HH barriers 27 No data Observer effect
students
Raskind PPWC HCW, Neonatal ICU HH e-mails bulletins, posters, and verbal 1 mo: 11% <.0001 Observer effect
(2007)48 families, and reminders 3 mo: 0% No attempt to limit the number of HH opportunities
visitors by an individual. If many subjects washed their
hands for several times, the final data might be
skewed
Sampling bias: Observations may not be
comprehensive due to disrupted and convenient
sampling method
Taylor (2012)49 PPWOC Families and Neonatal ICU Infection control reminders in video form 21 (sustained) <.0016 Intervention may have short-term effects
visitors
Helder NRCT HCW Neonatal ICU HH information on computer screensavers 8 <.001 Relatively short study duration
(2012)50 Study design: The effects of confounding variables
remains unknown due to the absence of the control
group

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Table A2
Continued

Primary Outcome (% improvement

author (y) Design Participants Location Intervention in HH) P value Comments on study design
Kim (2013)51 PPWOC Patients Tertiary hospital Antibiotic stewardship and HH program that 40 .043 Relatively small sample size and short study duration
emphasized the importance of HH by Potential confounder: The influence of infection
promoting infection control program with control programs on the reduction in Methicillin-
posters, electronic display, and screen savers resistant Staphylococcus aureus rates is not well
understood
Snow (2006)52 NRCT RNs, assistants, Unspecified Influence of mentors’ HH on HH among nursing 70 <.01 Observer effect
students students on various clinical rotations
Monsalve PPWC HCW Medical ICU Peer effects: Presence and proximity of other 7 <.01 HH opportunities only limited to in-and-out of the
(2014)53 HCW on HH of peers room

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Only collected HHC data that occurs outside patient’s
room (and not inside)
Higgins NRCT HCW Tertiary hospital Gaming technology that allowed users to learn 42 <.0001 Potential confounder: Extra ABHR in clinical areas had
(2013)54 and practice HH with an audit tool a confounding effect on the increased use of ABHR
Observer effect
Improving awareness with education (evaluation, monitoring, and feedback)
McGuckin PPWOC HCW Community hospital Patient education model: 1) brochures and 22 <.001 Relatively small sample size
(2004)55 videos to educate patients on HH importance, Potential confounder: 5 sinks were spoilt, 11 patients
particularly among HCW, 2) before patient who were discharged early
contact, patients were asked to check with
HCW if “they had wash/sanitized your hands,”
and 3) patients had a HH reminder banner to
stick on their hospital gowns to remind HCW
Mertz (2010)56 RCT RNs, assistants, General/unspecified unit Small group seminars, posters, and feedback 6 <.001 Potential confounder: Potential contamination of the
students program to the control group.
Only pooled unit-specific feedback was provided to
the HCW
Eveillard PPWOC HCW Long-term-care facility Knowledge transfer and performance feedback 20 <10^-5 Relatively small sample size and duration
(2011)57 Unequal sample proportion: Only 5% of observed
samples were physicians
FDP
Mody (2003)58 PPWC HCW Long-term-care facility New ABHR installation in strategic locations 35 .002 Self-reported HH data
Rupp (2008)59 PPWC RNs, assistants, Medical ICU New ABHR installation in strategic locations 31 (sustained) <.001 Patients were only followed up after 48-h transfer
students from ICU
Inability to draw an association between improved
HHC and HAI rates: Might be due to the limited
power of the study or the lack of HHC
Munoz-Price PPWC HCW Operating room Using a hand sanitizer dispenser on the 60 .01 The study was only conducted in 1 location
(2014)60 anesthesia machine in addition to the standard
wall-mounted dispensers
Yeung (2011)61 RCT HCW Long-term-care facility Pocket-sized ABHR 14 .001 Snowball sampling method
Generalizability of findings: May not be applicable to
other long-term-care facilities
Babiarz PPWC HCW Ultrasound area Novel sanitizer-dispensing door handle device 53 <.001 Study only examined a small number of exam rooms
(2014)62 at a single study site
Relatively short study duration

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Table A2
Continued

Primary Outcome (% improvement

author (y) Design Participants Location Intervention in HH) P value Comments on study design
Thomas PPWC HCW Medical ICU Moving the ABHR to more prominent locations 56 <.001 Potential confounding variables might be present
(2009)63 and closer to the patient during the move to the new ICU during phase I of the
study.
Birnbach RCT Physicians Mock-up simulation Relocation of ABHR 42 .0011 Relatively small sample size
(2010)64
Whitby PPWOC RNs, assistants, Medical ICU Increased sink numbers Did not improve .95 Potential confounder: Methicillin-resistant
(2004)65 students infectious disease, urology Staphylococcus aureus outbreak in study 1
unit
Unit-level protocols and procedures
Creedon NRCT HCW Medical, surgical ICU Enabled, reinforced, and predisposed HCW to 32 <.001 Lack of a follow-up period after the initial observation
(2006)66 observe HH guidelines Observer effect

