SYSTEMATIC REVIEW | VOLUME 4, ISSUE 3 | OPEN ACCESS DOI: 10.23937/2469-5823/1510097

WHO Multimodal Hand Hygiene Strategy and Alcohol Hand Rub Use is Effective in Reducing Hais and Antimicrobes in Developing Countries

Isata Victoria Mandoh1,2, Sulaiman Lansana Mandoh1 and Jia Bainga Kangbai3,4*

1Department of Nursing, School of Community Health Sciences, Njala University, Sierra Leone

2The University of Nottingham, United Kingdom

3Center for International Health, University of Munich (LMU), Germany

4Department of Environmental Health Sciences, Njala University, Sierra Leone

*Corresponding author: Jia Bainga Kangbai, Center for International Health, University of Munich (LMU), Germany.

Accepted: August 08, 2018 | Published: August 10, 2018

Citation: Mandoh IV, Mandoh SL, Kangbai JB (2018) WHO Multimodal Hand Hygiene Strategy and Alcohol Hand Rub Use is Effective in Reducing Hais and Antimicrobes in Developing Countries. Int Arch Nurs Health Care 4:097. doi.org/10.23937/2469-5823/1510097

Copyright: © 2018 Mandoh IV, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Abstract


Objectives

A major problem in public health in developing countries is hospital-acquired infections for which hand hygiene of healthcare workers features as a critical preventive mechanism. In this study we seek through systematic review of extant literatures to identify the most effective hand hygiene approach practiced by healthcare workers in developing countries that leads to hospital-associated infection and antimicrobial reduction.

Methods

In order to identify the hand hygiene method that is effective and appropriate in reducing both hospital-acquired infections and antimicrobial infection, we used a three-step search strategy to search to identify studies in which hand hygiene in the following libraries: Cochrane Registry, Medline, PsycINFO, JBI, Medline, EMBASE and CINAHL in The University of Nottingham e-library. We also used the System for Information on Grey Literature (SIGLE) to identify articles that contains our inclusion criteria. The Cochrane Collaboration Public Health Group data extraction tool was also used to extract the reviewed articles based on: author/s name, publication date, study design, setting, study size, study methods, hand hygiene interventions type, and study conclusion.

Results

Of the 1,413 articles retrieved for this review, only eight were eligible for inclusion. Three studies compared the efficacy of hand hygiene products on hospital- associated infection reduction. Six studies used the WHO multimodal hand hygiene strategy; of which one used positive deviance to improve hand hygiene compliance amongst healthcare workers.

Conclusion

Our review suggests the WHO multimodal hand hygiene strategy alongside with alcohol hand rub use can result in effective HAI and antimicrobial reduction as well as lead to an increase HH compliance.

Keywords


Multimodal, Hygiene, Infection, Healthcare

Introduction


Hospital-acquired infections (HAIs) also called nosocomial infections affects patients in healthcare [1,2]. The National Institute for Health and Care Excellence guidelines for HAI control states that HAI is acquired during healthcare interventions [3]. HAIs can worsen disease conditions [4] and is increasing in low-income countries [5]. The recent surge in HAI is associated with the rising prevalence of multidrug resistance infections [6] and emergence of infectious diseases [7]. Infectious disease mortality accounts for 26% of years of life lost (YLL) globally [8] and developing countries account for 88% of communicable diseases YLL [9,10]. Fifteen percent of HAIs cases occur in developing countries [11]. HAI global mortality and morbidity makes finding a solution a global concern [12]. The spread of HAIs in developing countries is due to factors relating to the training and qualification HCWs [13]. The identification of appropriate control interventions for HAIs is an urgent public health concern [14]. The frequency of using HH is crucial in preventing and controlling HAIs [15] but without compliance HH is unsuccessful [16]. The WHO World Alliance for Patient Safety's 'Clean Care is Safer Care' campaign launched in 2015 aim at increasing use of HH strategies [17]. Compliance to HH is still a global concern despite HH being an important HAI control strategy [18-22]. More evidence of HH impact in reducing HAI in developing countries is required [23] though few research have assessed HH effectiveness among HCWs in developing countries [24]. A South African cluster randomised controlled trial (RCT) showed no statistical or clinical significance associating HH products use and HAI reduction [25]. Karabay, et al. reported a statistical and clinical significant association between efficiency and alcohol hand rubbing among HCWs [26]. Salamati, Poursharifi, and Akbar Rahbarimanesh showed a significant association when education was combined with motivational interview to improve HH among HCWs [27]. The Hawthorne effect which affects HH effectiveness and validity can produce varying findings during overt and covert observational studies. Kovacs-Litman, Wong and Shojania reported varying HH compliance due to Hawthorne effect among physicians; 84% in overt observation vs. 50% in covert observation [18].

