Quote of the month: "It is not only tiring but irritating to talk to a health worker on the need to constantly wash hands after every procedure… When you ask why didn't you wash your hands, the answer is always 'I forgot, I am sorry'" Shehu U Muhammad, HIFA Member, Field Specialist, Nigeria, for the 1 Million Community Health Workers Campaign

Most of us learn how to wash our hands not long after we learn to walk. It’s also a powerful lesson for life. By following five simple actions - Wet, Lather, Scrub, Rinse, Dry – we banish bacteria, avoid becoming sick and stop the spread of germs to others.

Or do we? During November, HIFA members reviewed and discussed the implications of recent research by Glasgow Caledonian University, which indicated that a hand-washing technique developed by WHO held the key to effective hand hygiene. The whole procedure comprises eleven steps, but the Glasgow team found that completion of steps 2-7 alone was sufficient to achieve significant reduction of bacteria and prevention of healthcare-associated infections. Yet as the New York Times reported,only one-third of participants in the study were able to correctly complete the six steps, despite “having instructions on the technique in front of them and having their technique observed.”

HIFA members were quick to identify more immediate and pressing issues. Lucie Byrne-Davis (HIFA member, United Kingdom, Clinical Psychologist at Manchester Medical School) emphasized the need for external intervention to ensure that knowledge gained was being translated into practice. As Lucie stated, “just because someone knows to do something and knows how to do it and has the opportunity to do it, doesn’t mean they will.”

The potential for a gap to develop between knowledge and practice was illustrated by our Quote of the Month, in which Shehu U Muhammad describes his experience of training health workers. It’s important to provide some additional context here. The trainees at various Colleges of Health in Nigeria receive an incentive to wash their hands before and after procedures, in the form of “good” marks awarded during examinations. Yet they frequently fail to wash their hands, and when pressed for a reason why, they reply that they had forgotten to do so. In a separate message to the HIFA forum, Zainab Yunusa-Kaltungo (HIFA member, Nigeria, Doctor at Federal Teaching Hospital Gombe) related how, despite instructional posters pasted over every sink in the hospital, even the most senior clinicians don’t wash their hands, reasoning incorrectly that it’s not necessary as they wear surgical gloves.

Getting the hand hygiene message across to the general public is also challenging. Shehu U Muhammad reported that it was common to see a single cotton towel hanging up all day in eating-houses across the West African sub-region, for use by any number of people to dry their hands. These towels are also provided for use in toilets instead of disposable tissues. Due to the frequent absence of running water, the act of hand-washing often involves two or more people squeezing their fingers in a communal bowl of water, creating a kind of bacterial ecosystem where disease can breed freely.

High risk habits such as these haven’t arisen solely because of public unwillingness to switch to a more hygienic hand-washing option. As Joseph Ana (HIFA member, Nigeria, Lead Consultant and Trainer at the Africa Centre for Clinical Governance Research and Patient Safety) pointed out, disposable towels are difficult to obtain in Nigeria and expensive to buy, should any be found. He feels that “the greatest challenge is the lack of access to water, potable or otherwise, in most communities. Added to it is the 'culturally' popular habit of open defecation often even when latrines are provided.” Ultimately, therefore, the route to eradicating such threats to public health lies with, to use Joseph’s words: “Health Education, Health Education and Health Education of the population.”

As Shehu stated, the “framing and reframing of appropriate messages on hand washing relevant to various communities has been a big challenge”. But both Shehu and Chandrakant Revankar (HIFA member, Timor-Leste, medical doctor working in the field of communicable disease control) also agree that community health volunteers are ideally placed to overcome this impasse and become advocates for hand hygiene and hand-washing amongst health workers and citizens on the ground. The increased availability and improved specifications of mobile devices – profiled in a blog by HIFA members Geoff Royston and Neil Pakenham-Walsh, also during November – could provide a huge boost to their efforts. I’ll leave it to Shehu to explain why such a boost is increasingly needed now:

“Hand washing must be taught effectively and carefully to all, especially those whose hands are exposed to items and materials susceptible to be contaminated. Recently, ATM machines, paper money, handles of doors leading to toilets etc have been implicated as sources of contamination of hand and contaminated by hand. It is from hand to hand.”

Expert commentary by Jules Storr (HIFA member, UK, consultant to the WHO)

As a health care worker who has spent a large part of their working life dedicated to supporting hand hygiene improvement in health care in many countries of the world, the issues addressed within the November blog are fascinating and come as no surprise. Hats off to colleagues at GCU for their work, which seems to have caught the world's attention and certainly triggered a healthy discussion amongst the HIFA community.

