Access to and Use of Hand Hygiene Resources during the COVID-19 Pandemic in Two Districts in Uganda, January–April 2021

Caroline Pratt Waterborne Disease Prevention Branch, Division of Foodborne, Waterborne, and Environmental Diseases, U.S. Centers for Disease Control and Prevention, Atlanta, Georgia;
U.S. Epidemic Intelligence Service, U.S. Centers for Disease Control and Prevention, Atlanta, Georgia;

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Maureen Kesande Infectious Disease Institute, Makerere University, Kampala, Uganda;

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Fred Tusabe Infectious Disease Institute, Makerere University, Kampala, Uganda;

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Alexandra Medley Division of Foodborne, Waterborne, and Environmental Diseases, U.S. Centers for Disease Control and Prevention, Atlanta, Georgia

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Graeme Prentice-Mott Waterborne Disease Prevention Branch, Division of Foodborne, Waterborne, and Environmental Diseases, U.S. Centers for Disease Control and Prevention, Atlanta, Georgia;

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Matthew Lozier Waterborne Disease Prevention Branch, Division of Foodborne, Waterborne, and Environmental Diseases, U.S. Centers for Disease Control and Prevention, Atlanta, Georgia;

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Victoria Trinies Waterborne Disease Prevention Branch, Division of Foodborne, Waterborne, and Environmental Diseases, U.S. Centers for Disease Control and Prevention, Atlanta, Georgia;

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Sauda Yapswale Infectious Disease Institute, Makerere University, Kampala, Uganda;

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Stella Nabatyanga Infectious Disease Institute, Makerere University, Kampala, Uganda;

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Herbert Isabirye Infectious Disease Institute, Makerere University, Kampala, Uganda;

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Mohammed Lamorde Infectious Disease Institute, Makerere University, Kampala, Uganda;

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David Berendes U.S. Epidemic Intelligence Service, U.S. Centers for Disease Control and Prevention, Atlanta, Georgia;

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ABSTRACT.

To understand access to and use of hand hygiene in healthcare facilities (HCFs) and community locations during the COVID-19 pandemic, we evaluated factors associated with hand hygiene in 60 priority HCFs and community locations in two border districts in Uganda. We assessed water and hand hygiene resource availability and observed hand hygiene practice by staff or patrons. Regression modeling estimated factors associated with the availability or use of hand hygiene. In HCFs, most inpatient (61%), outpatient (71%), and laboratory or staff (90%) rooms contained hand hygiene materials. Only 38% of community locations had hand hygiene materials at all entrances and exits, 35% of congregation areas had hand hygiene materials. Overall, 38% of healthcare staff, 48% of patrons post-latrine use, and 21% of patrons entering or exiting community locations practiced hand hygiene. HCF hand hygiene access was lower in inpatient rooms (odds ratio [OR] = 0.17, 95% CI: 0.06–0.45) and outpatient rooms (OR = 0.23, 95% CI: 0.07–0.70) compared with laboratory/staff rooms. HCF hand hygiene practice was higher for doctors than nurses (OR = 3.58, 95% CI: 1.15–11.14) and with new versus existing patient encounters (OR = 2.27, 95% CI: 1.20–4.27); it was lower before versus after patient contact for both invasive (OR = 0.03, 95% CI: 0.00–0.20) and noninvasive (OR = 0.66, 95% CI: 0.45–0.95) procedures. In community settings, hand hygiene practice after using the latrine was higher than at an entrances/exits (OR = 3.39, 95% CI: 2.08–5.52). Hand hygiene rates were relatively low in healthcare and community settings. Greater emphasis on hand hygiene before patient interactions (at HCFs) and at community entrances/exits for patrons is also needed.

INTRODUCTION

Consistent and properly performed hand hygiene is a critical nonpharmaceutical intervention for preventing communicable diseases globally and is integral to mitigating the global COVID-19 pandemic, especially in low- and middle-income countries (LMICs) with low vaccine rates.1,2 Existing assessments show low availability of hand hygiene resources in rural Ugandan healthcare facilities (HCFs) and schools.3 Essential to quality healthcare, basic water services (water from an improved source available on-site) were present in 51% of HCFs in sub-Saharan Africa in 2019 and 61% in Uganda in 2022.4,5 In 2019, 30% of schools in Uganda had basic hygiene services (at least one handwashing station with water and soap), 24% had limited hygiene services (handwashing station with water but no soap), and 46% had no hygiene services (no handwashing station or no water).3 Assessments of hand hygiene in other community locations, such as community congregation points of elevated importance (e.g., markets, points of entry) during the pandemic6 were rare.

In addition to handwashing stations, alcohol-based hand rub (ABHR) can also be used for hand hygiene in many settings, but availability is limited in LMICs due to high commercial prices during the pandemic and limited local production.7,8 As demonstrated during Ebola virus disease outbreaks, local production using WHO formulas9,10 can help provide affordable and readily available ABHR.11

Although robust guidelines exist for hand hygiene access and use in HCFs,9,12 fewer guidelines exist for community (non-healthcare, public) settings, where hand hygiene is still critical to preventing the spread of respiratory and enteric diseases in spaces where people gather.13 Even when hand hygiene materials are available in HCFs, their use is often inconsistent: a 2014 survey of HCFs in Bangladesh found 69% of hospitals had hand hygiene at points of care, but only 17% of healthcare workers (HCWs) washed hands after patient contact and just 2% before patient contact.4 In a school-based intervention assessment in rural Uganda, students reporting “always” washing their hands at school increased markedly after receiving handwashing stations,14 soap, and a handwashing education program.15 In addition to capability and opportunity, motivation is also a key factor for why individuals do or do not perform behaviors like hand hygiene.16

To gain a better understanding of access to hand hygiene infrastructure and adherence to recommended hand hygiene in healthcare and community settings in the pandemic context, as well as inform mitigation and response measures, we evaluated priority HCF and community locations with potentially high risk for COVID-19 transmission in two border districts in Uganda in January–April 2021. Results will provide insight into access to and use of hand hygiene in LMICs during the COVID-19 pandemic and identify gaps in access and use in HCFs and community settings with a high risk of population mixing, which take on enhanced importance during respiratory outbreaks and the current pandemic.

MATERIALS AND METHODS

Locations.

Amuru (in northwestern Uganda) and Tororo (in eastern Uganda) are border districts that were targeted for COVID-19-focused mitigation activities due to high volumes of trucking and mobile populations that yielded concern for disease transmission. In these districts, 60 locations were identified as a priority for hand hygiene assessment due to high levels of mobile population mixing based on an assessment using the CDC’s Population Connectivity Across Borders tool17: 12 HCFs, 15 points of entry or police checkpoints (POE), 12 guesthouses, 10 markets, seven schools, and four places of worship.

Data collection.

Assessment visits at each location were performed in January–April 2021. The HCFs were assessed using a CDC tool focused on water, sanitation, and hygiene (WASH),18 modified to focus on hand hygiene and water access. This tool was adapted for use in community settings (see Supplemental Appendices A and B).

In HCFs, the tool assessed clinical services offered, the presence of ABHR and handwashing supplies, water sources, and the presence of ABHR and handwashing supplies in patient care areas (Supplemental Appendix A). For community settings, questions covered facility size, location, number of patrons, presence of ABHR and handwashing supplies, and water sources (Supplemental Appendix B). Responses were entered into SurveyCTO (version 2.71; Dobility, Inc., Cambridge, MA). In community settings, schematic drawings were created in consultation with location managers and included entrances/exits, latrines, eating areas, congregation areas, food preparation areas, current handwashing stations, and ABHR (Supplemental Appendix C).