In this systematic review we are set to identify the most effective and appropriate HH method used by HCWs in developing countries that is associated with HAI and antimicrobial reduction.

Methods


We reviewed extant literatures on HH interventions by HCWs in healthcare settings in developing countries published between 2005 and 2016. Study participants were 18 years and above, and residents of developing countries. Two reviewers (IVM and JT) assessed the selected data based on the inclusion criteria. We keyed search terms and/their alternatives for literatures using the review Patient problem, Intervention Comparison and Outcome(PICO) [28] to identify studies in which HH interventions were used. A three-step search strategy was used to search the following libraries: Cochrane Registry [29], Johanna Briggs Institute (JBI) [30], Excerpta Medica database (EMBASE) [31] and the Cumulative Index to Nursing and Allied Health Literature (CINHAHL) [31]. The sentence structure of online search filters (SIGN) was used to identify the required articles while the System for Information on Grey Literature (SIGLE) [32] was employed if the reviewed article heading contains the inclusion criteria.

The Cochrane Collaboration Public Health Group data extraction tool was used to extract the reviewed articles based on: (a) Author/s name; (b) Date of publication; (c) Study design; (d) Setting; (e) Study size; (f) Methods; (g) Interventions; and (h) Conclusion [29]. Critical appraisal was used to determine the methodological quality of the reviewed articles. Garg, Hackman and Tonelli have argued that a systematic review reliability and quality depends on the quality of the reviewed articles [30]. We also used the Cochrane Collaboration's PEDro scale [29] and the Effective Practice and Organisation of Care (EPOC-RoB) Tool [31] to review RCTs and Non-RCTs studies respectively in this review. A Cochrane's Collaboration GRADE tool was further employed as a guide for evidence estimation [31] while the Preferred Reporting Items for SRs and Meta-analysis (PRISMA-P) flow diagram [31] was used to assess for study bias and appropriateness. We further used the Cochrane Collaborations Risk of Bias Tool was used to summarise the risk assessment for 5 studies in this review.

The University of Nottingham, UK Institutional Review Board provided ethical clearance and approved this study.

Results and Discussions


We commenced the initial search for articles relating to the review topic on the 12th March 2016 to the final search date of 7th July 2016 but excluded large number of unrelated articles and limiters based on dates (2005-2016), language and geographical region (Table 1).

Table 1: Summary of literature search history. View Table 1

A summary of literature search history using search limiters such as Article title, published dates and geographic regions.

We retrieved 1,413 articles; 1,353 from databases and 60 from other sources. 1,405/1,413 (99.4%) were excluded following titles, abstracts and contents assessment. The 8/1,413 (0.6%) publications reviewed are: Li, et al. [33], Allegranzi, et al. [34], Sharma, et al. [35], Chen, et al. [36], Marra, et al. [37], Kampiatu and Cozean [38], Rosenthal, et al. [39], and Patel, et al. [40].

EPOC-RoB was used to summarise the methodological quality and risk for non-randomised controlled trials (Table 2).

Table 2: EPOC Tool for assessment of methodical quality of Non-RCTS. View Table 2

Eight studies based on sample selection randomisation, evidence of attrition bias, and evidence of allocation concealment and selection bias were reviewed.

The eight studies reviewed included four studies that used randomised sample selection (Kampiatu, et al. [38], Li, et al. [33], Marra, et al. [37], and Sharma, et al. [35]), and 4 studies (Allegranzi, et al. [34], Chen, et al. [36], Patel, et al. [40], Rosenthal, et al. [39]) that made use of evidence of attrition bias and allocation concealment as well as selection bias (Table 3).

Table 3: Appropriateness analysis of reviewed literatures. View Table 3

Fifty percent of the literature reviewed reported procedures to identify and eliminate study bias.

The Cochrane Collaborations Risk of Bias Tool was used to summarise the risk assessment for 5 studies in this review (Figure 1).

Figure 1: Cochrane risk of bias assessment tool for the studies reviewed. View Figure 1

Cochrane risk of bias assessment tool for the eight studies reviewed alongside with review terms including random sequencing, allocation concealment, participants blinding, outcome assessment blinding, attribution and reporting biases.

