Implementation of the WHO multimodal Hand Hygiene Improvement Strategy in a University Hospital in Central Ethiopia
Pfäfflin et al. Antimicrobial Resistance and Infection Control
Implementation of the WHO multimodal Hand Hygiene Improvement Strategy in a University Hospital in Central Ethiopia
Frieder Pfäfflin 0 1 2 3
Tafese Beyene Tufa 0 6
Million Getachew 0 6
Tsehaynesh Nigussie 0 6
Andreas Schönfeld 0 1 3
Dieter Häussinger 0 1 3
Torsten Feldt 0 1 3
Nicole Schmidt 4 5
0 Hirsch Institute of Tropical Medicine, research and training centre of DGHID, operated in cooperation with Arsi University , Asella , Ethiopia
1 Department of Gastroenterology, Hepatology and Infectious Diseases (DGHID), Heinrich Heine University , Düsseldorf , Germany
2 Department of Infectious Diseases and Pulmonary Medicine , Charité - Universitätsmedizin Berlin, Augustenburger Platz 1, 13353 Berlin , Germany
3 Department of Gastroenterology, Hepatology and Infectious Diseases (DGHID), Heinrich Heine University , Düsseldorf , Germany
4 Department for Infectious Disease Epidemiology, Robert Koch Institute , Berlin , Germany
5 Institute of Tropical Medicine and International Health , Charité - Universitätsmedizin Berlin, Berlin , Germany
6 Arsi University , Asella , Ethiopia
Background: The burden of health-care associated infections in low-income countries is high. Adequate hand hygiene is considered the most effective measure to reduce the transmission of nosocomial pathogens. We aimed to assess compliance with hand hygiene and perception and knowledge about hand hygiene before and after the implementation of a multimodal hand hygiene campaign designed by the World Health Organization. Methods: The study was carried out at Asella Teaching Hospital, a university hospital and referral centre for a population of about 3.5 million in Arsi Zone, Central Ethiopia. Compliance with hand hygiene during routine patient care was measured by direct observation before and starting from six weeks after the intervention, which consisted of a four day workshop accompanied by training sessions and the provision of locally produced alcohol-based handrub and posters emphasizing the importance of hand hygiene. A second follow up was conducted three months after handing over project responsibility to the Ethiopian partners. Health-care workers' perception and knowledge about hand hygiene were assessed before and after the intervention. Results: At baseline, first, and second follow up we observed a total of 2888, 2865, and 2244 hand hygiene opportunities, respectively. Compliance with hand hygiene was 1.4% at baseline and increased to 11.7% and 13.1% in the first and second follow up, respectively (p < 0.001). The increase in compliance with hand hygiene was consistent across professional categories and all participating wards and was independently associated with the intervention (adjusted odds ratio, 9.18; 95% confidence interval 6.61-12.76; p < 0.001). After the training, locally produced alcohol-based handrub was used in 98.4% of all hand hygiene actions. The median hand hygiene knowledge score overall was 13 (interquartile range 11-15) at baseline and increased to 17 (15-18) after training (p < 0.001). Health-care workers' perception surveys revealed high appreciation of the different strategy components. Conclusion: Promotion of hand hygiene is feasible and sustainable in a resource-constrained setting using a multimodal improvement strategy. However, absolute compliance remained low. Strong and long-term commitment by hospital management and health-care workers may be needed for further improvement.
Hand hygiene; Ethiopia; World Health Organization; Infection control; Health-care worker; Alcohol-based handrub
Hand hygiene is referred to as either hand washing with
soap and water or hand disinfection. Important benefits
of proper hand hygiene include reduction of nosocomial
infections , reduced transmission of multi-drug
resistant pathogens [2, 3], and cost effectiveness [4, 5].
Alcoholic handrub is regarded to be superior to washing
hands with soap and water. It has greater activity against
microorganisms, less time constraints, and better skin
tolerability [5–7]. Furthermore, alcoholic handrub is
better accessible in most settings as it can be provided
in pocket bottles and may thus be available at any time
at the point of care. The World Health Organization
(WHO) has identified formulations for the local
preparation of alcohol-based handrubs with substantially lower
costs compared to commercial products .
Compliance with hand hygiene varies greatly between
countries and settings but is globally low . Several
factors have been shown to be related to low compliance
with hand hygiene in developed countries . In
lowincome countries the major reason for non-compliance
with hand hygiene may be lack of adequate facilities
. The burden of health-care associated infections
(HAIs) is high in developing countries . WHO has
established a multimodal implementation strategy to
improve compliance with hand hygiene . Furthermore,
the concept “my five moments for hand hygiene“was
developed to perform hand hygiene in key moments
. Allegranzi et al. found that the implementation of
WHO’s hand-hygiene strategy is feasible and sustainable
in different settings and countries and leads to
significant compliance and knowledge improvement in
healthcare workers (HCWs) . There are, however, few data
on the implementation of the WHO multimodal hand
hygiene improvement strategy in Ethiopia, a country
with high rates of nosocomial infections .