Direct observations of hand hygiene by HCWs and patrons in healthcare and community settings were also performed (Supplemental Appendices D–F). In both settings, appropriate hand hygiene was defined as the use of soap and water for handwashing or the use of ABHR. Use of water alone for handwashing and, for healthcare providers, the use of gloves without prior handwashing or ABHR use were not considered appropriate hand hygiene.

In HCFs, enumerators observed hand hygiene practices of up to five HCWs before and after patient interaction.12 Enumerators recorded the type of HCW, whether the interaction was with a new or returning to an existing patient, whether the procedure performed was invasive or noninvasive, the availability of hand hygiene materials, and whether hand hygiene was performed before and after the patient interaction. Contact with the surrounding environment (e.g., touching shared medical equipment) constituted a break in a patient encounter. Enumerators followed a HCW for up to five patient interactions or 1.5 hours (whichever came first). Enumerators notified HCWs that they were observing medical procedures but did not specify that they were observing hand hygiene. HCW observations were recorded on paper (Supplemental Appendix D) and then entered into SurveyCTO.

In community settings, enumerators observed patron hand hygiene practices at entrances, exits, and after latrine use for 30 minutes or 20 observations, whichever came first. To reduce reactivity, enumerators positioned themselves as far away as possible while being able to observe both the observation area and the hand hygiene station.19 Sex and approximate age (estimated by the observer as child (roughly < 12–13 years old), adolescent (roughly 12–13 to 18 years old), or adult (roughly > 18 years old) of patrons were recorded as well as the hand hygiene materials available and the materials used (if any) by patrons. Observations of patients and visitors at entrances, exits, and latrines of HCFs were analyzed with those of other community locations. Patron observations were entered directly into SurveyCTO. Paper forms were used if the online platform or electronic device used for recording was not functioning at the time of data collection (Supplemental Appendices E and F).

Analysis and modeling.

Descriptive analyses and regression models for access to and use of hand hygiene were conducted in SAS version 9.4 (SAS Institute, Cary, NC). For all models, we identified interactions of interest by examining the cross-tabulations of factors with plausible associations with outcomes. We then assessed these potential interactions using tests of generalized score statistics (for generalized estimating equations [GEE] models) or likelihood ratio tests (other models). We used an α of 0.05 to determine statistical significance. We identified characteristics associated with outcomes of interest by estimating odds ratios (ORs) for individual binary outcomes (hand hygiene access in a given patient care area, its use by HCWs, its use by patrons) or by estimating prevalence ratios (PR) for count-based outcomes (number of hand hygiene facilities in a given community location).

Hand hygiene access: HCFs.

The odds of HCF rooms having hand hygiene materials available were modeled using logistic regression with GEE to account for clustering by HCF. We adjusted ad hoc for the type of room (inpatient rooms, laboratory or staff rooms, and outpatient rooms), source of drinking water for the HCF, and HCF level (Health Center III or IV, hospitals).

Hand hygiene access: community settings.

The number of entrances/exits or congregation areas with hand hygiene materials present out of total entrances/exits and congregation areas in a community location was estimated using modified Poisson regression, adjusted for the district, location type, access to a water source, and the type of water source.

Hand hygiene use: HCFs.

The odds of a HCW performing hand hygiene were modeled using logistic regression with GEE accounting for repeat observations within providers in HCF. These models were adjusted for HCW type, new versus existing patient, invasive or noninvasive procedure, HCF level, and whether the moment for hand hygiene was before or after the patient encounter.

Hand hygiene use: community setting.

The odds of a community setting patron performing hand hygiene was evaluated using logistic regression, adjusting for the type of location, location of observation (entrance/exit or a latrine), age and sex of the patient, and presence of an attendant enforcing or encouraging hand hygiene.

Ethics.

Protocols for data collection were reviewed by institutional review boards in Uganda (Infectious Diseases Institute and Uganda National Council for Science and Technology) and at CDC and were determined to be nonresearch (CDC project id: 0900f3eb81d6329d).

RESULTS

Hand hygiene access: HCFs.

Of the 12 HCFs assessed, 11 (92%) reported ever having ABHR on site, of which only one (9.1%) reported the amount of ABHR was always sufficient for HCF needs (Table 1). Water was onsite at all HCFs, and the most common water source used for handwashing was piped water (75%). Half of the HCFs reported interruptions to the water supply used for handwashing, four HCFs (33%) reported not having enough water for handwashing in the past 2 weeks. Within HCFs, 64% of inpatient, 71% of outpatient, and 90% of laboratory and staff rooms contained hand hygiene materials. All laboratory, maternity, delivery, duty, staff, or storage/unused rooms, but only 18% of patient care rooms (such as wards), contained at least one type of hand hygiene material (Supplemental Table 1). Handwashing stations were present in 59% of rooms and ABHR in 54% of all rooms (Supplemental Table 2). In all, 73% of all handwashing stations assessed were functional (not broken or in need of repair) and had water and soap. Therefore, 43% of all HCF rooms contained a functional handwashing station with soap and water.

Table 1

Hand hygiene availability in healthcare facilities

Facilities HC III HC IV Hospital All
N (%) 5 (42) 4 (33) 3 (25) 12
ABHR supply, n (%)
 ABHR present anywhere on site 4 (80) 4 (100) 3 (100) 11 (92)
 Amount of ABHR sufficient to meet all needs 1 (25) 0 (0) 0 (0) 1 (9)
 Interruptions to receiving ABHR* 1/2 (50) 1 (25) 2 (100) 4 (50)
Water supply, n (%)
 Water source
 Piped water 4 (80) 2 (50) 3 (100) 9 (75)
 Borehole 1 (20) 1 (25) 0 (0) 2 (17)
 Unprotected well 1 (20) 0 (0) 0 (0) 1 (8.3)
 The water source on location grounds 5 (100) 4 (100) 3 (100) 12 (100)
 Are there ever water interruptions? 2 (40) 3 (75) 1 (33) 6 (50)
 In the past 2 weeks, has there always been enough water for handwashing? 4 (80) 3 (75) 1 (33) 8 (67)
Patient care rooms
N (%) 28 (28) 36 (26) 37 (37) 101 (100)
 Any hand hygiene available 21 (75) 39 (68) 30 (81) 76 (75)
 Inpatient room 4 (80) 6 (50) 6 (75) 16 (64)
 Laboratory or staff room 8 (89) 8 (89) 12 (92) 28 (90)
 Outpatient room 9 (64) 25 (69) 12 (75) 32 (71)
ABHR details
 ≥ 1 ABHR dispenser present in the room 15 (54) 16 (44) 23 (86) 54 (53)
Handwashing station details
 Handwashing station present 17 (61) 19 (53) 24 (65) 60 (59)
 Water present 14 (82) 13 (72) 23 (96) 50 (85)
 HWS functional 16 (94) 14 (74) 22 (96) 52 (88)
 Soap present 12 (71) 12 (63) 21 (88) 45 (75)
 Water is present, HWS functional, and soap present 11 (39) 11 (31) 20 (54) 42 (42)

ABHR = alcohol-based hand rub; HC = health center; HSW = handwashing station.

Eight healthcare facilities responded to this question.

For all other sites, water access was ≤ 500 m away.

In adjusted models for access to hand hygiene in HCFs, inpatient (OR = 0.20, 95% CI: 0.08–0.52) and outpatient (OR = 0.25, 95% CI: 0.09–0.68) rooms had lower odds of containing hand hygiene materials compared with laboratory or staff rooms (Table 2).

Table 2

Unadjusted and adjusted estimates for hand hygiene resource availability in healthcare facilities by room type, source of drinking water, and healthcare facility type

Parameter Unadjusted Adjusted*
OR 95% CI OR 95% CI
Room type Inpatient room 0.19 0.07–0.55 0.20 0.08–0.52
Outpatient room 0.26 0.10–0.67 0.25 0.09–0.68
Laboratory or Staff room Ref. Ref.
Source of drinking water Not piped 0.42 0.16–1.11 0.41 0.13–1.30
Piped water Ref. Ref.
Healthcare facility type HC III 0.70 0.17–2.90 1.13 0.30–4.25
HC IV 0.53 0.22–1.30 0.91 0.32–2.62
Hospital Ref. Ref.

