World Health Organization Multimodal Improvement Strategy for Hand Hygiene: A Stepped-Wedge Cluster Randomized Trial

Area of Science:

• Global Health
• Infectious Disease Prevention
• Healthcare Quality Improvement

Background:

• Evidence on effective hand hygiene promotion in resource-limited settings is scarce.
• Previous studies often used limited designs, hindering understanding of long-term impact and sustainability.

Purpose of the Study:

• To assess the long-term impact of the World Health Organization (WHO) multimodal improvement strategy (MMIS) with locally manufactured alcohol-based handrub (ABHR) on hand hygiene adherence in Ugandan healthcare facilities.

Main Methods:

• A 45-month stepped-wedge cluster randomized trial involving 8 healthcare facilities in eastern Uganda.
• Sequential introduction of the WHO MMIS and locally manufactured ABHR, with a 12-month follow-up period.

Main Results:

• Hand hygiene adherence increased from 22.1% at baseline to 79.2% during intervention and remained high at 72.7% during follow-up.
• Significant improvements were observed in WHO Hand Hygiene Self-Assessment Framework (HHSAF) and Infection Prevention and Control Assessment Framework (IPCAF) scores.
• Alcohol-based handrub (ABHR) constituted over 99% of observed hand hygiene actions.

Conclusions:

• The WHO MMIS, supported by locally produced ABHR, achieved substantial and sustained improvements in hand hygiene adherence in Uganda.
• This study provides robust evidence for the scalability of this hand hygiene promotion strategy in resource-limited settings.