The comparability of study designs and the cost-effectiveness of HH products were considered during the review process. Higgins, et al. have pointed out the significance of comparability of studies in terms of effect size [41]. Sharma, et al. [35] and Li, et al. [33] recorded reduced colony-forming units (CFU) using different methods. Kampiatu, et al. [38], Sharma, et al. [35] and Chen, et al. [36] showed the effectiveness of HH products in reducing HAIs. Kampiatu, et al. [38] demonstrated the effectiveness of alcohol hand rub in reducing HAIs in healthcare settings in developing country from 23.1% to 0% (p < 0.005). Sharma, et al. [35] also demonstrated the effective use of alcohol in reducing CFU [OR 3.2 (95% CI 1.9, 5.3)]. Chen, et al. [36] reported a correlation (r = 0.9399, p = 0.001) between increased (99.9%) use of alcohol hand rub and HAIs trends (Table 4).

Table 4: Assessment of articles reviewed for study outcomes. View Table 4

Seventy five percent of the literature reviewed used WHO multimodal HH strategy while 87.5% reported HAI reduction as a result of HH strategy.

Allegranzi, et al. [34] and Rosenthal, et al. [39] reported the use of WHO multimodal strategy, alcohol hand rub and health education leads to HAI reduction and an increase in the use of alcohol hand rub as disinfectant. Patel, et al. [40] and Marra, et al. [37] demonstrated WHO multimodal HH strategy effectiveness in improving HH compliance among HCWs. Patel, et al. [40] reported a 13% and 6% increase in intervention compliance for 2014 and 2015 respectively (p < 0.05). Marra, et al. [37] study recorded an increase (96.1% increase, p < 0.05) in alcohol hand rub as disinfectant, reduction (2.9% reduction, p < 0.05) in HAIs and an improvement in compliance (15.9% compliance rate, p < 0.05). Li, et al. [33] reported a 97.2% CFU reduction when comparing the efficacy and time effectiveness of using alcohol hand rub (p < 0.001).

Our study produced evidence to demonstrate the significance of HH compliance before and after patient contact in HAI prevention. HH compliance among HCWs is a major problem especially in developing countries [24].

Three key concepts emerged from this study: Effectiveness of HH methods for HAI reduction, HH compliance determined by the HAI and CFU reduction and the comparative efficacy of HH products alongside with the WHO multimodal HH strategies in reducing HAI.

Kampiatu, et al. [38] reported HAI reduction from 23.1% to 0% (p < 0.005) in a study that assessed the effectiveness of persistent and sustained antimicrobial use on handwashing alone. We believe that the persistent effect (compliance) of antimicrobial product affected the outcome in the Kampiatu, et al. by acting as a confounder. Kampiatu, et al. [38] did not demonstrate the residual effect of antimicrobial product use in their study though their findings were consistent with the Czerwinski, Cozean and Cozean trial which reported a 100% antimicrobial reduction due to alcohol-based antiseptic use [41]. Also, an RCT by Chow, Ara and Chan demonstrated the efficacy and time effectiveness of alcohol hand rub [42].

Sharma, et al. [35] in their comparative analysis reported a statistically and clinically significant percentage reduction in CFU (< 50% reduction, p < 0.001). The Sharma, et al. [35] findings supports the study by Won, et al. which associated HH intervention using different antimicrobial products to HAI reduction (p = 0.003) [43]. The strength of the Sharma, et al. study was the evaluation of actual HH intervention during clinical activities. This method differs from the artificial method used in the laboratory-based randomized crossover trial by Gnatta, et al. [44]. Ling, et al. [45] and Chen, et al. [36] in a hospital-wide before-and-after study which superimposed HH intervention on an infection control programme also recorded a significant HAI reduction.

Rosenthal, et al. study observed a sustained improvement in HH compliance and a significant reduction in HAIs (RR = 0.59; 95% CI: 0.46~0.74, p < 0.0001) [39]. The Rosenthal, et al. study shows that HH intervention user enjoys a protective effect. A cost-benefit analysis which parallels the Rosenthal, et al. study shows significant cost difference in alcohol hand rub [39].