The main objective for this study was to assess
compliance with hand hygiene in selected wards of the
Asella Teaching Hospital (ATH) before and after the
implementation of the hand hygiene campaign. The
secondary objectives were to assess compliance with hand
hygiene for the different professional categories and the
different wards and to assess perception and knowledge
for the different professional categories before and after
the implementation of the hand hygiene campaign.
The study was carried out in selected wards of ATH in
the Arsi Zone, Oromia Region, Central Ethiopia. The
ATH is the university hospital of the Arsi University and
serves as a referral centre for a population of roughly 3.5
million in the Arsi and neighbouring zones. Hirsch
Institute of Tropical Medicine (HITM) is a research and
training centre of the Department of Gastroenterology,
Hepatology and Infectious Diseases (DGHID) of
Heinrich Heine University Düsseldorf, Germany,
operated in cooperation with the Arsi University on the
campus of ATH. All wards involved in perinatal and
maternal care were included. These comprised
gynaecology, obstetrics, paediatrics, and neonatology. The study
was funded by the European ESTHER alliance (Ensemble
pour une Solidarité Thérapeutique Hospitalière en
Réseau) within a hospital partnership project to reduce
perinatal and maternal morbidity and mortality due to
Ethics approval was obtained from College of Health
Arsi University Ethical Review Committee (reference
number A/U/H/C/120/10407/07). Additionally, written
support from hospital leaders was obtained before
starting project activities.
Activities consisted of three different phases in an
uncontrolled before-and-after design.
Phase 1 is referred to as baseline assessment. It
comprised a ward infrastructure survey, a HCWs’ perception
survey, a hand hygiene knowledge questionnaire, and
the observation of HCWs’ hand hygiene practices. The
ward infrastructure survey was carried out involving
senior members of the hospital management, the
respective wards, and the study team. Within this survey,
the availability of functional sinks was assessed and
locations were identified where wall-fixed alcoholic handrub
dispensers should be mounted. The HCWs’ perception
survey, the hand hygiene knowledge questionnaire, and
the observation form for hand hygiene practices were all
designed by WHO . Minor changes were made to
the hand hygiene knowledge questionnaire to adapt to
the local situation. English was the only language used
in presentations as this is the language of medical
education in Ethiopia. Question and answer sessions were held
in English and Amharic. The observation of HCWs’
hand hygiene practices was carried out by two trained
HCWs. Observations were performed only during day
shifts for logistical reasons. The observers came to the
wards at random times without prior announcement.
They acted as unobtrusively as possible but disclosed
their task readily on enquiry. Observation sessions lasted
about 20 (±10) minutes. The purpose of breaking down
the observation into sessions was to acquire an overview
of practices . Potential opportunities for hand
hygiene according to the “my 5 moments of hand hygiene”
were recorded and the actual number of episodes of
hand hygiene. Hand washing referred to washing hands
with either water alone or with soap and water, hand
disinfection referred to the use of alcohol-based hand
rub. Compliance with hand hygiene was calculated by
the number of occasions when hand hygiene was
performed divided by the number of total hand hygiene
opportunities. All professional health care providers and
students who were working in the selected wards were
included in the study. HCWs were divided into two
broad professional categories: (1) nurse/midwife/health
officer/emergency surgeon (nurse with training in
emergency surgery)/nurse student/midwife student/health
officer student, (2) medical doctor/intern/medical
student. The other two professional categories foreseen by
WHO (auxiliary and other HCW) were not considered
as they play a negligible role during patient care at ATH.
Phase 2 was the intervention. A four-day workshop
was conducted with lectures on cultural aspects and
scientific evidence of hand hygiene, and nosocomial
infections in neonatology. Practical issues of the
implementation of the multimodal hand hygiene
improvement strategy were explained and baseline
results of the HCWs’ perception survey and the hand
hygiene knowledge questionnaire were presented. The
workshop addressed hospital management, department
heads, head nurses, focal persons for hygiene in the
selected wards, and all interested staff of ATH. Four
further half-day trainings were conducted to specifically
address HCWs who could not attend the workshop.
Additionally, all interns of ATH were explicitly invited
to attend the trainings as they undergo rotations within
the different wards and it was anticipated that some of
them would be assigned to work on the wards where
study activities were undertaken. HCWs who could not
attend any training session were handed a pocket bottle
with alcohol-based handrub after a short explanation of
the concept “my five moments in hand hygiene”. Posters
emphasizing the importance of hand hygiene were
placed at strategic sites within ATH.