HC = health center; OR = odds ratio; Ref. = reference.

Adjusted for room type, drinking water source, and healthcare facility type.

Includes unprotected well or manual borehole.

Hand hygiene access: community settings.

Across location types, the prevalence of hand hygiene materials at entrances/exits was highest in schools (70%, Table 3) and lowest in markets (22%). Prevalence of hand hygiene materials in congregation areas within community locations (e.g., eating areas) was highest in places of worship (63%) and lowest in guesthouses (32%). ABHR was most frequently reported in schools (86%) and least frequently reported in markets (20%); most locations except POEs reported insufficient ABHR to meet all needs. All markets, half of the schools, and points of entry reported interruptions in their ABHR supply line. The most common water source at places of worship, POEs, and guesthouses were piped water, while schools had mostly piped and manual boreholes. Water sources for markets were more mixed. All places of worship, guesthouses, and schools; 71% of POEs; and 44% of markets had onsite water sources. Although 76% of locations reported ever having water interruptions, 83% reported having enough water for handwashing in the past 2 weeks. Further information on study sites can be found in Supplemental Table 3.

Table 3

Hand hygiene materials availability in community locations

Location type Markets Place of worship Guest houses Schools Point of entry All
N (%) 10 (22) 4 (8.3) 12 (25) 7 (15) 15 (31) 48
ABHR supply, n (%)
 ABHR present anywhere on site 2 (20) 1 (25) 5 (42) 6 (86) 8 (53) 22 (46)
 Amount of ABHR sufficient to meet all needs (N = 22) 0 (0) 1 (100) 1 (20) 0 (0) 6 (75) 8 (36)
 Interruptions to receiving ABHR (N = 22) 2 (100) 0 (0) 1 (20) 3 (50) 4 (50) 10 (46)
Water supply, n (%)
 Piped water 3 (30) 3 (75) 5 (42) 3 (43) 11(73) 25 (52)
 Manual borehole 3 (30) 1 (25) 3 (25) 3 (43) 3 (20) 13 (27)
 Protected well 3 (30) 0 (0) 4 (33.3) 0 (0) 0 (0) 7 (14.6)
 Unprotected well 0 (0) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0)
 Tank 0 (0) 0 (0) 0 (0) 1 (14.3) 0 (0) 1 (2.1)
 No water source 1 (10) 0 (0) 0 (0) 0 (0) 1 (6.7) 2 (4.2)
 Water source on grounds location* 4 (44) 4 (100) 12 (100) 7 (100) 10 (71) 37 (60)
 Are there ever water interruptions? 6 (67) 3 (75) 6 (50) 6 (86) 14 (100) 35 (76)
 In the past 2 weeks, has there always been enough water for handwashing? 3 (60) 4 (100) 4 (67) 5 (83) 9 (100) 25 (83)
Hand hygiene availability, n (%)
 All entrances/exits with hand hygiene materials present (N = 116) 9 (22) 5 (46) 6 (30) 7 (70) 17 (52) 44 (38)
 % congregation areas with hand hygiene materials present (N = 131) 9 (35) 5 (63) 6 (32) 20 (37) 6 (24) 46 (35)

ABHR = alcohol-based hand rub.

For sites without water sources on the grounds, water access was ≤ 500 m away in all cases.

Hand hygiene availability is defined as the presence of ABHR or a handwashing station.

Of 21 entrances/exits assessed in the healthcare facility, 10 (48%) had hand hygiene materials present.

For hand hygiene availability in community settings (limited to entrances/exits and congregation areas, but not toilets), models adjusted for the district, location type, and water source showed no statistically significant associations, although hand hygiene availability was borderline lower for locations with nonpiped water versus piped water (Table 4). We were not able to test interactions of location type and water source due to small sample size.

Table 4

Unadjusted and adjusted estimates for hand hygiene resource availability in community settings

Parameter Unadjusted Adjusted*
PR 95% CI PR 95% CI
District Amuru 0.42 0.24–0.73 0.56 0.30–1.06
Tororo Ref. Ref.
Location type POE 0.94 0.47–1.87 0.83 0.47–1.49
Guesthouse 0.73 0.29–1.84 0.67 0.31–1.46
Place of worship 1.25 0.61–2.54 0.79 0.41–1.54
Market 0.64 0.26–1.54 0.67 0.26–1.47
School Ref. Ref.
Water source Not piped 0.43 0.23–0.81 0.53 0.27–1.02
No water 0.47 0.06–3.77 0.58 0.06–5.73
Piped water Ref. Ref.

POE = point of entry; PR = prevalence ratio; Ref. = reference.

Adjusted for the district, location type, access to water source, and water source.

Hand hygiene use: HCFs.

In 442 direct observations of hand hygiene by HCWs (221 before patient encounter, 221 after patient encounter), hand hygiene was performed before 26% of patient encounters and after 50% of patient encounters, most commonly by using ABHR (23% and 34%, respectively), resulting in an overall hand hygiene rate of 38% (Table 5). Doctors performed hand hygiene most often (68%) and nurses and laboratory technicians least often (29% and 30%, respectively). Before patient interaction, HCWs donned new gloves without prior handwashing or ABHR use in 33% of observations. Laboratory technicians had a low rate of hand hygiene at 4% and most frequently donned gloves without handwashing or using ABHR. Gloves were present in the room at 84% of observations, followed by ABHR (71%), and soap and water (59%).

Table 5

Overall hand hygiene adherence rates in healthcare facilities by healthcare worker type

Variable Materials available by hand hygiene observations, n (%) Appropriate hand hygiene performed,* n (%)
Before patient contact Total 221 (50) 57 (26)
Gloves 186 (84) 72 (33)
Soap and water 131 (59) 14 (6.3)
Chlorinated water 0 (0) 0 (0)
ABHR 157 (71) 51 (23)
None 0 (0) 92 (42)
After patient contact Total 221 (50) 110 (50)
Soap and water 131 (59) 35 (16)
Chlorinated water 0 (0) 0 (0)
ABHR 157 (71) 75 (34)
None 0 (0) 111 (50)
Overall Any hand hygiene performed 441 (100) 167 (38)
No. of hand hygiene observations, n (%) Appropriate hand hygiene performed,* n (%)
Type of healthcare worker (n) Doctor (5) 40 (9.0) 27 (68)
Midwife (9) 76 (17) 27 (36)
Nurse (17) 144 (33) 43 (30)
Clinical officer (11) 90 (20) 43 (48)
Laboratory tech (11) 92 (21) 27 (29)
Type of contact Invasive 154 (35) 46 (30)
Noninvasive 286 (65) 119 (42)

ABHR = alcohol-based hand rub.

Appropriate hand hygiene includes the use of soap and water or ABHR (does not include the use of gloves alone).

Laboratory technician hand hygiene rate is 4.4% before patient interaction.

Two were missing.

In the adjusted model for HCW hand hygiene adherence, doctors had higher odds of performing hand hygiene than nurses (OR = 3.58, 95% CI: 1.15–11.14, Table 6). The odds of an HCW performing hand hygiene were higher for new patients versus returning to interact with the same patient after contact with the surroundings (OR = 2.27, 95% CI: 1.20–4.27). Interactions between contact type (invasive versus noninvasive) and the timing of the patient interaction (before versus after-patient contact) were significant. Compared with after patient contact, the odds of before-patient contact were low for invasive contacts (OR = 0.66, 95% CI: 0.45–0.95) but even lower for noninvasive contacts (OR = 0.03, 95% CI: 0.00–0.20).