The study by Allegranzi revealed an improvement (OR, 2.50; 95% CI, 1.8-3.5) in HAIs reduction across all medical specialties with enhanced knowledge increasing compliance by 28.1% [39]. Though the Allegranzi suggested that HH intervention should be multimodal, the quality of the study for such a decision is questionable since it was conducted with no proper control group to validate their claims. Patel, et al. showed that compliance to HH using the WHO multimodal strategy could lead to a 42% increase in CFU reduction in the subsequent year [41]. Chen, et al. however demonstrated that incentive ($160.00) can increase performance using HH compliance as a quality indicator [40]. The Chen, et al. study however lacks detailed rationale for the variation in the effect of HH intervention on HAI.

Yardly, et al. suggests that encouraging HH compliance could lead to the over-estimation of self-reported HH adherence [46]. Patel, et al. reported a 42% increase in CFU reduction following the HH-related intervention [41] which is lower than that of Randle, Firth and Natalie (74% increase) [47]. The low compliance rate in the Patel, et al. trial could be due to selection bias in the choice of intervention wards which may have peer influence that could have impinged negatively on the staffs.

Peer influence had a significant positive effect on HCWs in the study by Marra, et al. which recorded a 55.1% compliance improvement [37]. Moongtui reported a 74% improved compliance among HCWs due to peer feedback [48].

Our review suggests that HH strategies including alcohol hand rub use can result in increased compliance and HAI reduction. Six out of 8 studies reviewed (Kampiatu, et al. [35]; Li, et al. [36]; Marra, et al. [37], Sharma, et al. [38]; Chen, et al. [40], and Allegranzi, et al. [39]) shows a statistical and clinical significance for alcohol hand rub with positive cost-benefit ratio (23.7 with 3% discount rate). The Allegranzi, et al. [45] study produced similar results though with low applicability to low-resource countries hence the recommendation for the use of locally produced alcohol hand rubs in resource poor countries to cut cost [45].

One limitation of this systematic review is the methodological heterogeneity of the studies reviewed which did not allow the quantification of the relative efficacy of the interventions and outcome.

Our review is consistent with that of Picheansathian which reported the effectiveness of alcohol-based hand rub in controlling HAIs [49]. We discovered that alcohol hand rub is the most effective HH intervention among HCWs in developing countries. We recommend alcohol hand rub use alongside with the WHO multimodal strategy to promote HH concordance among HCWs. We are also recommending further RCT study to scientifically analyse the effectiveness of HH interventions.

Declarations


Ethics approval and consent to participate

The Institutional Review Board of the University of Nottingham, UK approved this study and provided ethical clearance for conducting this study.

Consent for publication

Not applicable.

Availability of data and materials

No dataset was used for this study. This is a systematic review that reviewed previously published works.

Competing interests

All authors declared they have no competing interest.

Funding

No part of this study received funding or compensation whatsoever during its conception, execution or for publication.

Authors' contribution

IVM conceived and designed this study as well as organized the conduct of this research in the research field. IVM, SM and JBK reviewed literatures. IVM and JBK drafted the manuscript. JBK critically reviewed and revised the manuscript.

Acknowledgements

Our sincere thanks to the supervisors and lecturers at the Nursing Department of The University of Nottingham, UK.

Authors' information

Not applicable.

References


  1. Becerra MR, Tantaleán JA, Suárez VJ, Alvarado MC, Candela JL, et al. (2010) Epidemiologic surveillance of nosocomial infections in a Pediatric Intensive Care Unit of a developing country. BMC Pediatr 10: 66.

  2. Breathnach AS (2009) Nosocomial infections. Medicine 37: 557-561.

  3. National Institute for Health and Care Excellence (NICE) (2012) Infection: Prevention and control of healthcare- and community care Costing statement Implementing. NICE guidance, 1-11.

  4. https://www.nice.org.uk/guidance/qs61/resources/guidance-infection-prevention-and-control-pdf.

  5. Braun BI, Kusek L, Larson E (2009) Measuring adherence to hand hygiene guidelines: A field survey for examples of effective practices. Am J Infect Control 37: 282-288.

  6. Dettenkofer M, Ebner W, Els T, Babikir R, L├╝cking C, et al. (2001) Surveillance of nosocomial infections in a neurology intensive care unit. J Neurol 248: 959-964.

  7. Rosenthal VD, Guzman S, Safdar N (2005) Reduction in nosocomial infection with improved hand hygiene in intensive care units of a tertiary care hospital in Argentina. Am J Infect Control 33: 392-397.

  8. http://doi.org/10.1596/978-1-4648-0675-9.