WHOrecommended handrub formulations were produced
according to WHO guidelines . Demonstrations of
the production were given by HITM staff during the
workshop. Each HCW working in the pre-selected wards
received a 100 ml pocket bottle filled with alcoholic
handrub. A sticker on the pocket bottle indicated that
once empty, refill for the bottle would be available at
HITM. Wall-fixed hand disinfectant dispensers were
mounted prior to the workshop and were filled
immediately after the workshop with alcoholic handrub. Stickers
on the containers indicated that refill would be available
Phase 3 was the follow up assessment. The hand
hygiene knowledge questionnaire was repeated
immediately after the workshop or the training sessions,
respectively. Starting from six weeks after the
intervention, the HCWs’ perception survey and the observation
of hand hygiene activities were repeated as described
above. Study results were presented to hospital
management and all concerned HCWs. An award was issued to
the ward, which reached highest compliance with hand
hygiene in the first follow up. Responsibility for the hand
hygiene project was gradually transferred to ATH. A
second follow up assessment was performed by only one
observer (TN) starting from three months after the first
follow up additionally recording the use of gloves but
not recording the type of ward (Fig. 1).
To detect a difference of 10% between rates of hand
hygiene compliance before and after the implementation,
286 opportunities for hand hygiene had to be observed
at baseline and follow up for each category .
Compliance at baseline and at follow up overall and for the
different professional categories was compared with χ2
tests. Multivariable logistic regression was used with the
observation period (before or after the intervention) as
the main independent variable. Type of ward and
professional category were included as potential confounders.
These confounders were chosen as in most studies it has
been shown that compliance with hand hygiene varied
by hospital ward and professional category, with higher
compliance among nurses compared to doctors .
Hand hygiene knowledge questionnaire scores were
calculated for each participant as the sum of all correct
Fig. 1 Time axis of study procedures. NOTE: Red star denotes workshop accompanied by placement of posters, filling of wall-fixed handrub
dispensers, and distribution of pocket bottle hand disinfectants; thin green arrows denote half-day trainings for HCWs who could not attend the
workshop. The HCWs’ perception survey was performed at baseline and at first follow up but not at second follow up
answers (each correct answer equalling 1 point). Results
are expressed as medians and interquartile ranges
(IQRs). Statistical significance was assessed by Wilcoxon
rank-sum test, as participants were anonymous and
pairing was therefore impossible. Results from the
HCWs’ perception survey are shown as medians and
IQRs of points given by participants on the 7-point
Likert scale and were assessed by Wilcoxon rank-sum
test. Data analysis was performed using EpiInfo, version
3.5.4 and SPSS, version 20. Two-tailed p values of less
than 0.05 were considered to indicate statistical
Observation of compliance with hand hygiene
At baseline, first, and second follow up 146, 167, and
212 observation sessions were conducted, respectively.
The median observation time per session was 22 (IQR
15–26) and 20 (IQR 16–25) minutes at baseline and first
follow up, respectively. The duration of the observation
sessions was not recorded during the second follow up.
A total of 164 HCWs participated in the trainings. All
participants were listed and cross matched with
registration lists. Due to intense staff rotation and unclear
spelling of names we cannot give an exact number of how
many HCWs were assigned to work in the respective
wards during our study activities. We estimate, however,
that at least 90% of the targeted HCWs were trained.
Compliance with hand hygiene
A total of 7997 hand hygiene opportunities were
assessed at baseline and follow up. Compliance with
hand hygiene was 1.4% at baseline and rose to 11.7%
and 13.1% in the first and second follow up, respectively.
A significant increase in compliance with hand hygiene
was seen across both professional categories and in all
Only the major professional categories are displayed. Therefore, the sum of opportunities for these categories does not equal the total number of opportunities.
Category I: nurse/midwife/health officer/emergency surgeon/nurse, midwife, health officer student; Category II: medical doctor/intern/medical student. NOTE: HH,
hand hygiene; b.p.c., before patient contact; b.a.p., before aseptic procedure; a.b.f.e., after body fluid exposure; a.p.c., after patient contact; a.c.p.s., after contact
with patient surroundings; ND, no data. 1Detemined by χ2 tests with compliance at baseline as the reference.
indications except for “before aseptic procedures” in
the first follow up (Table 1). The increase in
compliance with hand hygiene was associated with the
intervention (crude odds ratio, 9.19: 95% confidence
interval (CI) 6.62-12.77; p < 0.001). This association
remained significant after adjustment for the potential
confounders ‘type of ward’ and ‘professional category’
(adjusted odds ratio, 9.18; 95% CI 6.61-12.76; p < 0.001).
Compliance with hand hygiene in the neonatology
ward was higher compared to the paediatric ward as
a reference at baseline (3.6% vs. 1.0%, p = 0.001) and
at first follow up (24.5% vs. 6.2%, p < 0.001). Out of
41 hand hygiene actions at baseline 23 (56.1%) were
handrub and 18 (43.9%) were hand washing, whereas
at follow up handrub accounted for 619 (98.4%) and
hand washing for 10 (1.6%) out of 629 hand hygiene
The use of gloves was solely assessed during the
second follow up. Gloves were used in 393 out of the 422
(93.1%) indications before aseptic procedures whereas
gloves were used in 76 out of 1822 (4.2%) indications in
the remaining four indications.