Table 6

Unadjusted and adjusted estimates for hand hygiene adherence of healthcare workers in healthcare facilities

Parameter Unadjusted Adjusted*
OR 95% CI OR 95% CI
Healthcare worker type Clinical officer 2.15 0.86–5.36 2.30 0.87–6.09
Doctor 4.88 1.59–14.94 3.58 1.15–11.14
Laboratory technician 0.98 0.51–1.87 1.07 0.42–2.72
Midwife 1.29 0.48–3.48 1.39 0.52–3.70
Nurse Ref. Ref.
New patient Yes 1.92 1.07–3.47 2.27 1.20–4.27
No Ref. Ref.
Facility level Health Center IV 1.12 0.52–2.41 1.20 0.50–2.88
Hospital 1.81 0.87–3.79 1.81 0.80–4.12
Health Center III Ref. Ref.
Patient interaction Invasive contact
 Before 0.03 0.00–0.20 0.03 0.00–0.20
 After Ref. Ref.
Noninvasive contact
 Before 0.69 0.49–0.97 0.66 0.45–0.95
 After Ref. Ref.

OR = odds ratio; Ref. = reference.

Adjusted for patient interaction, contact type, healthcare worker type, new patient, and facility level.

Hand hygiene use: community settings.

Direct observations of hand hygiene took place at the entrances/exits, and outside latrines at three guesthouses, eight HCFs, four markets, six points of entry, four schools, and two places of worship; 10 entrances/exits and five latrines had no observations due to either no water or absence of hand hygiene station. Most observations were at HCFs (37%), of male patrons (56%), and at entrances/exits (67%, Table 7). Handwashing stations were most commonly present (79%), followed by both handwashing stations and ABHR (17%), then ABHR only (4%). Hand hygiene was attempted in 30% of observations, but 23% counted as appropriate hand hygiene adherence (use of soap and water or ABHR). Soap and water was the most common hand hygiene method used by patrons (62%). Hand hygiene was attempted most frequently at markets (62%) and least frequently at points of entry (21%). Hand hygiene was performed twice as often after latrine use (48%) than entering or exiting a facility (21%).

Table 7

Hand hygiene rates in community settings by patron and location type

Variable No. of hand hygiene observations, n (%) Hand hygiene performed, n (%)
Type of location Point of entry 119 (18) 25 (21)
Guesthouse 58 (8.8) 17 (29)
Place of worship 71 (11) 27 (38)
Market 68 (10) 42 (62)
Healthcare facility 242 (37) 53 (22)
Schools 99 (15) 33 (33)
Area Entrance/exit 441 (67) 93 (21)
Latrine 216 (33) 104 (48)
Attendant Present 213 (32) 60 (28)
Not present 444 (68) 137 (31)
Patron age* Child 38 (5.8) 7 (18)
Adolescent 135 (21) 52 (39)
Adult 484 (74) 138 (29)
Patron sex Female 292 (44.) 100 (34)
Male 365 (56) 97 (27)
Type of hand hygiene present ABHR dispenser 28 (4.3) 8 (29)
Handwashing station 520 (79) 36 (33)
Both ABHR and handwashing station 109 (17) 153 (29)
Type of hand hygiene performed Plain water only 47 (24)
Water and soap 123 (62)
Chlorinated water 1 (0.5)
ABHR 26 (13)
Time spent performing hand hygiene < 20 seconds 75 (38)
≥ 20 seconds 122 (62)

ABHR = alcohol-based hand rub.

Approximate age was estimated by the observer as child (roughly < 12–13 years old), adolescent (roughly 12–13 to 18 years old), or adult (roughly > 18 years old).

In the adjusted model, children had lower odds of performing hand hygiene than adults (OR = 0.37, 95% CI: 0.15–0.92, Table 8). Patrons at places of worship (OR = 2.82, 95% CI: 1.28–6.20) and markets (OR = 2.19, 95% CI: 1.01–4.40) had higher odds of performing hand hygiene than students in schools (the reference). The odds of patrons performing hand hygiene after using the latrine were 3.39 times higher than at a community entrance or exit (95% CI: 2.08–5.52). Attendants present at a location were not associated with the odds of performing hand hygiene.

Table 8

Unadjusted and adjusted estimates for hand hygiene adherence by patrons in community settings at entrances/exits and congregation points

Parameter Unadjusted Adjusted*
OR 95% CI OR 95% CI
Age Child 0.54 0.23–1.25 0.37 0.15–0.92
Adolescent 1.45 0.98–2.16 0.98 0.59–1.60
Adult Ref. Ref.
Location type Point of entry 0.45 0.25–0.81 0.85 0.43–1.67
Guesthouse 0.70 0.35–1.38 1.41 0.62–3.21
Place of worship 1.03 0.56–1.91 2.82 1.28–6.20
Market 2.72 1.46–5.07 2.19 1.01–4.40
Healthcare facility 0.47 0.29–0.77 0.75 0.43–1.33
Schools Ref. Ref.
Sex Female 1.43 1.03–1.99 1.29 0.89–1.87
Male Ref. Ref.
Attendant Present 0.98 0.69–1.39 1.41 0.87–2.27
Absent Ref. Ref.
Area type Latrine 3.23 2.28–4.56 3.39 2.08–5.52
Entrance/exit Ref. Ref.

OR = odds ratio; Ref. = reference.

Adjusted for patron age and sex, location type, presence of an attendant, and area type.

DISCUSSION

This assessment of hand hygiene access and use in two districts in Uganda with high population mobility suggests that despite the ongoing pandemic and associated increases in awareness of preventive behaviors, appropriate hand hygiene was infrequently performed (< 50% during key moments) in HCFs and community locations. Access to hand hygiene materials in HCFs was lower in the patient care rooms than in laboratories and administrative rooms, suggesting a need for prioritization at the point of care. Hand hygiene practice among HCWs was highest after patient contact, reflecting a need for continued emphasis for HCWs to practice hand hygiene to protect patients in addition to themselves. In community settings, markets had lower access to hand hygiene materials than schools, and locations with piped water had borderline better access to hand hygiene materials compared with nonpiped water, suggesting new areas of prioritizing increased water quantity and availability to enable hand hygiene. Hand hygiene practice was more than twice as likely outside latrines than at entrances/exits, emphasizing the need for consistent messaging on hand hygiene at key moments, particularly at novel key moments that emerged during the COVID-19 pandemic such as entrances and exits.2,20

This assessment is one of the few to compare hand hygiene access and use between both healthcare and community settings.6 Critically, 38% of HCWs interacting with patients, 48% of patrons after using a latrine, and 21% of patrons entering and exiting a community setting were observed to practice hand hygiene, representing low adherence despite increases in global and local awareness of hand hygiene as a key preventive measure during the COVID-19 pandemic.20 With the COVID-19 pandemic, the importance of mitigation measures—including hand hygiene—in community spaces has grown. With the exception of schools, however, standardized guidance on WASH access in community spaces is absent to date.3,21,22 HCF and school guidelines3,4 may inform those for other community spaces, but adaptation and evaluation are needed.

In HCFs in this evaluation, access to hand hygiene in patient care rooms may have been lower than in administration and staff rooms due to differential prioritization of limited funds and supplies. Past studies in limited resource HCFs have also more frequently found hand hygiene materials in staff areas than inpatient or visitor areas,23 given limited funds to supply, equip, and maintain handwashing stations in HCFs are frequently reported,24,25 such as too few staff to refill handwashing stations.26 For ABHR, staff or facility administrators may limit access in areas with patient or visitor traffic (including patient care areas) to ensure sustained ABHR access to staff, especially in high-use situations such as pandemics. Given the quicker ease of use and reduced burden on water supply, increased access to ABHR can improve overall hand hygiene adherence.27

Healthcare workers may have had better hand hygiene adherence after patient contact, compared with before, because they felt their own hands were “dirty” after patient contact and may have been motivated to protect themselves from infection or illness.28 This inherent feeling of perceived (or actual) contamination can be a stronger motivator to perform hand hygiene than the elected practice of performing hand hygiene on hands that “feel” clean before patient contact.29 Similarly, protection of self—more so than patient—may be an important motivator: for example, past research in Arua, Uganda indicated that previous nosocomial infection in an HCW was associated with higher levels of hand hygiene.30 Training and reminders on protecting patients for HCWs, in addition to increased access to ABHR, may be needed to improve hand hygiene adherence in HCF.

