We know that hand hygiene matters. Hand hygiene is the single most cost effective way to prevent the spread of disease – including COVID-19. While we will continue to highlight individual studies on hand hygiene behaviour, it is occasionally helpful take a look at the big picture and analyze the current state of hand hygiene research. This is the work that researchers have done in the latest edition of The Journal of Hospital Infection, where they laid out a comprehensive review of healthcare-related hand hygiene clinical trials, covering 57 papers published between 2014 and 2020.
Hand hygiene interventions work
Many of these studies measured hand hygiene compliance. The average compliance rate across all the studies was 41%.[1] Of these studies, many were tracking the effectiveness of hand hygiene interventions. The heartening news is that, on average, hand hygiene compliance increased to 67% after intervention—a boost of 26%. Papers that studied single and multiple interventions both found positive outcomes. Either approach can lead to “modest to moderate increases in HH compliance across a variety of healthcare environments.”[2]
These interventions included “education and training; provision of HH infrastructure; reminders; performance feedback; teamwork interventions; and leadership interventions/administrative support.”[3]
Studies that used the International Nosocomial Infection Control Consortium’s (INICC) multidimensional approach framework had the largest increases in hand hygiene compliance. With an average increase of 35%, this framework bested the frameworks produced by the WHO and UNICEF, which had 18% and 26% compliance improvements, respectively.
The framework created by the INICC included a multi-modal approach with almost all of the types of hand hygiene interventions commonly studied, which may explain its success. This multi-modal approach included “administrative involvement at infection control meetings, ABHR supply, poster reminders, staff education sessions and monthly feedback…on HH compliance figures.”
Wearable electronic trackers can be problematic
While many studies uses electronic monitoring, the type of monitoring matters to healthcare professionals. Participants in clinic trials who were tracked via wearable monitoring devices reported “negative attitudes… [and] distrusted the accuracy of the collated data.”[4] In some studies, this distrust led to participants formally withdrawing from studies or not wearing their tracking bracelets. These findings were echoed in a recent paper that found that healthcare professionals are very receptive to group-based electronic recording and feedback, but not individual tracking. [link]
Hand hygiene research highlights global inequities
The majority of the studies that met the criteria of the review came from Europe and North America, which account for only 15% of the world’s population. Asia, Africa, and South America have been underrepresented in academic studies of healthcare hand hygiene. This poses a problem, since conclusions about hand hygiene interventions that originate in wealthier countries may not be universally applicable.
“Collectively, these data suggest a concentration of HH clinical research in wealthier countries. Given that rates of HCAIs are higher in developing countries, this geographic focus clearly represents a limitation of HH research to date, and limits the extent to which conclusions can be generalized to developing regions.”[5]
One caveat to this conclusion is that this review excluded papers that were not published in English.
What research is still needed?
There is a need for more full clinical trials to either be run in non-Western countries, or for the resulting papers to be translated into English for a global audience. In addition to the need for greater geographic diversity, this review was able to identify other types of necessary research. These included the need to study a greater range of healthcare facilities, the creation or codification of electronic recording standards, and a deeper understanding of what nurses can teach other healthcare professionals.
Most of these clinical trials took place in hospitals, leading to a lack of data about long-term and primary care facilities. As the role that long-term care facilities can play in curbing or exacerbating pandemics has been revealed this past year, hopefully more research on hand hygiene behaviour will take place in these settings.
More research is needed that uses and analyzes electronic technology, which the found to be “effective, albeit based on limited data.”[6] Specifically, the reviewers pointed out that only one of the studies that used electronic data recording used the WHO guidelines and that having international global hand hygiene guidelines include sections on electronic recording would be helpful for future research.[7]
Lastly, the reasons for nurses higher rates of hand hygiene compliance compared to other healthcare professionals needs to be studied.[8] These factors could help drive improvements in hand hygiene practices through healthcare institutions.
While there is much we still do not know about hand hygiene behaviour, study after study shows that hand hygiene interventions work to increase compliance and that there are multiple frameworks that can consistently improve hand hygiene behaviour in healthcare environments. What we know now and has been confirmed in almost 60 studies over the past half-decade, can be put to use to save lives and break the chain of infection.
[1] Clancy, C., et al. “Hand Hygiene-Related Clinical Trials Reported between 2014 and 2020: A Comprehensive Systematic Review.” Journal of Hospital Infection, Mar. 2021, 10.1016/j.jhin.2021.03.007. Accessed 19 Mar. 2021. Pg. 20.
[2] Clancy, C., et al. pg. 23.
[3] Clancy, C., et al. pg. 22.
[4] Clancy, C., et al. pg. 22.
[5] Clancy, C., et al. pg. 21.
[6] Clancy, C., et al. pg. 22.
[7] Clancy, C., et al. pg. 23.
[8] Clancy, C., et al. pg. 21.
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