Hand hygiene knowledge questionnaire
The hand hygiene knowledge questionnaire was
distributed before and immediately after the training sessions.
A total of 141 HCWs filled the questionnaire before the
training. Out of these, 70 HCWs belonged to category I
and 61 HCWs belonged to category II. The remaining
10 participants did not belong to either of the predefined
categories. After the training, the questionnaire was
filled by a total of 139 HCWs (category I: 67; category II
63; neither category 9). The median knowledge score for
all participants was 13 (IQR 11–15) at baseline and
increased to 17 (IQR 15–18) after training (p < 0.001).
Knowledge scores for category I and II at baseline were
12 (IQR 9–14) and 15 (IQR 12–17) and increased to 16
(IQR 12–18) (p < 0.001) and 18 (IQR 16–19) (p < 0.001),
respectively (Fig. 2).
Health-care workers’ perception of the strategy
At baseline and at first follow up, 100 HCWs’ perception
surveys were handed to focal persons for hygiene for
further distribution among HCWs. The return rates at
baseline and follow up were 61% and 53%, respectively
Before the training and at first follow up, the
effectiveness of hand hygiene was judged to be high or very high
by more than 90% of the HCWs. Self-assessment of
compliance with hand hygiene revealed high estimates
(70% compliance with hand hygiene at baseline and
follow up) that did not match with observation results
(see Additional file 1).
After the training, HCWs perceived the impact and
different elements of the multimodal hand hygiene
campaign to be very positive. All questions asked in the
HCWs perception survey received median scores of 7 on
the 7-point Likert scale, thus indicating maximum
agreement (Table 3).
Fig. 2 Knowledge of hand hygiene before and after the training. Box plot of overall scores (maximum score 25); 5%, 25%, 50%, 75%, 95% percentiles
and outliers (circles); asterix denotes two outliers with equal scores. NOTE: Pre, before the intervention; post, after the intervention. Category I: nurse/
midwife/health officer/emergency surgeon/nurse, midwife, health officer student; Category II: medical doctor/intern/medical student
The healthcare facility makes
alcohol-based handrub available
at each point of care
Clear and simple instructions for
hand hygiene are made visible
for every HCW
HCWs regularly receive the results
of their hand hygiene performance
Hand hygiene posters are displayed 3 (2–7) 6 (5–7)
at point of care as reminders
Leaders at your institution support 5 (2–7) 6 (4–7)
and openly promote hand hygiene
Patients are invited to remind
HCWs to perform hand hygiene
Category I: nurse/midwife/health officer/emergency surgeon/nurse, midwife,
health officer student; Category II: medical doctor/intern/medical student. NOTE:
HCW, health-care worker; WHO, World Health Organization. HCWs were asked to
respond to the listed statements following the introductory question: “In your
opinion, how effective would the following actions be to increase hand hygiene
permanently in your institution?” aDetermined by Wilcoxon rank-sum test. bData
show median scores (IQR) on a 7-point Likert scale (with extremes labelled as
“not effective” at the lower and “very effective” at the higher end)
Consumption of alcohol-based hand rub
The consumption of locally produced alcohol-based
handrub was solely recorded at HITM. It increased
steadily after the training until the end of the first follow
up (Fig. 3). Before the intervention, alcohol-based
solutions were produced in the hospital pharmacy and
Baseline Follow up P valuea
responsibility for production of alcoholic handrub was
transferred to ATH after the first follow up. Therefore,
the consumption of alcohol-based disinfectants can only
be indicated as shown.
In our study, we found a very low compliance with hand
hygiene at baseline. Compliance at baseline was similar
to two studies that had been undertaken in Ethiopia
[19, 20] but was lower compared to a study from
Bamako, Mali . The main reason for the low
baseline compliance appears obvious: hand hygiene
products and facilities were not available on the
wards. Alcoholic disinfectants were only used for
disinfection of patients’ skin prior to aseptic procedures.
For this purpose, usually one bottle of gentian
violetstained alcoholic solution was provided on each ward.
The accessibility of soap and water was similarly
difficult. The majority of sinks were non-functional for
different reasons. Furthermore, the water supply of
ATH was limited. This was especially true during the
dry season when water supply was completely cut for
several days in a row on various occasions.
