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Washing hands saves lives and money in healthcare facilities, but people still don’t do it

In the 1840s, a physician named Ignaz Semmelweis noticed that women were more likely to develop an infection and die after giving birth when their babies were delivered by doctors and medical students, compared to midwives. Given that doctors and medical students also performed autopsies, Semmelweis hypothesised that a certain “particle” from the deceased bodies might be responsible for the high death rate of women who had given birth. He tested this hypothesis by requesting doctors and medical students wash their hands before delivering babies. A year later, the clinic recorded a substantial decrease in the number of women dying after birth. At the time, when ‘germ theory’ was not yet clinically respected, this finding was not well-received by the scientific community.

Today, we fully appreciate the impact of hygiene on preventing the spread of infections such as antimicrobial resistance, diarrhoea, influenza, and hand-foot and mouth disease in communities and healthcare facilities. Despite this, hand hygiene compliance among healthcare workers is far from meeting the stringency required.

According to the World Health Organization (WHO), approximately 70% of healthcare workers and 50% of surgical teams do not regularly practice hand hygiene. The 2019 WHO global survey on infection prevention and control in healthcare facilities revealed that only 16% of healthcare facilities across the world achieved all minimum requirements of infection, prevention and control (IPC). None of the facilities in this 16% were from low-income countries (LICs). In fact, as many as one in three healthcare facilities in LICs lack sufficient hand hygiene amenities at the point of care, while basic hygiene services are absent in half of healthcare facilities in LICs. Poor adherence to hand hygiene is a global problem, with studies identifying heavy workloads, improperly designed healthcare facilities, unsuitable training, and poor behavioural patterns as barriers to compliance.

Some of these barriers are more manageable than others. For example, mandatory training with regular refreshers combined with a national IPC program can help keep training up to date in healthcare settings. Designing healthcare facilities to optimise hand hygiene is more challenging, particularly in older healthcare buildings, and looks very different in LICs compared to high-income countries (HICs). Based on feedback from frontline staff, strategic placement of alcohol-based hand rub and supply of moisturisers could enhance overall workflow and encourage uptake of hand hygiene in high-income settings. Similar solutions could be applied in LICs, such as providing soap and hand-washing stations in strategic areas. Some emergency responses to the Covid-19 pandemic such as local production of alcohol-based hand rub is an affordable hand hygiene alternative in LICs. Inexpensive behavioural interventions, such as nudging, visual cues, and framing, could also be applied in any setting to remind staff of hand hygiene procedures and create a supportive organisational culture.

Scaling up hand hygiene interventions requires dedicated funding streams. A costing analysis led by United Nations Children’s Fund (UNICEF) and WHO estimated a US$845 million upfront investment is required to install and maintain hygiene services in healthcare facilities of the 46 least developed countries. The Organisation for Economic Co-operation and Development (OECD) demonstrates these cash injections are a good investment, estimating returns of up to 16 times the original investment. These returns could be reinvested into financing ongoing maintenance and training.

Handwashing is one of the simplest and most cost-effective ways to prevent transmission of infections, but people still don’t do it. More creative solutions analysing handwashing behaviours are therefore needed to encourage good hand hygiene practice in healthcare facilities. Cross-sectoral collaboration will then help implement these behavioural interventions and inform investment cases to encourage compliance.

Let’s use World Hand Hygiene Day as a reminder to everyone, both healthcare workers and the general community, that washing hands is one of the easiest ways we can all save lives.

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