Implementation of hand hygiene in health-care facilities: results from the WHO Hand Hygiene Self-Assessment Framework global survey 2019

Abstract

Background: Hand hygiene is at the core of effective infection prevention and control (IPC) programmes. 10 years after the development of the WHO Multimodal Hand Hygiene Improvement Strategy, we aimed to ascertain the level of hand hygiene implementation and its drivers in health-care facilities through a global WHO survey.

Methods: From Jan 16 to Dec 31, 2019, IPC professionals were invited through email and campaigns to complete the online Hand Hygiene Self-Assessment Framework (HHSAF). A geospatial clustering algorithm selected unique health-care facilities responses and post-stratification weighting was applied to improve representativeness. Weighted median HHSAF scores and IQR were reported. Drivers of the HHSAF score were determined through a generalised estimation equation.

Findings: 3206 unique responses from 90 countries (46% WHO Member States) were included. The HHSAF score indicated an intermediate hand hygiene implementation level (350 points, IQR 248-430), which was positively associated with country income level and health-care facility funding structure. System Change had the highest score (85 points, IQR 55-100), whereby alcohol-based hand rub at the point of care has become standard practice in many health-care facilities, especially in high-income countries. Institutional Safety Climate had the lowest score (55 points, IQR 35-75). From 2015 to 2019, the median HHSAF score in health-care facilities participating in both HHSAF surveys (n=190) stagnated.

Interpretation: Most health-care facilities had an intermediate level of hand hygiene implementation or higher, for which health-care facility funding and country income level were important drivers. Availability of resources, leadership, and organisational support are key elements to further improve quality of care and provide access to safe care for all.

Funding: WHO, Geneva University Hospitals and Faculty of Medicine, and WHO Collaborating Center on Patient Safety, Geneva, Switzerland.

Figure 1

Overview of the selection process for the Hand Hygiene Self-Assessment Framework global survey 2019 with number of selected responses per step HHSAF=Hand Hygiene Self-Assessment Framework. IPC= infection prevention and control. *The HHSAF consists of 27 indicators, distributed over five elements: System Change, Training and Education, Evaluation and Feedback, Reminders in the Workplace, and Institutional Safety Climate. †Participation in the HHSAF global survey was on an individual basis; therefore, multiple survey responses could originate from the same health-care facility. To eliminate duplication, responses from the same health-care facilities were identified through a geospatial clustering algorithm, and a single response per health-care facility was selected through a pre-defined selection strategy. Health-care facility was selected through a predefined selection strategy. ‡The following countries (number of survey responses) were excluded: Togo (n=1), Israel (n=1), Democratic Republic of the Congo (n=9), Hungary (n=1), Ethiopia (n=11), Sri Lanka (n=2), China (n=85), Morocco (n=2), Republic of Korea (n=1), Cameroon (n=1), Kenya (n=2), Brazil (n=8), Venezuela (n=1), USA (n=11), Peru (n=1), Indonesia (n=8), Algeria (n=1), Pakistan (n=5), and India (n=15).

Figure 2

Country origin of survey responses included in the current analysis of the global Hand Hygiene Self-Assessment Framework survey 2019 Total number of countries=90. Total number with nationally coordinated data collection=33. The designations employed and the presentation of the material in this publication do not imply the expression of any opinion whatsoever on the part of WHO concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted and dashed lines on maps represent approximate border lines for which there may not yet be full agreement. Published with permission of the WHO GIS Centre for Health, DNA/DDI.