In addition to the lack of alcoholic handrub and water
– although presumably less important – compliance
with hand hygiene at baseline may have been low for
social reasons. One senior physician mentioned that he
was reluctant to use his own pocket bottle hand
disinfectant in order not to create envy and shame among
Observation at follow up showed a significant increase
of compliance with hand hygiene. This increase was
consistent across both predefined professional categories
and in all four wards and persisted in the second follow
up after responsibility for hand hygiene had been
transferred to ATH. Improvement was associated with the
intervention and this association remained significant
after adjustment for potential confounders. However,
compliance with hand hygiene remained low compared
to data from developed countries. In a landmark study,
which was conducted in the University of Geneva
Table 2 HCWs’ perception of the 5 components of the WHO
multimodal hand hygiene improvement strategy
Table 3 HCWs’ perception about impact and different elements of the multimodal hand hygiene improvement strategy
Has the use of alcohol-based handrub made hand hygiene easier to practice in your daily work?
Is the use of alcohol-based handrub well tolerated by your hands?
Did knowing the results of hand hygiene observation in your ward help you to improve your hand hygiene practices?
Has the fact of being observed made you paying more attention to your hand hygiene practices?
Were the educational activities that you participated in important to improve your hand hygiene practices?
Has your awareness of your role in preventing HAIs by improving your hand hygiene practices increased during the current hand
hygiene promotional campaign?
NOTE: IQR, interquartile range; HAI, health-care associated infection. Results are shown as median scores on a 7-point Likert scale (with extremes labelled as “not
at all” at the lower end and “very important” or “very much” at the higher end)
Fig. 3 Consumption of alcohol-based handrub. Consumption of alcohol-based handrub in selected wards of Asella Teaching Hospital from the
intervention (month 0) until the end of the first follow up. Display of total monthly consumption in litres
Hospitals, compliance with hand hygiene rose from
47.6% at baseline to 66.2% over a four-year period .
Particularly high rates of compliance with hand hygiene
were observed in selected sites with vulnerable patients
like intensive-care units after the implementation of a
hand hygiene campaign [22, 23]. It must be considered,
however, that in these studies only specific indications
for hand hygiene were assessed (e.g. after completion of
patient contact, on entrance into the unit). The concept
“my five moments in hand hygiene” was not applied.
One important study assessed the implementation of
WHO’s hand hygiene improvement strategy in five
countries with different socio-economic background
. Overall compliance before the intervention was
significantly lower in low-income and middle-income
countries than in high-income countries.
Compliance with hand hygiene improved across all
indications except for “before aseptic procedures” in the
first follow up. To our knowledge, this finding was not
reported from previous studies. After having noticed
preferential use of gloves before aseptic procedures at
baseline and at first follow up, the use of gloves was
systematically assessed during the second follow up.
Observation revealed a high percentage of use of gloves
(>90%) solely in the indication ‘before aseptic
procedures’. The failure to change or remove contaminated
gloves has been identified as major component of
inadequate infection control practices . We had
emphasized the need for hand hygiene regardless of the use of
gloves in our trainings. However, data show that this
imperative was not understood and must be stressed
further. Compliance with hand hygiene was highest after
body fluid exposure and after patient contact. This
possibly reflects the HCWs’ priority for self-protection
rather than for protection of the patients. Self-protection
has been shown to be the engine for hand hygiene
adherence in several studies [5, 14, 25].
Interestingly, compliance with hand hygiene was
similar in HCWs from category I and category II. This is in
contrast to many studies, which found lower compliance
in doctors than in nurses [5, 9], although Allegranzi et
al. observed better compliance with hand hygiene in
doctors than in nurses in Mali . They hypothesized
that the better compliance with hand hygiene in doctors
could be due to a higher level of education and a
stronger perception of their professional role . The
compliance with hand hygiene was higher in the neonatology
ward when compared to the paediatrics ward as a
reference. One possible reason for this – apart from the
presumptions that hygiene is of critical importance in
neonatology and many HCWs in neonatology may be
particularly dedicated to their work - may have been the
presence of a professor who emphasized a lot the
importance of hand hygiene in routine patient care. It has
been shown that role models may influence compliance
with hand hygiene . In our case the professor was a
person that many HCWs looked up to and thus at least
some HCWs may have tried to copy his behavior.
We produced alcohol-based handrub locally. Costs of
local production were less than one fifth compared to
commercially bought products. The skin tolerability of
the handrub was perceived to be very good. After the
intervention, hand hygiene actions were almost
exclusively performed with handrub indicating high
acceptance. The consumption of alcohol-based handrub
increased steadily from the intervention until the end of
the first follow up. The amount of alcohol-based
handrub used was selected as indirect marker for
compliance with hand hygiene in many settings although
assessment based on product consumption cannot
determine whether hand hygiene actions are performed
in the right indications .
