World Health Organization Multimodal Improvement Strategy for Hand Hygiene

Importance: Evidence on hand hygiene promotion in resource-limited settings remains sparse, and its generalizability and long-term sustainability are poorly understood. Previous studies have predominantly relied on single-center, short-duration, before-and-after interventional designs. Objective: To assess the long-term impact of the World Health Organization (WHO) multimodal improvement strategy (MMIS) supported by locally manufactured alcohol-based handrub (ABHR) on hand hygiene performance across multiple health care facilities in Uganda. Design, Setting, and Participants: This stepped-wedge cluster randomized trial was conducted at 8 health care facilities across 4 districts in eastern Uganda from November 1, 2020, to July 31, 2024 (45 months). Participants included all health care workers at the participating sites. Intervention: Following a baseline phase of 12 to 21 months, the WHO MMIS combined with locally manufactured ABHR was sequentially introduced in each district at 3-month intervals and implemented for 12 to 21 months (ie, the intervention phase), followed by a 12-month follow-up period without additional intervention. Main Outcomes and Measures: The primary outcome was hand hygiene adherence among health care workers. Secondary outcomes included scores on the WHO Hand Hygiene Self-Assessment Framework (HHSAF) and the Infection Prevention and Control Assessment Framework (IPCAF). Results: A total of 27 895 hand hygiene opportunities were observed. Hand hygiene adherence increased from 22.1% (95% CI, 11.4%-32.8%) at baseline to 79.2% (95% CI, 67.2%-91.2%; P < .001) during the intervention phase and remained high at 72.7% (95% CI, 57.8%-87.6%; P < .001) during follow-up. Median HHSAF scores improved significantly from 145.00 (IQR, 52.50-202.50) at baseline to 383.75 (IQR, 367.50-417.50 [P = .008]) during the intervention phase and 366.25 (IQR, 316.25-380.00 [P = .008]) during follow-up. Median IPCAF scores followed a similar pattern, from 335.00 (IQR, 235.00-520.25) at baseline to 657.50 (IQR, 648.75-705.00) (P = .008) during the intervention phase and 676.25 (IQR, 656.25-705.00) (P = .008) during follow-up. ABHR accounted for more than 99% of observed hand hygiene actions during the intervention and follow-up phases. Conclusions and Relevance: In this study of hand hygiene promotion in eastern Uganda, the WHO MMIS supported by locally produced ABHR led to substantial and sustained improvements in hand hygiene adherence. This stepped-wedge cluster randomized trial provides robust evidence supporting the scalability of this approach at regional and national levels in resource-limited settings. Trial Registration: University Hospital Medical Information Network Clinical Trials Identifier: UMIN000039483.