Hand hygiene in health care is often described as a simple act, which it undoubtedly is. Successful, sustainable hand hygiene improvement is however a complex challenge that requires understanding of the social as well as the medical sciences. WHO’s tools and resources for hand hygiene improvement embrace this complexity and are based on a multifaceted/multimodal strategy comprised of five parts: system change, training and education, evaluation and feedback, reminders in the workplace and institutional safety climate. How a healthcare worker performs the physical act of cleaning their hands is important, but it is in fact one small piece of the hand hygiene improvement jigsaw. To get to the point where a healthcare worker is about to put their hands together to start the process of germ removal is influenced by the degree to which there is: a supportive system in place; effective evidence-based training has been executed together; evaluation and feedback employed; reminders are used strategically and a supportive hospital culture exists. This is what an effective multifaceted strategy looks like and it matters for successful, sustainable hand hygiene improvement, as shown by this Lancet paper.  

Together with my colleague Claire Kilpatrick (a fellow HIFA member and WHO colleague working in this field) we have worked on how to translate this WHO multimodal strategy into something sticky – we think this is a good start: build it, teach it, check it, sell it, live it 

Those responsible for leading the charge on hand hygiene as part of their efforts to improve the quality of health care should constantly be looking at their multimodal strategy – is it working, where are the gaps, are year on year improvements being realised ?

The authors of the GCU study suggest that there is little point in getting the moments for hand hygiene correct if the correct technique is not applied. My own personal riposte to this is that there is little point fixing on hand hygiene technique, whether it be 1, 2 or a 100 steps, if your target audience has no means to clean their hands (no handrub, no soap, no running water), has had no training in the why, when and how of hand hygiene, never receives any feedback on their hand hygiene performance, has never seen a promotional prompt or cue to action at the place they provide hands on care, and works in a clinic or hospital where their superiors do not value and champion hand hygiene.

The debate in this blog is hugely welcome but we must be careful to embrace an holistic, multifaceted approach that draws on social science thinking if we are to protect the vulnerable in the most effective and efficient way.

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Martin Carroll was previously Head of the International Department at the British Medical Association, London UK, and has worked on issues affecting health in LMICs since 2003. He represented the BMA on the HIFA Steering Group from 2008-16 and is now an independent adviser to the group.   Martin is a member of two HIFA working groups - Multilingualism and Evaluating Impact of Healthcare Information - and the HIFA Social Media Working Group.  Twitter: @MMCarroll 

Julie Storr has over a decade of experience working for WHO on the development, implementation and evaluation of global improvement programmes in the field of patient safety, quality and infection prevention and control, with a focus on behaviour change. Her current work spans two WHO units – quality Universal Health Coverage and Global Infection Prevention and Control (IPC). Her technical and leadership expertise was called on to support WHO’s Ebola response and recovery efforts in 2014/15, with a focus on national IPC policy development in Sierra Leone. She led on the development of the recently published evidence based WHO Guidelines on the Core Components of Infection Prevention and Control Programmes at the National and Acute Health Care Facility Level. She was previously President of the Infection Prevention Society of the UK and Ireland, Assistant Director at the English National Patient Safety Agency and Director of the seminal cleanyourhands campaign. Julie has authored a book (Perspectives and Perceptions of IPC – highly commended at the 2016 BMA Medical Book Awards), published widely in the academic literature and is peer reviewer of a range of academic journals including Implementation Science, and on the international advisory board of the Journal of Infection Prevention. She is currently studying for a doctorate in public health (health care leadership and management) at Johns Hopkins Bloomberg School of Public Health, Baltimore. She is Social Media Coordinator (Tw:  @hifa_org  FB: HIFAdotORG) & a Steering Group Member for HIFA. 

Metrics: In November 2017 we exchanged 258 messages from 104 members in 34 countries (Australia, Bangladesh, Burkina Faso, Cameroon, Canada, Denmark, France, Germany, Honduras, Hong Kong, Iceland, India, Ireland, Italy, Jordan, Kenya, Malawi, Morocco, Nepal, Nigeria, Norway, Pakistan, Rwanda, Siera Leone, South Africa, St Kitts and Nevis, Sudan, Switzerland, Thailand, Timor Leste, Uganda, UK, USA, Zimbabwe). Our top contributors were Chris Zielinski (UK-5) and Joseph Ana (Nigeria-5). Thank you all for sharing your views and your experience.

Photo credit: By Lars Klintwall Malmqvist (Larsklintwallmalmqvist) (Own work) [Public domain], via Wikimedia Commons