The COVID-19 pandemic has emphasized the need for hand hygiene in community settings, such as markets, alongside locations with long-standing guidance for WASH access (e.g., schools).2 Markets, in particular, are key community locations with close interactions between patrons and vendors. Hand hygiene needs in community settings reinforce the need for concomitant water sources meeting safely managed criteria within the drinking water ladder. Hand hygiene materials were available in a few entrances/exits or congregation areas (38% and 35%, respectively). Hand hygiene can only take place when supplies are available. In addition to hand hygiene stations themselves, water that is onsite and available when needed may be an applicable initial benchmark in these settings.4,31,32 Even among households, which have less water demand than community locations, multiple sources are sometimes required to maintain sufficient water quantity for needs beyond drinking33,34; additional demands for water for hygiene in community spaces present challenges to consistent handwashing in LMIC settings.35 Water-efficient solutions for handwashing stations, such as soap and water designs that minimize wastage while not in use,3638 may also reduce demands on water supply. Complementary use of ABHR can also increase access with a smaller footprint than handwashing stations, although ABHR should be prioritized where hands are least likely to be visibly dirty and with consistent messaging to reinforce appropriate use.39 Local production of ABHR may enable more affordable, consistent access in community settings, although supply chain models are currently undefined, as are roles and guidance for management.6 Community settings may require managers or influencers to ensure hand hygiene materials are consistently available and used, similar to the role played by infection prevention and control focal persons in HCFs.9,40,41

Higher rates of hand hygiene after latrine use than at entrances or exits emphasizes the need for sustained, consistent messaging tying hand hygiene to key moments, particularly to novel key moments during a pandemic. Long-standing guidance emphasizes hand hygiene at multiple key moments in community settings (including after toileting, around food preparation and eating, and after touching animals, or sneezing, coughing, or blowing one’s nose, among others), many of which are times for handwashing specifically.22,42 Hand hygiene—and handwashing specifically—after using the toilet has been most commonly emphasized in WASH initiatives. Hand hygiene at entrances and exits to community spaces is a COVID-19 pandemic-related guidance43,44 that may improve access to hand hygiene facilities but may not always be tied to an existing key moment (and consequently, existing habits) or may be subject to social pressures that make it more difficult to form habits and yield lower adherence.22 If these locations are to be considered key moments for hand hygiene beyond the pandemic, user-centered approaches to ensuring coherent and more generalizable evidence-based messaging on these moments may be necessary.45

This assessment had several limitations. First, the generalizability of the two districts analyzed should be considered as other districts in Uganda, and in other LMICs, may have had different supplies and rates of hand hygiene. Although study teams were familiar with the methodology of direct observation of hand hygiene from previous assessments,46 trainings of enumerators could only be given remotely during the pandemic. Despite messaging to HCWs that observations were about medical practices generally and not hand hygiene specifically, HCWs could have changed practices during observations due to the Hawthorne effect.47 Additionally, frequent COVID-19 awareness campaigns during this time period could have resulted in greater attention to hand hygiene during this period and potentially overestimated rates even though rates were already relatively low.

Although this assessment revealed basic hand hygiene material access and use, further information on the supply chain of ABHR (e.g., factors preventing a sufficient amount from being available7,8), barriers to use (e.g., concern among religious groups for ABHR containing alcohol48), and current educational resources and gaps (e.g., emphasizing that donning gloves without first using ABHR or soap and water does not constitute appropriate hand hygiene49) are needed.

Even during the global COVID-19 pandemic, hand hygiene rates were low in both community and healthcare settings. In HCFs, increased access to hand hygiene materials in patient care areas and emphasis on appropriate hand hygiene before patient interactions are needed. In community settings, emphasis on hand hygiene at key moments and guidance and messaging for new community locations requiring hand hygiene are actionable next steps to improve access to and use of hand hygiene across LMICs.

Supplemental Materials

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ACKNOWLEDGMENTS

We wish to acknowledge the team at the Infectious Disease Institute at Makerere University who completed the enumeration and data collection, as well as all participants in the communities who lent us their valuable time. The American Society of Tropical Medicine and Hygiene has waived the Open Access fee for this COVID-19 article.

REFERENCES

  • 1.

    Pittet D , 2005. Clean hands reduce the burden of disease. Lancet 366: 185187.

  • 2.

    World Health Organization , 2020. Water, Sanitation, Hygiene, and Waste Management for SARS-CoV-2, the Virus That Causes COVID-19. Interim Guide. Geneva, Switzerland: WHO.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 3.

    World Health Organization and UNICEF , 2020. Progress on Drinking Water, Sanitation, and Hygiene in Schools; Special Focus on COVID-19. Geneva, Switzerland: WHO.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 4.

    World Health Organization and UNICEF , 2019. WASH in Healthcare Facilities: Global Baseline Report. Geneva, Switzerland: WHO.

  • 5.

    Uganda Ministry of Health , 2022. National Micro Planning Handbook for Water, Sanitation and Hygiene (WASH) in Healthcare Facilities (HCFs) in Uganda. Kampala, Uganda: the Ugandan Ministry of Health.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 6.

    Berendes D et al., 2022. Improving water, sanitation, and hygiene (WASH), with a focus on hand hygiene, globally for community mitigation of COVID-19. PLoS Water 1: e0000027.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 7.

    Loftus MJ , Guitart C , Tartari E , Stewardson AJ , Amer F , Bellissimo-Rodrigues F , Lee YF , Mehtar S , Sithole BL , Pittet D , 2019. Hand hygiene in low- and middle-income countries. Int J Infect Dis 86: 2530.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 8.

    Peters A , Guitart C , Pittet D , 2021. Addressing the global challenge of access to supplies during COVID-19: mask reuse and local production of alcohol-based hand rub. Environ Heal Manag Nov Coronavirus Dis 2021: 419441.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 9.

    World Health Organization , 2009. WHO Guidelines on Hand Hygiene in Health Care. Geneva, Switzerland: WHO.

  • 10.

    World Health Organization , 2010. Guide to Local Production: WHO-recommended Handrub Formulations Introduction. Geneva, Switzerland: WHO.

  • 11.

    Bausch FA , Heller O , Bengaly L , Matthey-Khouity B , Bonnabry P , Touré Y , Kervillain GJ , Bah EI , Chappuis F , Hagon O , 2018. Building local capacity in hand-rub solution production during the 2014–2016 ebola outbreak disaster: the case of Liberia and Guinea. Prehosp Disaster Med 33: 660667.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 12.

    Centers for Disease Control and Prevention , 2021. Healthcare Providers. Hand Hygiene. Available at: https://www.cdc.gov/handhygiene/providers/index.html. Accessed September 30, 2021.

    • PubMed
    • Export Citation
  • 13.

    Centers for Disease Control and Prevention , 2020. Show Me the Science—Why Wash Your Hands? Available at: https://www.cdc.gov/handwashing/why-handwashing.html. Accessed December 20, 2020.

    • PubMed
    • Export Citation
  • 14.

    Watt J , 1988. The Tippy Tap: a simple handwashing device for rural areas. J Trop Pediatr 34: 9192.

  • 15.

