Methods to improve healthcare worker hand hygiene to decrease infection in hospitals

Patients in hospital, nursing homes and long-term care facilities are at high risk of developing infections that they did not have before admission. Most healthcare-associated infections are spread by direct contact, especially via the hands of healthcare workers. Traditionally, hand hygiene, such as washing hands before and after touching patients, has been considered the single most important way of reducing infections. Increasingly, the use of alcohol-based hand rub is used alongside or in replacement of traditional washing with soap and water. However, compliance with hand hygiene is poor.

This updated review sought to establish whether there are effective strategies to improve hand hygiene compliance, whether such strategies are effective over short or longer term and whether increased compliance reduces healthcare-associated infections.

There were four studies, two from the original review in 2007 and two from the update, which assessed the success of campaigns to improve hand hygiene compliance. Follow-up continued for longer than 12 months in two of the studies, but none of the studies was of high quality. Success in improving hand hygiene was inconsistent among the four studies.

There is still not enough evidence to be certain what strategies improve hand hygiene compliance. Introducing alcohol-based hand rub accompanied by education/training is not enough, while using multiple strategies, including involvement of staff in planning activities or applying social marketing strategies, may be helpful. More research is needed.

Authors' conclusions: 

The quality of intervention studies intended to increase hand hygiene compliance remains disappointing. Although multifaceted campaigns with social marketing or staff involvement appear to have an effect, there is insufficient evidence to draw a firm conclusion. There remains an urgent need to undertake methodologically robust research to explore the effectiveness of soundly designed and implemented interventions to increase hand hygiene compliance.

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Health care-associated infection is a major cause of morbidity and mortality. Hand hygiene is regarded as an effective preventive measure.


To update the review done in 2007, to assess the short and longer-term success of strategies to improve hand hygiene compliance and to determine whether a sustained increase in hand hygiene compliance can reduce rates of health care-associated infection.

Search strategy: 

We conducted electronic searches of: the Cochrane Central Register of Controlled Trials; the Cochrane Effective Practice and Organisation of Care Group specialised register of trials; MEDLINE; PubMed; EMBASE; CINAHL; and the BNI. Originally searched to July 2006, for the update databases were searched from August 2006 until November 2009.

Selection criteria: 

Randomised controlled trials, controlled clinical trials, controlled before and after studies, and interrupted time series analyses meeting explicit entry and quality criteria used by the Cochrane Effective Practice and Organisation of Care Group were eligible for inclusion. Studies reporting indicators of hand hygiene compliance and proxy indicators such as product use were considered. Self-reported data were not considered a valid measure of compliance. Studies to promote hand hygiene compliance as part of a care bundle approach were included, providing data relating specifically to hand hygiene were presented separately. Studies were excluded if hand hygiene was assessed in simulations, non-clinical settings or the operating theatre setting.

Data collection and analysis: 

Two reviewers independently extracted data and assessed data quality.

Main results: 

Four studies met the criteria for the review: two from the original review and two from the update. Two studies evaluated simple education initiatives, one using a randomized clinical trial design and the other a controlled before and after design. Both measured hand hygiene compliance by direct observation. The other two studies were both interrupted times series studies. One study presented three separate interventions within the same paper: simple substitutions of product and two multifaceted campaigns, one of which included involving practitioners in making decisions about choice of hand hygiene products and the components of the hand hygiene program. The other study also presented two separate multifaceted campaigns, one of which involved application of social marketing theory. In these two studies follow-up data collection continued beyond 12 months, and a proxy measure of hand hygiene compliance (product use) was recorded. Microbiological data were recorded in one study. Hand hygiene compliance increased for one of the studies where it was measured by direct observation, but the results from the other study were not conclusive. Product use increased in the two studies in which it was reported, with inconsistent results reported for one initiative. MRSA incidence decreased in the one study reporting microbiological data.