There were several challenges in our setting, which
may have hampered achievement of better compliance
with hand hygiene. First, we faced intense staff rotation
on all levels within ATH. Since the beginning of the
planning process until the end of the second follow up
assessment, the position of medical director of ATH
changed three times. Staff rotation on the wards resulted
in observation of entirely different teams at baseline and
follow up. Second, during the follow up assessment we
were frequently shown empty wall-fixed alcoholic
handrub dispensers and empty private pocket bottle hand
disinfectants. Refill of alcoholic hand-rub had
occasionally been fetched at HITM but then no further
distribution among HCWs of the respective ward had been
undertaken. On one ward, alcoholic handrub had been
locked and was only accessible for one HCW. Third,
although we did not measure the consumption of
alcoholic handrub from wall-fixed dispensers and from
pocket bottles independently, we felt that wall-fixed
dispensers were used preferentially. According to our ward
infrastructure, wall-fixed dispensers were mounted in
selected sites with intense patient care. It seems obvious
that the provision of wall-fixed dispensers to every room
where patient care is performed would have been
preferable. The concentration solely on the provision of
alcohol-based handrub was regarded as a limitation by
many HCWs and parts of the management of ATH.
Whitby and McLaws demonstrated, however, that
improved accessibility to sinks does not lead to
improvement in compliance with hand hygiene . In addition,
WHO recommends the combined provision of pocket
bottles and wall-fixed dispensers filled with
alcoholbased handrub without focusing on water supply .
Just before the end of this study, management of ATH
implemented a hygiene committee. The committee took
over responsibilities like identification of further
structural necessities. It has been shown that designated staff
is one major critical component of an effective infection
control program .
Results of the hand hygiene knowledge questionnaire
were significantly better after the training than before
the training. The improvement was seen in both
professional categories and was similar to the improvement
detected in a study from Bamako, Mali . It may seem
surprising that even immediately after the training the
median scores reached were still far below the possible
maximum score. We found that the way several
questions should have been answered was not understood by
many examinees (e.g. in some questions it is stated “tick
one answer only” whereas in others there is no such
statement. Many examinees wrongly only ticked one
answer in these questions, too and therefore lost the
chance to reach higher scores). We had already adapted
the questionnaire to the local situation in accordance
with WHO recommendations. However, some structural
modifications may be necessary especially for HCWs
who are not used to multiple choice exams and may be
confused by the changing design of the questions. In
further studies, current tools could be compared with
adapted tools to confirm or refute our concern.
In contrast to Allegranzi et al., who detected
significant increases in median perception scores for all five
components of the multimodal WHO hand hygiene
improvement strategy, we only found increased median
scores in the component “reminders at the workplace”
. This may be explained by the high baseline scores
in our study. HCWs estimated their compliance with
hand hygiene and the compliance of their co-workers to
be high. Estimates differed greatly from our observation
findings. This is in line with various studies, which
reported that the correlation between self-assessment and
observation findings is low [29, 30]. The acceptance of
the different elements of the hand hygiene campaign
and the perceived impact of hand hygiene were very
high as indicated by maximum scores after the training.
This finding supports the multimodal approach
recommended by WHO. We cannot know, however, which
element was most important for the observed outcomes
and how the outcomes would have been if one or several
elements had been omitted.
Our study has several limitations. First, although
English is the official language of medical education in
Ethiopia, not all HCWs have good English language
skills. HCWs insisted on English presentations and
WHO could not provide working materials in Amharic.
We managed to establish question and answer sessions
in Amharic after each training but we cannot exclude
that outcomes would have been better if Amharic had
been used preferentially.
Second, it seems logical that HCWs are reminded of
performing hand hygiene actions in the presence of an
observer. Observation at second follow up was entirely
performed by local staff (TN), whereas international staff
(NS) did most of the observation at baseline and at first
follow up. Assessments of different observers may vary.
However, all observers were well trained in WHO hand
hygiene observation methods, and criteria defined by
WHO are straightforward to minimize inter-observer
Third, the hospital management addressed the wish of
extension of our hygiene activities to the entire hospital
arguing that all HCWs and patients should benefit from
the positive effects of proper hand hygiene. We felt that
our approach was adequate as pilot project to
demonstrate feasibility and efficacy. Hospital management was
in charge of ensuring sustainability of the project and of
extending activities to the ward that had not yet been
Fourth, we performed two follow up assessments in
relatively short time intervals after the intervention. It
would have been preferable to perform a time series
analysis with several follow ups to longitudinally assess
compliance with hand hygiene.
Last but not least, the clinical relevance of our
intervention remains unclear in the light of compliance rates
that were still low at follow up. To assess the rates of
HAIs in ATH surveillance activities would have to be
implemented. Surveillance is essential to record the
burden of infectious diseases and the effect of interventions.
Moreover, by itself, surveillance can lead to reduction in
HAIs . The most widely used surveillance definitions
for HAIs come from the Centers for Disease Control
and Prevention (CDC) and the National Healthcare
Safety Network . They are rarely applied in
lowincome countries as strict criteria have to be used
including bacterial culture in most settings. Future
research may help to develop criteria, which are adapted
to the settings in resource-constrained countries. Ideally,
prospective investigations should assess both compliance
with hand hygiene and rates of HAIs.