    Zhang C , Mosa AJ , Hayward AS , Matthews SA , 2013. Promoting clean hands among children in Uganda: a school-based intervention using “Tippy-Taps.” Public Health 127: 586589.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 16.

    Michie S , van Stralen MM , West R , 2011. The behaviour change wheel: a new method for characterising and designing behaviour change interventions. Implement Sci 6: 112.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 17.

    Centers for Disease Control and Prevention , 2021. Population Connectivity across Borders (PopCAB) Toolkit. Available at: https://www.cdc.gov/coronavirus/2019-ncov/global-covid-19/popcab-toolkit.html. Accessed August 30, 2021.

    • PubMed
    • Export Citation
  • 18.

    Centers for Disease Control and Prevention , 2020. CDC and Hilton Foundation Partner to Improve Global Water, Sanitation, and Hygiene. Available at: https://www.cdc.gov/ncezid/what-we-do/partnership-in-action/hilton-foundation.html. Accessed December 10, 2020.

    • PubMed
    • Export Citation
  • 19.

    Ram PK et al., 2010. Is structured observation a valid technique to measure handwashing behavior? Use of acceleration sensors embedded in soap to assess reactivity to structured observation. Am J Trop Med Hyg 83: 10701076.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 20.

    World Health Organization , 2020. WHO: Interim Recommendation on Obligatory Hand Hygiene against Transmission of COVID-19. Geneva, Switzerland: WHO.

  • 21.

    World Health Organization/UNICEF , 2020. Hygiene Baselines Pre-COVID-19 Global Snapshot Source: WHO/UNICEF Joint Monitoring Programme for Water Supply, Sanitation and Hygiene. Geneva, Switzerland: WHO.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 22.

    UNICEF , 2021. State of the World’s Hand Hygiene: A Global Call to Action to Make Hand Hygiene a Priority in Policy and Practice. New York, NY: UNICEF.

  • 23.

    Huttinger A , Dreibelbis R , Kayigamba F , Ngabo F , Mfura L , Merryweather B , Cardon A , Moe C , 2017. Water, sanitation and hygiene infrastructure and quality in rural healthcare facilities in Rwanda. BMC Health Serv Res 17: 111.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 24.

    Kayiwa D et al., 2020. Assessment of water, sanitation and hygiene service availability in healthcare facilities in the greater Kampala metropolitan area, Uganda. BMC Public Health 20: 111.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 25.

    Guo A , Bowling JM , Bartram J , Kayser G , 2017. Water, sanitation, and hygiene in rural health-care facilities: a cross-sectional study in Ethiopia, Kenya, Mozambique, Rwanda, Uganda, and Zambia. Am J Trop Med Hyg 97: 10331042.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 26.

    Ataiyero Y , Dyson J , Graham M , 2019. Barriers to hand hygiene practices among health care workers in sub-Saharan African countries: a narrative review. Am J Infect Control 47: 565573.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 27.

    Ndegwa L , Hatfield KM , Sinkowitz-Cochran R , D’Iorio E , Gupta N , Kimotho J , Woodard T , Chaves SS , Ellingson K , 2019. Evaluation of a program to improve hand hygiene in Kenyan hospitals through production and promotion of alcohol-based Handrub—2012–2014. Antimicrob Resist Infect Control 8: 49.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 28.

    Sethi AK , Acher CW , Kirenga B , Mead S , Donskey CJ , Katamba A , 2012. Infection control knowledge, attitudes, and practices among healthcare workers at Mulago Hospital, Kampala, Uganda. Infect Control Hosp Epidemiol 33: 917923.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 29.

    Whitby M , McLaws M-L , Ross MW , 2006. Why healthcare workers don’t wash their hands: a behavioral explanation. Infect Control Hosp Epidemiol 27: 484492.

  • 30.

    Wasswa P , Nalwadda CK , Buregyeya E , Gitta SN , Anguzu P , Nuwaha F , 2015. Implementation of infection control in health facilities in Arua district, Uganda: a cross-sectional study. BMC Infect Dis 15: 19.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 31.

    Aregu MB , Kanno GG , Ashuro Z , Alembo A , Alemayehu A , 2021. Safe water supply challenges for hand hygiene in the prevention of COVID-19 in Southern Nations, Nationalities, and People’s Region (SNNPR), Ethiopia. Heliyon 7: e08430.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 32.

    Stoler J , Wendy J , Wutich A , 2020. Beyond handwashing: water insecurity undermines COVID-19 response in developing areas. J Glob Health 10: 010355.

  • 33.

    Elliott M , MacDonald MC , Chan T , Kearton A , Shields KF , Bartram JK , Hadwen WL , 2017. Multiple household water sources and their use in remote communities with evidence from Pacific Island countries. Water Resour Res 53: 91069117.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 34.

    Elliott M , Foster T , MacDonald MC , Harris AR , Schwab KJ , Hadwen WL. , 2019. Addressing how multiple household water sources and uses build water resilience and support sustainable development. NPJ Clean Water 21: 15.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 35.

    Kibe PM , Kisia L , Bakibinga P , 2020. COVID-19 and community healthcare: perspectives from Nairobi’s informal settlements. Pan Afr Med J 35: 106.

  • 36.

    Ashraf S et al., 2017. Nonrandomized trial of feasibility and acceptability of strategies for promotion of soapy water as a handwashing agent in rural Bangladesh. Am J Trop Med Hyg 96: 421429.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 37.

    Deutsche Gesellschaft fur Internationale Zusammenarbeit , 2020. WASHaLOT 3.0: Group Washing Facility. Available at: https://www.giz.de/de/downloads/Sanitation%20for%20Millions%20WASHaLOT3.0%20An%20innovative%20handwashing%20technology%20in%20Uganda.pdf. Accessed August 9, 2023.

    • PubMed
    • Export Citation
  • 38.

    Whinnery J , Penakalapati G , Steinacher R , Wilson N , Null C , Pickering AJ , 2016. Handwashing with a water-efficient tap and low-cost foaming soap: the Povu Poa “Cool Foam” system in Kenya. Glob Health Sci Pract 4: 336341.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 39.

    Pickering AJ , Davis J , Boehm AB , 2011. Efficacy of alcohol-based hand sanitizer on hands soiled with dirt and cooking oil. J Water Health 9: 429433.

  • 40.

    World Health Organization , 2019. Minimum Requirements for Infection Prevention and Control Programmes. Geneva, Switzerland: WHO.

  • 41.

    Insitute of Epidemiology Disease Control and Research/Water Aid , 2020. Handwashing Stations: An Easy-to-Use Technological and Context-Based Handwashing Stations manual. Dhaka, Bangladesh: WaterAid.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 42.

    Centers for Disease Control and Prevention , 2020. Show Me the Science—When & How to Use Hand Sanitizer in Community Settings. Available at: https://www.cdc.gov/handwashing/show-me-the-science-hand-sanitizer.html. Accessed December 1, 2020.

    • PubMed
    • Export Citation
  • 43.

    World Health Organization , 2020. Recommendations to Member States to Improve Hand Hygiene Practices to Help Prevent the Transmission of the COVID-19 Virus. Available at: https://www.who.int/publications/i/item/recommendations-to-member-states-to-improve-hand-hygiene-practices-to-help-prevent-the-transmission-of-the-covid-19-virus. Accessed December 14, 2020.

    • PubMed
    • Export Citation
  • 44.

    Centers for Disease Control and Prevention , 2020. Mitigation Measures for COVID-19 in Households and Markets in Non-US Low-Resource Settings. Available at: https://www.cdc.gov/coronavirus/2019-ncov/global-covid-19/global-urban-areas.html?CDC_AA_refVal=https%3A%2F%2Fwww.cdc.gov%2Fcoronavirus%2F2019-ncov%2Fglobal-covid-19%2Fmarkets.html. Accessed December 1, 2020.