J.R.J. Neo et al. / American Journal of Infection Control 44 (2016) 691-704

Eldridge PPWC HCW Medical, surgical ICU Six Sigma Process: Focus—Identify, implement, 33 (sustained) <.001 Observer effect
(2006)67 and sustain changes
Chassin PPWOC HCW 8 hospitals Six Sigma Process: Focus—Identify, implement, 33 (sustained) <.001 Cannot determine if HHI was the sole reason behind
(2015)68 and sustain changes increased HHC
Change management
Golan (2006)69 PPWC HCW Medical ICU Enforcing gown use requirements Did not improve .85 A large number of observers: Data collection may not
be consistent. Did not account for interrater
reliability
Howard PPWOC HCW Surgical ICU, Clean practice protocol: Hand decontamination, 59 <.00001 Duration between audit cycles: Relatively short
(2009)70 breast, cardiovascular, glove and gown use, patient infective isolation, interval
gastrointestinal, urology notes and garments contamination, and Further studies that examine long-term effects is
unit cleaning of clinical instruments necessary
Erasmus PPWOC RNs, assistants, Surgical ICU Action planning: If–then plans that relate an 16 <.001 Relatively small sample size and short study duration
(2010)71 students surgery unit environmental cue with an intended action Observer effect
Scheithauer PPWOC HCW Hemodialysis unit Optimized HH standard operating procedures for 32 <.001 Observer effect
(2012)72 RNs, assistants, dialysis connections and disconnections Potential confounder: The influence of patient
students outcome on improving HHC was not explored
Institution-wide programs
Ebnöther PPWOC HCW Tertiary hospital Infection control program: Addition of infection 20 .01 The specific influence of a particular HHI is unclear
(2008)73 control staff, repeated HH instructions, new
guidelines for preoperative antibiotic
prophylaxis, patient isolation
Rosenthal PPWC RNs, assistants, Teaching hospital Patient safety program that engages student 43 (sustained) No data Interrater reliability
(2009)74 students volunteers to conduct HH observations Observer effect
HH data for night shifts are not systematically
measured
Larson (2007)75 PPWOC HCW Entire facility/unspecified Enforcement of the Centers for Disease Control Did not improve <.001 Potential confounder: Unstandardized surveillance of
area and Prevention HH guideline HH opportunities
Assessment of HHC: Only 2 days
Observer effect
Multimodal Interventions
Aboumatar NRCT HCW General/unspecified unit Education: Feedback 200 (sustained) <.001 Observer effect
(2012)76 FDP: Environmental changes HHC between specific opportunities cannot be
Leadership: Leadership engagement determined
Study design limited by quasiexperimental design
Lack of data: How increased HHC from program could
improve patient outcome

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Table A2
Continued

Primary Outcome (% improvement

author (y) Design Participants Location Intervention in HH) P value Comments on study design
Tromp (2012)77 PPWC RNs, assistants, Internal medicine unit Education: Training, feedback, mentoring 48 (sustained) <.05 Rather low response rate (60%)
students FDP: Introduction of ABHR HHC was lower in nonobservational setting (ie,
Leadership: Role model, social influence, outpatient clinic)
mentoring
Martino PPWOC RNs, assistants, Emergency unit Education: Sessions emphasizing ABHR over Nurses: 9 .03 Observer effect
(2011)78 students soap and water, presentation of baseline HH Physicians: −14 .008 The study was only conducted in 1 department
rates to all units to show the need to improve
compliance
FDP: Introduction of pocket-size ABHR

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Leadership: Physician and nurse champions
were selected to promote HH
Walker PPWC HCW Surgical unit Education: Continuous education Experiment 1: 41 No data Due to the presence of various confounders, the
(2014)79 FDP: Conspicuous and visible monitors Experiment 2: 36 relationship between HHI, and improved HHC
Leadership: Dissemination of HH information to (Sustained) cannot be ascertained
leaders
Harbarth PPWC HCW Pediatric ICU Education: Training, feedback 8 <.001 Long-term impact was not assessed
(2002)80 FDP: Introduction of ABHR Observer effect
Lam (2004)81 PPWC HCW Neonatal ICU Education: Problem-based and task-oriented HH Before patient contact: 13 .0002 Observer effect
training After patient contact: 20 <.0001
FDP: Addition of ABHR
Protocols and procedures: Revised minimal
handling protocol, clustering of nursing care,
regular HH audit, hospital-associated infection
surveillance
Hugonnet PPWOC HCW Medical, neonatal, Education: Training, monitoring, feedback 16 (sustained) <.001 Observer effect
(2002)82 pediatric, surgical ICU FDP: Introduction of ABHR Inability to estimate the relative efficacy of the
different multimodal intervention components
Hussein PPWOC HCW Medical ICU Education: Training using posters and shirt 42 <.0001 The observed number of HH opportunities is different
(2007)83 buttons sponsored by the Centers for Disease between the 2 study periods
Control and Prevention
FDP: Improved ABHR accessibility
Johnson PPWOC Physicians RNs, Teaching hospital Education: Reeducate importance of HH through 40 <.001 Observer effect
(2014)84 assistants, newsletters, screen savers, posters, in-person
students education, and computer-based training
modules
Education: HH education was provided to
medical students before they began clinical
clerkships and to resident physicians during
orientation. Patients and their families were
engaged in improvement efforts, given
standard information as to when to expect
HCW to perform HH and instructed to speak
up when HCW did not perform HH
FDP: Use and relocation of ABHR to more
convenient locations