  9. Allegranzi B, Pittet D (2009) Role of hand hygiene in healthcare-associated infection prevention. J Hosp Infect 73: 305-315.

  10. Brabb T, Newsome D, Burich A, Hanes M (2012) Infectious Diseases. 637-683.

  11. Murni I, Duke T, Triasih R, Kinney S, Daley AJ, et al. (2013) Prevention of nosocomial infections in developing countries, a systematic review. Paediatr Int Child Health 33: 61-78.

  12. Pittet D, Allegranzi B, Storr J, Nejad SB, Dziekan G, et al. (2008) Infection control as a major World Health Organization priority for developing countries. J Hosp Infect 68: 285-292.

  13. Parker Fiebelkorn A, Person B, Quick RE, Vindigni SM, Jhung M, et al. (2012) Systematic review of behavior change research on point-of-use water treatment interventions in countries categorized as low- to medium-development on the human development index. Soc Sci Med 75: 622-633.

  14. World Health Organization (2009) WHO guidelines on hand hygiene in health care. First Global Patient Safety Challenge. Clean Care is Safer Care. WHO, Geneva.

  15. Eksi F, Mehli M, Akgun S, Bayram A, Balci I, et al. (2010) Evaluation of two different hand hygiene procedures during routine patient care. J Int Med Res 38: 2084-2092.

  16. Bennett SD, Otieno R, Ayers TL, Odhiambo A, Faith SH, et al. (2015) Acceptability and use of portable drinking water and hand washing stations in health care facilities and their impact on patient hygiene practices, western Kenya. PLoS One 10: e0126916.

  17. Luangasanatip N, Hongsuwan M, Limmathurotsakul D, Lubell Y, Lee AS, et al. (2015) Comparative efficacy of interventions to promote hand hygiene in hospital: Systematic review and network meta-analysis. BMJ 351: 3728.

  18. Rosenthal VD, Maki DG, Rodrigues C, Alvarez-Moreno C, Leblebicioglu H, et al. (2010) Impact of International Nosocomial Infection Control Consortium (INICC) strategy on central line-associated bloodstream infection rates in the intensive care units of 15 developing countries. Infect Control Hospital Epidemiol 31: 1264-1272.

  19. Gammon J, Morgan-Samuel H, Gould D (2008) A review of the evidence for suboptimal compliance of healthcare practitioners to standard/universal infection control precautions. J Clin Nurs 17: 157-167.

  20. Gould DJ, Moralejo D, Drey N, Chudleigh JH (2010) Interventions to improve hand hygiene compliance in patient care. Cochrane Database Syst Rev, CD005186.

  21. Huang C, Ma W, Stack S (2012) The hygienic efficacy of different hand-drying methods: A review of the evidence. Mayo Clin Proc 87: 791-798.

  22. Whitby M, McLaws ML, Slater K, Tong E, Johnson B (2008) Three successful interventions in health care workers that improve compliance with hand hygiene: Is sustained replication possible? Am J Infect Control 36: 349-355.

  23. Curtis V, Cairncross S (2003) Effect of washing hands with soap on diarrhoea risk in the community: A systematic review. Lancet Infect Dis 3: 275-281.

  24. Yawson AE, Hesse AA (2013) Hand hygiene practices and resources in a teaching hospital in Ghana. J Infect Dev Ctries 7: 338-347.

  25. Nthumba PM, Stepita-Poenaru E, Poenaru D, Bird P, Allegranzi B, et al. (2010) Cluster-randomized, crossover trial of the efficacy of plain soap and water versus alcohol-based rub for surgical hand preparation in a rural hospital in Kenya. Br J Surg 97: 1621-1628.

  26. Karabay O, Sencan I, Sahin I, Alpteker H, Ozcan A, et al. (2005) Compliance and efficacy of hand rubbing during in-hospital practice. Med Princ Pract 14: 313-317.

  27. Salamati P, Poursharifi H, Akbar Rahbarimanesh A, Koochak HE, Najafi Z (2013) Effectiveness of motivational interviewing in promoting hand hygiene of nursing personnel. Int J Prev Med 4: 441-447.

  28. Schardt C, Adams MB, Owens T, Keitz S, Fontelo P (2007) Utilization of the PICO framework to improve searching PubMed for clinical questions. BMC Med Inform Decis Mak 7: 16.