    • PubMed
    • Export Citation
  • 45.

    Sax H , Allegranzi B , Uckay I , Larson E , Boyce J , Pittet D , 2007. “My five moments for hand hygiene”: a user-centred design approach to understand, train, monitor and report hand hygiene. J Hosp Infect 67: 921.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 46.

    Lamorde M et al., 2020. Access to alcohol-based hand rub is associated with improved hand hygiene in an Ebola-threatened district of Western Uganda. Infect Control Hosp Epidemiol 41: s457.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 47.

    Srigley Dr JA , Furness C , Baker GR , Gardam M , 2014. Quantification of the Hawthorne effect in hand hygiene compliance monitoring using an electronic monitoring system: a retrospective cohort study. BMJ Qual Saf 23: 974980.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 48.

    Ng WK , Shaban RZ , van de Mortel T , 2019. The effect of a hand hygiene program featuring tailored religion-relevant interventions on healthcare workers’ hand rubbing compliance and beliefs in the United Arab Emirates: a cohort study. Infect Dis Health 24: 115123.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 49.

    Muhumuza C , Gomersall JS , Fredrick ME , Atuyambe L , Okiira C , Mukose A , Ssempebwa J , 2015. Health care worker hand hygiene in the pediatric special care unit at Mulago National Referral Hospital in Uganda: a best practice implementation project. Int J Evid-Based Healthc 13: 1927.

    • PubMed
    • Search Google Scholar
    • Export Citation

Author Notes

Address correspondence to David Berendes, U.S. Centers for Disease Control and Prevention, 1600 Clifton Rd., MS H24-11, Atlanta, GA 30329. E-mail: uws8@cdc.gov

Disclaimer: The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the U.S. Centers for Disease Control and Prevention.

Authors’ addresses: Caroline Pratt, Waterborne Disease Prevention Branch, Division of Foodborne, Waterborne, and Environmental Diseases, U.S. Centers for Disease Control and Prevention, Atlanta, GA, and U.S. Epidemic Intelligence Service, U.S. Centers for Disease Control and Prevention, Atlanta, GA, E-mail: cqpratt@gmail.com. Maureen Kesande, Fred Tusabe, Sauda Yapswale, Stella Nabatyanga, Herbert Isabirye, Mohammed Lamorde, Infectious Disease Institute, Makerere University, Kampala, Uganda, E-mails: mkesande@idi.co.ug, ftusabe@idi.co.ug, syapswale@idi.co.ug, snabatyanga@idi.co.ug, hisabirye@idi.co.ug, and mlamorde@idi.co.ug. Alexandra Medley, Division of Foodborne, Waterborne, and Environmental Diseases, U.S. Centers for Disease Control and Prevention, Atlanta, GA, E-mail: muv3@cdc.gov. Graeme Prentice-Mott, Matthew Lozier, and Victoria Trinies, Waterborne Disease Prevention Branch, Division of Foodborne, Waterborne, and Environmental Diseases, U.S. Centers for Disease Control and Prevention, Atlanta, GA, E-mails: qbt1@cdc.gov, wfu2@cdc.gov, and omo3@cdc.gov. David Berendes, U.S. Epidemic Intelligence Service, U.S. Centers for Disease Control and Prevention, Atlanta, GA, E-mail: uws8@cdc.gov.

  • 1.

    Pittet D , 2005. Clean hands reduce the burden of disease. Lancet 366: 185187.

  • 2.

    World Health Organization , 2020. Water, Sanitation, Hygiene, and Waste Management for SARS-CoV-2, the Virus That Causes COVID-19. Interim Guide. Geneva, Switzerland: WHO.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 3.

    World Health Organization and UNICEF , 2020. Progress on Drinking Water, Sanitation, and Hygiene in Schools; Special Focus on COVID-19. Geneva, Switzerland: WHO.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 4.

    World Health Organization and UNICEF , 2019. WASH in Healthcare Facilities: Global Baseline Report. Geneva, Switzerland: WHO.

  • 5.

    Uganda Ministry of Health , 2022. National Micro Planning Handbook for Water, Sanitation and Hygiene (WASH) in Healthcare Facilities (HCFs) in Uganda. Kampala, Uganda: the Ugandan Ministry of Health.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 6.

    Berendes D et al., 2022. Improving water, sanitation, and hygiene (WASH), with a focus on hand hygiene, globally for community mitigation of COVID-19. PLoS Water 1: e0000027.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 7.

    Loftus MJ , Guitart C , Tartari E , Stewardson AJ , Amer F , Bellissimo-Rodrigues F , Lee YF , Mehtar S , Sithole BL , Pittet D , 2019. Hand hygiene in low- and middle-income countries. Int J Infect Dis 86: 2530.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 8.

    Peters A , Guitart C , Pittet D , 2021. Addressing the global challenge of access to supplies during COVID-19: mask reuse and local production of alcohol-based hand rub. Environ Heal Manag Nov Coronavirus Dis 2021: 419441.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 9.

    World Health Organization , 2009. WHO Guidelines on Hand Hygiene in Health Care. Geneva, Switzerland: WHO.

  • 10.

    World Health Organization , 2010. Guide to Local Production: WHO-recommended Handrub Formulations Introduction. Geneva, Switzerland: WHO.

  • 11.

    Bausch FA , Heller O , Bengaly L , Matthey-Khouity B , Bonnabry P , Touré Y , Kervillain GJ , Bah EI , Chappuis F , Hagon O , 2018. Building local capacity in hand-rub solution production during the 2014–2016 ebola outbreak disaster: the case of Liberia and Guinea. Prehosp Disaster Med 33: 660667.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 12.

    Centers for Disease Control and Prevention , 2021. Healthcare Providers. Hand Hygiene. Available at: https://www.cdc.gov/handhygiene/providers/index.html. Accessed September 30, 2021.

    • PubMed
    • Export Citation
  • 13.

    Centers for Disease Control and Prevention , 2020. Show Me the Science—Why Wash Your Hands? Available at: https://www.cdc.gov/handwashing/why-handwashing.html. Accessed December 20, 2020.

    • PubMed
    • Export Citation
  • 14.

    Watt J , 1988. The Tippy Tap: a simple handwashing device for rural areas. J Trop Pediatr 34: 9192.

  • 15.

    Zhang C , Mosa AJ , Hayward AS , Matthews SA , 2013. Promoting clean hands among children in Uganda: a school-based intervention using “Tippy-Taps.” Public Health 127: 586589.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 16.

    Michie S , van Stralen MM , West R , 2011. The behaviour change wheel: a new method for characterising and designing behaviour change interventions. Implement Sci 6: 112.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 17.

    Centers for Disease Control and Prevention , 2021. Population Connectivity across Borders (PopCAB) Toolkit. Available at: https://www.cdc.gov/coronavirus/2019-ncov/global-covid-19/popcab-toolkit.html. Accessed August 30, 2021.

    • PubMed
    • Export Citation
  • 18.

    Centers for Disease Control and Prevention , 2020. CDC and Hilton Foundation Partner to Improve Global Water, Sanitation, and Hygiene. Available at: https://www.cdc.gov/ncezid/what-we-do/partnership-in-action/hilton-foundation.html. Accessed December 10, 2020.

    • PubMed
    • Export Citation
  • 19.

    Ram PK et al., 2010. Is structured observation a valid technique to measure handwashing behavior? Use of acceleration sensors embedded in soap to assess reactivity to structured observation. Am J Trop Med Hyg 83: 10701076.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 20.

    World Health Organization , 2020. WHO: Interim Recommendation on Obligatory Hand Hygiene against Transmission of COVID-19. Geneva, Switzerland: WHO.

  • 21.