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Table A2
Continued

Primary Outcome (% improvement

author (y) Design Participants Location Intervention in HH) P value Comments on study design
Whitby PPWOC HCW Medical ICU Studied 3 HHIs that had past success: Liquid- Program 1 and 2: Did not .238 HHI replicated in this study may not be entirely similar
(2008)85 infectious disease, soap substitution, the Geneva Program, and the improve Program 3: 48% .328 to those from previous studies
urology unit Washington Program. Only the Washington (sustained) <.001
Program sustainably improved HH
Dierssen-Sotos PPWOC HCW Medical ICU Education: Education strategy, feedback 16.6 (sustained) <.005 Observer effect
(2010)86 emergency unit FDP: Addition of ABHR There might be other confounding factors in the
before–after study design
Mayer (2011)15 NRCT HCW Medical ICU Education: Monitoring, feedback Cohort 1: 24 <.001 Observer effect

J.R.J. Neo et al. / American Journal of Infection Control 44 (2016) 691-704

emergency, oncology FDP: Introduction of ABHR Cohort 2: 15 HHC rate may be inflated
unit (sustained)
Huis (2013)87 RCT HCW Nursing unit Education: Knowledge transfer, feedback (−) 2-70 <.01 Low response rate (48%)
Leadership: Leaders directed strategies Psychometric properties in the survey were not tested
Doron (2011)88 PPWOC HCW General/unspecified unit Education: Marketing, monitoring, feedback 22 <.0001 Relatively short study duration
Leadership: Strong commitment from hospital
leadership
Won (2004)89 NRCT HCW Neonatal ICU Education: Lecture, posters, instructions, 37 No data Observer effect
feedback
Protocols and procedures: Financial incentive
Bouadma PPWOC HCW Medical ICU Education: Interdisciplinary task force, training, 68 (sustained) <.0001 Some major recommendations were not evaluated
(2010)90 feedback Observer effect
Protocols and procedures: Compliance Observer bias
assessment
Trick (2007)91 PPWC RNs, assistants, Entire facility/unspecified Education: Knowledge transfer, reminder poster 15 (sustained) .002 Potential confounder: Data compared across groups
students area FDP: Addition of ABHR was not matched by the type of care provided in
each hospital unit. Did not control for workload; that
is, nurse to patient ratio was not recorded
Observer effect
Martin- RCT HCW Children’s hospital Education: Knowledge transfer, reminder posters 21 <.001 Potential confounder: The HHI may contaminate the
Madrazo FDP: Installation of ABHR control group. Time of study coincided with H1N1
(2012)92 pandemic
Ho (2012)93 RCT HCW Long-term-care facility Education: Knowledge transfer, reminders, Arm 1: 34 <.001 Selection bias: Homes that participated could be more
health talks, videos, training, feedback Arm 2: 27 inclined toward HHC
FDP: Introduction of ABHR racks, pull reels Observer bias
Lederer PPWOC RNs, assistants, Entire facility/unspecified Education: Marketing protocols and procedures; 49 (sustained) No data Observer effect
(2009)94 students area clinical improvements
Oh (2012)95 PPWOC HCW Outpatient clinic Education: 5 moments of HH 73 <.0001 Observer bias
FDP: Appropriate ABHR placement Relatively small sample size collected from 1 location
Leadership: Guiding nurses in a welcoming
manner, adopting an open communication
approach

ABHR, alcohol-based handrub; FDP, facility design and planning; HCW, health care workers; HH, hand hygiene; HHC, hand hygiene compliance; HHI, hand hygiene intervention; ICU, intensive care unit; NRCT, nonrandomized
controlled trial; PPWC, pre- and postintervention with control group; PPWOC, pre- and postintervention without control group; RCT, randomized controlled trial; RN, registered nurse.