We successfully implemented the WHO multimodal
hand hygiene improvement strategy in selected wards of
ATH. The intervention was highly appreciated by
participating HCWs. The increase in compliance with hand
hygiene persisted after responsibility for the project had
been transferred to ATH. A time series analysis should
be performed to further assess the longitudinal evolution
of compliance with hand hygiene. Compliance with hand
hygiene was low compared to similar projects.
Simultaneous surveillance of HAIs could help to assess the
clinical impact of such interventions.
Additional file 1: HCWs perception. (XLSX 13 kb)
Additional file 2: Observation raw data total numbers. (SAV 806 kb)
Additional file 4: Perception survey. (SAV 54 kb)
Additional file 5: Alcoholic handrub. (XLSX 10 kb)
ATH: Asella Teaching Hospital; CDC: Centers for Disease Control and
Prevention; CI: Confidence interval; DGHID: Department of Gastroenterology,
Hepatology and Infectious Diseases; ESTHER: Ensemble pour une Solidarité
Thérapeutique Hospitalière en Réseau; HAI: Health-care associated infection;
HCW: Health-care worker; HITM: Hirsch Institute of Tropical Medicine;
IQR: Interquartile range; WHO: World Health Organization
The study was funded by the European ESTHER alliance, award number
LSC-2013-83152725. The funder had no role in conception of the study,
data collection, data analysis, and writing of the manuscript.
Availability of data and materials
All data generated or analysed during this study are included in this
published article (and its Additional files 1, 2, 3, 4 and 5).
FP: study design, facilitation of contacts, provision of trainings, data analysis,
writing of manuscript; TBT: study design, facilitation of contacts, provision of
trainings; MG: production of alcohol-based handrub, provision of trainings,
statistical analysis; TN: provision of trainings, data collection; AS: responsibility
for second follow up; DH: facilitation of contacts, facilitation of infrastructure,
study coordination; TF: facilitation of contacts, provision of training, drafting
of manuscript; NS: provision of trainings, data collection, data entry, writing
of manuscript. All authors read and approved the final manuscript.
Consent for publication
Ethics approval and consent to participate
Ethics approval was obtained from College of Health Arsi University Ethics Review
Committee, reference A/U/H/C/120/10407/07. The need for consent to participate
was waived as no individual person’s data were collected in any form.
1. Harbarth S , Sax H , Gastmeier P. The preventable proportion of nosocomial infections: an overview of published reports' . J Hosp Infect . 2003 ; 54 ( 4 ): 258 - 66 .
2. ' MDRO_literature-review .pdf'. [Online]. Available: http://www.who.int/gpsc/ 5may/ MDRO_literature-review .pdf. Accessed 6 Nov 2016 .
3. Pittet D , et al. Effectiveness of a hospital-wide programme to improve compliance with hand hygiene . Infection Control Programme'. Lancet . 2000 ; 356 ( 9238 ): 1307 - 12 .
4. Pittet D , Sax H , Hugonnet S , Harbarth S. Cost Implications of Successful Hand Hygiene Promotion '. Infect Control Hosp Epidemiol . 2004 ; 25 ( 03 ): 264 - 6 .
5. ' World Health Organization, WHO Guidelines on Hand Hygiene in Health Care. First Global Patient Safety Challenge Clean Care is Safer Care .' [Online]. Available: http://apps.who.int/iris/bitstream/10665/44102/1/9789241597906_ eng.pdf. Accessed 7 Nov 2016 .
6. Kampf G , Löffler H , Gastmeier P. Hand hygiene for the prevention of nosocomial infections' . Dtsch Arztebl Int . 2009 ; 106 ( 40 ): 649 - 55 .
7. Löffler H , Kampf G , Schmermund D , Maibach HI . How irritant is alcohol?' . Br J Dermatol . 2007 ; 157 ( 1 ): 74 - 81 .
8. 'Guide_to_ Local_Production .pdf'. [Online]. Available: http://www.who.int/ gpsc/5may/Guide_to_ Local_Production.pdf. Accessed 7 Nov 2016 .
9. Pittet D , Mourouga P , Perneger TV . Compliance with handwashing in a teaching hospital . Infection Control Program'. Ann Intern Med. Jan . 1999 ; 130 ( 2 ): 126 - 30 .
10. Uneke CJ , Ndukwe CD , Oyibo PG , Nwakpu KO , Nnabu RC , Prasopa-Plaizier N. Promotion of hand hygiene strengthening initiative in a Nigerian teaching hospital: implication for improved patient safety in low-income health facilities' . Braz J Infect Dis Off Publ Braz Soc Infect Dis . 2014 ; 18 ( 1 ): 21 - 7 .
11. Allegranzi B , et al. Burden of endemic health-care-associated infection in developing countries: systematic review and meta-analysis' . Lancet . 2011 ; 377 ( 9761 ): 228 - 41 .
