title: Effectiveness of a multimodal hand hygiene campaign and obstacles to success in Addis Ababa, Ethiopia.
abstract: BACKGROUND
  Hand hygiene is the cornerstone of infection control and reduces rates of healthcare associated infection. There are limited data evaluating hand hygiene adherence and hand hygiene campaign effect in resource-limited settings, especially in Sub-Saharan Africa. This study assessed the impact of implementing a World Health Organization (WHO)-recommended multimodal hand hygiene campaign at a hospital in Ethiopia.
  
  
  METHODS
  This study included a before-and-after assessment of health care worker (HCW) adherence with WHO hand hygiene guidelines. It was implemented in three phases: 1) baseline evaluation of hand hygiene adherence and hospital infrastructure; 2) intervention (distribution of commercial hand sanitizer and implementation of an abbreviated WHO-recommended multimodal hand hygiene campaign); and 3) post-intervention evaluation of HCW hand hygiene adherence. HCWs' perceptions of the campaign and hand sanitizer tolerability were assessed through a survey performed in the post-intervention period.
  
  
  RESULTS
  At baseline, hand washing materials were infrequently available, with only 20% of sinks having hand-washing materials. There was a significant increase in hand hygiene adherence among HCWs following implementation of a WHO multimodal hand hygiene program. Adherence increased from 2.1% at baseline (21 hand hygiene actions/1000 opportunities for hand hygiene) to 12.7% (127 hand hygiene actions /1000 opportunities for hand hygiene) after the implementation of the hand hygiene campaign (OR = 6.8, 95% CI 4.2-10.9). Hand hygiene rates significantly increased among all HCW types except attending physicians. Independent predictors of HCW hand hygiene compliance included performing hand hygiene in the post-intervention period (aOR = 5.7, 95% CI 3.5-9.3), in the emergency department (aOR = 4.9, 95% CI 2.8-8.6), during patient care that did not involve Attending Physician Rounds (aOR = 2.4, 95% CI 1.2-4.5), and after patient contact (aOR = 2.1, 95% CI 1.4-3.3). In the perceptions survey, 64.0% of HCWs indicated preference for commercially manufactured hand sanitizer and 71.4% indicated their hand hygiene adherence would improve with commercial hand sanitizer.
  
  
  CONCLUSIONS
  There was a significant increase in hand hygiene adherence among Ethiopian HCWs following the implementation of a WHO-recommended multimodal hand hygiene campaign. Dissatisfaction with the current WHO-formulation for hand sanitizer was identified as a barrier to hand hygiene adherence in our setting.
authors.affiliation: Emory University School of Medicine, 1648 Pierce Drive NE, Atlanta, GA 30322, USA. karen.e.schmitz@gmail.com.
authors.forename: Karen
authors.initials: K
authors.lastname: Schmitz
authors.forename: Russell R
authors.initials: RR
authors.lastname: Kempker
authors.forename: Admasu
authors.initials: A
authors.lastname: Tenna
authors.forename: Edward
authors.initials: E
authors.lastname: Stenehjem
authors.forename: Engida
authors.initials: E
authors.lastname: Abebe
authors.forename: Lia
authors.initials: L
authors.lastname: Tadesse
authors.forename: Ermias Kacha
authors.initials: EK
authors.lastname: Jirru
authors.forename: Henry M
authors.initials: HM
authors.lastname: Blumberg