  29. Cochrane Collaboration (2006) Cochrane Handbook for Systematic Reviews of Interventions.

  30. Joanna Briggs Institute and Ovid Technologies (1997) Joanna Briggs Institute. EBP database. Joanna Briggs Institute, Adelaide South Australia.

  31. Higgins JPT, Green S (2011) Cochrane Handbook for Systematic Reviews of Interventions. The Cochrane Collaboration.

  32. Shamseer L, Moher D, Clarke M, Ghersi D, Liberati A, et al. (2015) Preferred reporting items for systematic review and meta-analysis protocols (PRISMA-P) 2015: Elaboration and explanation. BMJ 350: 7647.

  33. Li X, Xu C-J, Zhao S-J (2014) Experimental study on disinfection effect of different dose of rapid hand disinfectant. International Journal of Nursing Sciences 1: 212-214.

  34. Allegranzi B, Sax H, Bengaly L, Richet H, Minta DK, et al. (2010) Successful implementation of the World Health Organization hand hygiene improvement strategy in a referral hospital in Mali, Africa. Infect Control Hosp Epidemiol 31: 133-141.

  35. Sharma VS, Dutta S, Taneja N, Narang A (2013) Comparing hand-hygiene measures in a neonatal ICU: A randomized cross-over trial. Indian Pediatr 50: 917-921.

  36. Chen YC, Sheng WH, Wang JT, Chang SC, Lin HC, et al. (2011) Effectiveness and limitations of hand hygiene promotion on decreasing healthcare-associated infections. PLoS One 6: e27163.

  37. Marra AR, Noritomi DT, Westheimer Cavalcante AJ, Sampaio Camargo TZ, Bortoleto RP, et al. (2013) A multicenter study using positive deviance for improving hand hygiene compliance. Am J Infect Control 41: 984-988.

  38. Kampiatu P, Cozean J (2015) A controlled crossover study of a persistent antiseptic to reduce hospital-acquired infection. Afr J Infect Dis 9: 6-9.

  39. Rosenthal VD, Bijie H, Maki DG, Mehta Y, Apisarnthanarak A, et al. (2012) International Nosocomial Infection Control Consortium (INICC) report, data summary of 36 countries, for 2004-2009. Am J Infect Control 40: 396-407.

  40. Patel B, Engelbrecht H, McDonald H, Morris V, Smythe W (2016) A multifaceted hospital-wide intervention increases hand hygiene compliance. S Afr Med J 106: 32-35.

  41. Czerwinski SE, Cozean J, Cozean C (2014) Novel water-based antiseptic lotion demonstrates rapid, broad-spectrum kill compared with alcohol antiseptic. J Infect Public Health 7: 199-204.

  42. Chow A, Arah OA, Chan SP, Poh BF, Krishnan P, et al. (2012) Alcohol handrubbing and chlorhexidine handwashing protocols for routine hospital practice: A randomized clinical trial of protocol efficacy and time effectiveness. Am J Infect Control 40: 800-805.

  43. Won SP, Chou HC, Hsieh WS, Chen CY, Huang SM, et al. (2004) Handwashing program for the prevention of nosocomial infections in a neonatal intensive care unit. Infect Control Hosp Epidemiol 25: 742-746.

  44. Gnatta JR, Pinto FM, Bruna CQ, Souza RQ, Graziano KU, et al. (2013) Comparison of hand hygiene antimicrobial efficacy: Melaleuca alternifolia essential oil versus triclosan. Rev Lat Am Enfermagem 21: 1212-1219.

  45. Ling ML, How KB (2012) Impact of a hospital-wide hand hygiene promotion strategy on healthcare-associated infections. Antimicrob Resist Infect Control 1: 13.

  46. Yardley L, Miller S, Schlotz W, Little P (2011) Evaluation of a Web-based intervention to promote hand hygiene: Exploratory randomized controlled trial. J Med Internet Res 13: e107.

  47. Randle J, Firth J, Vaughan N (2013) An observational study of hand hygiene compliance in paediatric wards. J Clin Nurs 22: 2586-2592.

  48. Moongtui W, Gauthier DK, Turner JG (2000) Using peer feedback to improve handwashing and glove usage among Thai health care workers. Am J Infect Control 28: 365-369.

  49. Picheansathian W, Pearson A, Suchaxaya P (2008) The effectiveness of a promotion programme on hand hygiene compliance and nosocomial infections in a neonatal intensive care unit. Int J Nurs Pract 14: 315-321.