    World Health Organization/UNICEF , 2020. Hygiene Baselines Pre-COVID-19 Global Snapshot Source: WHO/UNICEF Joint Monitoring Programme for Water Supply, Sanitation and Hygiene. Geneva, Switzerland: WHO.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 22.

    UNICEF , 2021. State of the World’s Hand Hygiene: A Global Call to Action to Make Hand Hygiene a Priority in Policy and Practice. New York, NY: UNICEF.

  • 23.

    Huttinger A , Dreibelbis R , Kayigamba F , Ngabo F , Mfura L , Merryweather B , Cardon A , Moe C , 2017. Water, sanitation and hygiene infrastructure and quality in rural healthcare facilities in Rwanda. BMC Health Serv Res 17: 111.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 24.

    Kayiwa D et al., 2020. Assessment of water, sanitation and hygiene service availability in healthcare facilities in the greater Kampala metropolitan area, Uganda. BMC Public Health 20: 111.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 25.

    Guo A , Bowling JM , Bartram J , Kayser G , 2017. Water, sanitation, and hygiene in rural health-care facilities: a cross-sectional study in Ethiopia, Kenya, Mozambique, Rwanda, Uganda, and Zambia. Am J Trop Med Hyg 97: 10331042.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 26.

    Ataiyero Y , Dyson J , Graham M , 2019. Barriers to hand hygiene practices among health care workers in sub-Saharan African countries: a narrative review. Am J Infect Control 47: 565573.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 27.

    Ndegwa L , Hatfield KM , Sinkowitz-Cochran R , D’Iorio E , Gupta N , Kimotho J , Woodard T , Chaves SS , Ellingson K , 2019. Evaluation of a program to improve hand hygiene in Kenyan hospitals through production and promotion of alcohol-based Handrub—2012–2014. Antimicrob Resist Infect Control 8: 49.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 28.

    Sethi AK , Acher CW , Kirenga B , Mead S , Donskey CJ , Katamba A , 2012. Infection control knowledge, attitudes, and practices among healthcare workers at Mulago Hospital, Kampala, Uganda. Infect Control Hosp Epidemiol 33: 917923.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 29.

    Whitby M , McLaws M-L , Ross MW , 2006. Why healthcare workers don’t wash their hands: a behavioral explanation. Infect Control Hosp Epidemiol 27: 484492.

  • 30.

    Wasswa P , Nalwadda CK , Buregyeya E , Gitta SN , Anguzu P , Nuwaha F , 2015. Implementation of infection control in health facilities in Arua district, Uganda: a cross-sectional study. BMC Infect Dis 15: 19.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 31.

    Aregu MB , Kanno GG , Ashuro Z , Alembo A , Alemayehu A , 2021. Safe water supply challenges for hand hygiene in the prevention of COVID-19 in Southern Nations, Nationalities, and People’s Region (SNNPR), Ethiopia. Heliyon 7: e08430.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 32.

    Stoler J , Wendy J , Wutich A , 2020. Beyond handwashing: water insecurity undermines COVID-19 response in developing areas. J Glob Health 10: 010355.

  • 33.

    Elliott M , MacDonald MC , Chan T , Kearton A , Shields KF , Bartram JK , Hadwen WL , 2017. Multiple household water sources and their use in remote communities with evidence from Pacific Island countries. Water Resour Res 53: 91069117.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 34.

    Elliott M , Foster T , MacDonald MC , Harris AR , Schwab KJ , Hadwen WL. , 2019. Addressing how multiple household water sources and uses build water resilience and support sustainable development. NPJ Clean Water 21: 15.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 35.

    Kibe PM , Kisia L , Bakibinga P , 2020. COVID-19 and community healthcare: perspectives from Nairobi’s informal settlements. Pan Afr Med J 35: 106.

  • 36.

    Ashraf S et al., 2017. Nonrandomized trial of feasibility and acceptability of strategies for promotion of soapy water as a handwashing agent in rural Bangladesh. Am J Trop Med Hyg 96: 421429.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 37.

    Deutsche Gesellschaft fur Internationale Zusammenarbeit , 2020. WASHaLOT 3.0: Group Washing Facility. Available at: https://www.giz.de/de/downloads/Sanitation%20for%20Millions%20WASHaLOT3.0%20An%20innovative%20handwashing%20technology%20in%20Uganda.pdf. Accessed August 9, 2023.

    • PubMed
    • Export Citation
  • 38.

    Whinnery J , Penakalapati G , Steinacher R , Wilson N , Null C , Pickering AJ , 2016. Handwashing with a water-efficient tap and low-cost foaming soap: the Povu Poa “Cool Foam” system in Kenya. Glob Health Sci Pract 4: 336341.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 39.

    Pickering AJ , Davis J , Boehm AB , 2011. Efficacy of alcohol-based hand sanitizer on hands soiled with dirt and cooking oil. J Water Health 9: 429433.

  • 40.

    World Health Organization , 2019. Minimum Requirements for Infection Prevention and Control Programmes. Geneva, Switzerland: WHO.

  • 41.

    Insitute of Epidemiology Disease Control and Research/Water Aid , 2020. Handwashing Stations: An Easy-to-Use Technological and Context-Based Handwashing Stations manual. Dhaka, Bangladesh: WaterAid.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 42.

    Centers for Disease Control and Prevention , 2020. Show Me the Science—When & How to Use Hand Sanitizer in Community Settings. Available at: https://www.cdc.gov/handwashing/show-me-the-science-hand-sanitizer.html. Accessed December 1, 2020.

    • PubMed
    • Export Citation
  • 43.

    World Health Organization , 2020. Recommendations to Member States to Improve Hand Hygiene Practices to Help Prevent the Transmission of the COVID-19 Virus. Available at: https://www.who.int/publications/i/item/recommendations-to-member-states-to-improve-hand-hygiene-practices-to-help-prevent-the-transmission-of-the-covid-19-virus. Accessed December 14, 2020.

    • PubMed
    • Export Citation
  • 44.

    Centers for Disease Control and Prevention , 2020. Mitigation Measures for COVID-19 in Households and Markets in Non-US Low-Resource Settings. Available at: https://www.cdc.gov/coronavirus/2019-ncov/global-covid-19/global-urban-areas.html?CDC_AA_refVal=https%3A%2F%2Fwww.cdc.gov%2Fcoronavirus%2F2019-ncov%2Fglobal-covid-19%2Fmarkets.html. Accessed December 1, 2020.

    • PubMed
    • Export Citation
  • 45.

    Sax H , Allegranzi B , Uckay I , Larson E , Boyce J , Pittet D , 2007. “My five moments for hand hygiene”: a user-centred design approach to understand, train, monitor and report hand hygiene. J Hosp Infect 67: 921.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 46.

    Lamorde M et al., 2020. Access to alcohol-based hand rub is associated with improved hand hygiene in an Ebola-threatened district of Western Uganda. Infect Control Hosp Epidemiol 41: s457.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 47.

    Srigley Dr JA , Furness C , Baker GR , Gardam M , 2014. Quantification of the Hawthorne effect in hand hygiene compliance monitoring using an electronic monitoring system: a retrospective cohort study. BMJ Qual Saf 23: 974980.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 48.

    Ng WK , Shaban RZ , van de Mortel T , 2019. The effect of a hand hygiene program featuring tailored religion-relevant interventions on healthcare workers’ hand rubbing compliance and beliefs in the United Arab Emirates: a cohort study. Infect Dis Health 24: 115123.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 49.

    Muhumuza C , Gomersall JS , Fredrick ME , Atuyambe L , Okiira C , Mukose A , Ssempebwa J , 2015. Health care worker hand hygiene in the pediatric special care unit at Mulago National Referral Hospital in Uganda: a best practice implementation project. Int J Evid-Based Healthc 13: 1927.

    • PubMed
    • Search Google Scholar
    • Export Citation
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