Data published in JAMA Network Open suggest that tools for the collection and rapid visualization of hand hygiene adherence data are viable in low-resource settings.

In a prospective multicenter quality improvement preintervention and postintervention study, researchers assessed adherence to the 5 Moments for Hand Hygiene protocol suggested by the World Health Organization (WHO). Adherence of staff at the inpatient therapeutic feeding center and pediatric ward of Anka General Hospital, Anka, Nigeria, and at the postoperative ward of Noma Children’s Hospital, Sokoto, Nigeria, was assessed.

To complete assessments, a new data collection form, which investigators called the Hand Hygiene Observation Tool, was designed for the purposes of this study. A total of 686 preintervention adherence observations and 673 postintervention adherence observations were conducted.

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Postintervention overall hand hygiene adherence increased from 32.4% to 57.4%. In the feeding center at Anka General Hospital, adherence increased from 24.3% to 63.7% (P <.001). Further, prior to the intervention, physicians demonstrated a higher rate of adherence to the WHO recommendations (47.2%) compared with nurses (17.7%). However, after the intervention, the adherence rates for both physicians and nurses were similar (physicians, 69.9%; nurses, 71.2%). The moments of lowest adherence rates were prior to touching a patient and after touching a patient’s surroundings (44.4%, and 59.4%, respectively).

In the pediatric ward at Anka General Hospital, adherence to the WHO 5 Moments increased from 50.9% to 68.8% (P <.001). Results also showed that physicians had the highest adherence rate before and after the intervention (62.6% and 82.5%, respectively). Nurses’ adherence rate increased from 45.9% to 68.4% between the preintervention and postintervention periods (P <.001). The lowest overall adherence postintervention occurred before contacts with patients (53.1%), before aseptic procedure (58.3%), and after touching patients’ surroundings (57.4%).

In the Noma Children’s Hospital, overall adherence increased from 17.6% to 39.8% (P <.001). However, while adherence in Noma increased among nurses, from 11.5% to 61.4% (P <.001), there was a decrease among physicians from 34.2% to 8.6%. Results also showed that adherence to the WHO’s 5 Moments remained <50% for the moments before contact with patients (39.2%) and after touching a patient’s surroundings (15.5%).

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In this study, investigators found that while educational discussions with staff were useful in starting dialogues around hand hygiene, researcher time was limited and the duration of sessions was too short. The discussions therefore could not serve as a qualitative investigation regarding perceptions and barriers to hand hygiene or as a teaching opportunity to increase awareness and adherence. In addition, the results cannot be extrapolated to other settings and may not be representative of possible long-term adherence improvements. This is a result of the quasiexperimental design of this pilot study, which was conducted over a short time period. Finally, there is likely some bias because the Hand Hygiene Observation Tool requires direct observations of hand hygiene, and observations were carried out by 2 observers. However, attempts were made to limit differences in observation through training and by using mobile devices to make observations.

Investigators concluded that the use of an application-based adherence monitoring tool with a real-time dashboard could contribute to hand hygiene improvement strategies and health care worker engagement and buy in. They also believe it can improve standardization and sustainability of the strategies. Further, researchers concluded that any attempt to improve hand hygiene requires a multimodal approach, including education, observations, supplies, feedback about adherence to staff, and directives on implementing hand hygiene.


Lenglet A, van Deursen B, Viana R, et al. Inclusion of real-time hand hygiene observation and feedback in a multimodal hand hygiene improvement strategy in low-resource settings. JAMA Netw Open. 2019;2:e199118.