Effectiveness of a multimodal hand hygiene campaign and obstacles to success in Addis Ababa, Ethiopia

BACKGROUND: Hand hygiene is the cornerstone of infection control and reduces rates of healthcare associated infection. There are limited data evaluating hand hygiene adherence and hand hygiene campaign effect in resource-limited settings, especially in Sub-Saharan Africa. This study assessed the impact of implementing a World Health Organization (WHO)-recommended multimodal hand hygiene campaign at a hospital in Ethiopia. METHODS: This study included a before-and-after assessment of health care worker (HCW) adherence with WHO hand hygiene guidelines. It was implemented in three phases: 1) baseline evaluation of hand hygiene adherence and hospital infrastructure; 2) intervention (distribution of commercial hand sanitizer and implementation of an abbreviated WHO-recommended multimodal hand hygiene campaign); and 3) post-intervention evaluation of HCW hand hygiene adherence. HCWs’ perceptions of the campaign and hand sanitizer tolerability were assessed through a survey performed in the post-intervention period. RESULTS: At baseline, hand washing materials were infrequently available, with only 20% of sinks having hand-washing materials. There was a significant increase in hand hygiene adherence among HCWs following implementation of a WHO multimodal hand hygiene program. Adherence increased from 2.1% at baseline (21 hand hygiene actions/1000 opportunities for hand hygiene) to 12.7% (127 hand hygiene actions /1000 opportunities for hand hygiene) after the implementation of the hand hygiene campaign (OR = 6.8, 95% CI 4.2-10.9). Hand hygiene rates significantly increased among all HCW types except attending physicians. Independent predictors of HCW hand hygiene compliance included performing hand hygiene in the post-intervention period (aOR = 5.7, 95% CI 3.5-9.3), in the emergency department (aOR = 4.9, 95% CI 2.8-8.6), during patient care that did not involve Attending Physician Rounds (aOR = 2.4, 95% CI 1.2-4.5), and after patient contact (aOR = 2.1, 95% CI 1.4-3.3). In the perceptions survey, 64.0% of HCWs indicated preference for commercially manufactured hand sanitizer and 71.4% indicated their hand hygiene adherence would improve with commercial hand sanitizer. CONCLUSIONS: There was a significant increase in hand hygiene adherence among Ethiopian HCWs following the implementation of a WHO-recommended multimodal hand hygiene campaign. Dissatisfaction with the current WHO-formulation for hand sanitizer was identified as a barrier to hand hygiene adherence in our setting.