This document summarizes two successful hand hygiene programs that reduced hospital-acquired infections. Both programs followed the World Health Organization's multimodal strategy and "My Five Moments for Hand Hygiene" guidelines. The Australian program established a national initiative with educators, workshops, and auditors that increased hand hygiene compliance and reduced infections. In Mali, Africa, the WHO strategy was fully implemented at a hospital, with education, monitoring, and locally produced hand sanitizer. This also increased compliance and reduced infections. Overall, the key factors identified for successful programs were following WHO guidelines, multidisciplinary strategies, education and training, monitoring and feedback.

1. Reducing Hospital-Acquired Infections:
A Systematic Evaluation of Two Successful Hand Hygiene Programs
Anthony Valdez
Humboldt Center for Evolutionary Anthropology, Department of Anthropology, Humboldt State University, Arcata, California, 95521
Introduction
Nosocomial or hospital-acquired infections (HAI’s), remain a major cause of morbidity and mortality in healthcare settings. One of the major ways to reduce the number of HAI’s is the implementation of successful hand hygiene (HH)
programs (Pittet, 2000). Numerous studies have documented the importance of HH in health-care settings, yet HH compliance among health-care workers (HCW’s) is extremely low (Pittet, 2000). Here, I evaluated HH programs from
two countries and identified factors contributing to their success. Based on the data, it is clear that a major factor in developing successful hand hygiene compliance programs is the development of a multimodal, multidisciplinary strategy
that is adopted by local, state and federal levels as suggested by The World Health Organization guidelines on hand hygiene.
The World Health Organization (WHO)
Australian National Hand Hygiene Initiative The World Health Organization: Guidelines on Hand Hygiene
 Based on WHO’s “My five moments for Hand Hygiene” “My five moments for hand
 A cultural change program that established a multi-site model which involved the employment of both WHO Multimodal 5 step Hand Hygiene Strategy:
central and state-based HH educators (Grayson et al, 2011). This approach allowed both the central development
hygiene”
of important culture change, education, and data recording materials. One System Change
 National Program with Government funding Alcohol-based handrubs at point of care and access to safe
 Executive Leadership and Jurisdictional Support (Grayson et al, 2011). continuous water supply, soap and towels.
 Conducted up to 200 training workshops in all Australian states and territories.
 Established a network of ‘gold standard’ auditors who helped train other HCWs. Two Training and education
 Results: Increase of HH compliance and drop in HAI prevalence. Providing regular training to all Health-care workers.
Three Evaluation and feedback
Monitoring hand hygiene practices, infrastructure,
perceptions, and knowledge, while providing results
feedback to health-care workers.
Four Reminders in the workplace
Prompting and reminding health-care workers.
Hand hygiene is a core element of patient Five Institutional safety climate
safety. Its promotion represents a challenge that Individual active participation, institutional support, patient
requires a multimodal strategy using clear and simple participation.
conceptual framework.
This graph illustrates an increase in educational engagement Knowledge of hand hygiene before and after the WHO’s ‘My five
through the National Hygiene Initiative. moments for hand hygiene’ in Mali, Africa.
Hand Hygiene in Mali, Africa The development of “My five moments for hand
 Full implementation of the WHO strategy at University Hospital, Bamako, Mali hygiene” involved a user-centered approach
 Local production of pocket bottles of the WHO hand rubbing formulation. incorporating strategies of human factors and
 Increased ministerial engagement on national scale. cognitive behavior (Sax et al, 2007). It describes
 Implementation of the WHO’s Multimodal 5 step HH fundamental reference points for HCWs in a time- ??
 Key educational messages was based on the WHO’s “My five moments for hand hygiene.” space framework and designates moments when
 Participants attend an education session including training films. hand hygiene is necessary (Sax et al, 2007).
 Results: Increase of HH compliance and drop in HAI prevalence. “My five moments for hand hygiene” bridges the
gap between scientific evidence and daily health World Health Organization, figure 1
practice (Sax et al, 2007).
Implications
 Successful hand hygiene programs followed the World Health Organization Guidelines on hand hygiene in healthcare settings. The guidelines provide HCWs with a thorough review of evidence on HH in healthcare and specific
recommendations to improve practices. The WHO guidelines are unique in that they provide global perspectives in implementation, they bridge the gap between developing and developed countries, and provide innovated insight on
religious and cultural aspects.
 Educational and motivational programs for healthcare workers were also factors for successful hand hygiene programs, including factors that influence behavior. It is important to note that educational programs are not enough for
lasting improvement and other behavioral influences should be included. Education is important and critical for success and represents one of the cornerstones for improvement of hand hygiene (www.who.int).
 Political commitment is essential to achieve improvement in infection control, 38 countries have national or subnational campaigns, excluding the United States (Figure 1). It is important for national governments to make improving HH
adherence a national priority and consider a funded, coordinated implementation program while strengthening the infection control capacities within healthcare settings. Furthermore, national governments should encourage healthcare
settings to use hand hygiene as a quality indicator in patient safety (www.who.int).
 The United States needs to get on board with its own hand hygiene initiative to increase compliance, to lower HAI prevalence and costs, and to save lives.
Acknowledgments
I would like to thank the Department of Anthropology, the College of Arts, Humanities, and Social Sciences, the Office of Research and Supporting Programs, and May Patiño for help with this research.
References
1
Allegranzi, Benedetta, Hugo Sax, Loséni Bengaly, Hervé Richet, Daouda K Minta, Marie-Noelle Chraiti, Fatoumata Maiga Sokona, Angèle Gayet-Ageron, Pascal Bonnabry, and Didier Pittet.(2010). "Successful Implementation of the World Health Organization Hand Hygiene Improvement Strategy in a Referral Hospital in Mali, Africa." Infection Control and Hospital Epidemiology : The Official Journal of the Society of Hospital Epidemiologists of America, 31.2. 133-141.
Grayson, M Lindsay, Philip L Russo, Marilyn Cruickshank, Jacqui L Bear, Christine A Gee, Clifford F Hughes, Paul D R Johnson, Rebecca McCann, Alison J McMillan, Brett G Mitchell, Christine E Selvey, Robin E Smith, and Irene Wilkinson. (2011). "Outcomes from the First 2 Years of the Australian National Hand Hygiene Initiative." The Medical Journal of Australia, 195.10. 615-619.
Pittet, Didier. Improving Hand Hygiene Worldwide. [Webinar]. Retrieved from http://http://www.who.int/gpsc/5may/news/webinars/pittet_ppt_20100505_en.pdf.
Pittet, Didier. (2000). “Improving compliance with hand hygiene in hospitals”. Infection Control and Hospital Epidemiology, 21(6), 381-386.
Sax, H, B Allegranzi, I Uçkay, E Larson, J Boyce, and D Pittet. ( 2007). "'My Five Moments for Hand Hygiene': A User-centred Design Approach to Understand, Train, Monitor and Report Hand Hygiene." The Journal of Hospital Infection, 67.1. 9-21.