12. 'Guide_to_Implementation.pdf'. [Online]. Available: http://www.who.int/ gpsc/5may/Guide_to_ Implementation.pdf. Accessed 7 Nov 2016 .
13. Sax H , Allegranzi B , Uçkay I , Larson E , Boyce J , Pittet D. “ My five moments for hand hygiene”: a user-centred design approach to understand, train, monitor and report hand hygiene' . J Hosp Infect . 2007 ; 67 ( 1 ): 9 - 21 .
14. Allegranzi B , et al. Global implementation of WHO's multimodal strategy for improvement of hand hygiene: a quasi-experimental study' . Lancet Infect Dis . 2013 ; 13 ( 10 ): 843 - 51 .
15. Kotisso B , Aseffa A. Surgical wound infection in a teaching hospital in Ethiopia' . East Afr Med J . 1998 ; 75 ( 7 ): 402 - 5 .
16. ' WHO | Tools for evaluation and feedback' . [Online]. Available: http://www. who.int/gpsc/5may/tools/evaluation_feedback/en/. Accessed 1 July 2016 .
17. Sax H , Allegranzi B , Chraïti M-N , Boyce J , Larson E , Pittet D. The World Health Organization hand hygiene observation method' . Am J Infect Control . 2009 ; 37 ( 10 ): 827 - 34 .
18. Pittet D , Boyce JM . Hand hygiene and patient care: pursuing the Semmelweis legacy' . Lancet Infect Dis . 2001 ; 1 ( Supplement 1 ): 9 - 20 .
19. Schmitz K , et al. Effectiveness of a multimodal hand hygiene campaign and obstacles to success in Addis Ababa , Ethiopia'. Antimicrob Resist Infect Control . 2014 ; 3 ( 1 ): 8 .
20. Feyissa GT , Gomersall JCS , Robertson-Malt S. Compliance to Hand Hygiene Practice among Nurses in Jimma University Specialized Hospital in Ethiopia: a best practice implementation project' . JBI Database Syst Rev Implement Rep . 2014 ; 12 ( 1 ): 318 - 37 .
21. Allegranzi B , et al. Successful implementation of the World Health Organization hand hygiene improvement strategy in a referral hospital in Mali , Africa'. Infect Control Hosp Epidemiol . 2010 ; 31 ( 2 ): 133 - 41 .
22. Mayer JA , Dubbert PM , Miller M , Burkett PA , Chapman SW . Increasing handwashing in an intensive care unit' . Infect Control IC . 1986 ; 7 ( 5 ): 259 - 62 .
23. Raskind CH , Worley S , Vinski J , Goldfarb J. Hand hygiene compliance rates after an educational intervention in a neonatal intensive care unit' . Infect Control Hosp Epidemiol . 2007 ; 28 ( 9 ): 1096 - 8 .
24. Thompson BL , Dwyer DM , Ussery XT , Denman S , Vacek P , Schwartz B. Handwashing and Glove Use in a Long-Term-Care Facility' . Infect Control Hosp Epidemiol . 1997 ; 18 ( 2 ): 97 - 103 .
25. Borg MA , et al. Self-protection as a driver for hand hygiene among healthcare workers' . Infect Control Hosp Epidemiol . 2009 ; 30 ( 6 ): 578 - 80 .
26. Schneider J , et al. Hand hygiene adherence is influenced by the behavior of role models' . Pediatr Crit Care Med J Soc Crit Care Med World Fed Pediatr Intensive Crit Care Soc . 2009 ; 10 ( 3 ): 360 - 3 .
27. Whitby M , McLaws M-L. Handwashing in healthcare workers: accessibility of sink location does not improve compliance' . J Hosp Infect . 2004 ; 58 ( 4 ): 247 - 53 .
28. Hughes JM . Study on the efficacy of nosocomial infection control (SENIC Project): results and implications for the future' . Chemotherapy . 1988 ; 34 ( 6 ): 553 - 61 .
29. O'Boyle CA , Henly SJ , Larson E. Understanding adherence to hand hygiene recommendations: the theory of planned behavior' . Am J Infect Control . 2001 ; 29 ( 6 ): 352 - 60 .
30. Jenner EA , Fletcher BC , Watson P , Jones FA , Miller L , Scott GM . Discrepancy between self-reported and observed hand hygiene behaviour in healthcare professionals' . J Hosp Infect . 2006 ; 63 ( 4 ): 418 - 22 .
31. Gastmeier P , et al. Effectiveness of a nationwide nosocomial infection surveillance system for reducing nosocomial infections' . J Hosp Infect . 2006 ; 64 ( 1 ): 16 - 22 .
32. ' CDC/NHSN Surveillance Definitions for Specific Types of Infections - 17pscnosinfdef_current .pdf'. [Online]. Available: http://www.cdc.gov/nhsn/ pdfs/pscmanual/17pscnosinfdef_current.pdf. Accessed 7 Nov 2016 .