Good hand hygiene is an important measure to stop the spread of germs which may cause people to get sick. The Global Handwashing Partnership estimates that inadequate hand hygiene results in nearly 300,000 deaths each year, with most deaths being among children younger than five years old (Tharaldson and Moore, 2017). It is important first aid providers practise good hand hygiene to avoid spreading germs and to reduce the likelihood of themselves or others getting an infection. During a Pandemic, more frequent hand washing is recommended.
Guidelines
- Handwashing should be done with soap and water. **
- Hand hygiene can be achieved using an alcohol-based hand gel with at least 70% volume of ethanol or 60% of other alcohol for maximum efficacy. *
- Hand hygiene education and access to soap and water may improve hand hygiene compliance in healthcare workers and within the community, including schools. *
Good practice points
- First aid providers should wash their hands before and after providing first aid care to an ill or injured person.
- Hands should also be washed at the critical times listed below at minimum:
> after using the toilet or changing a nappy
> before, during and after food preparation
> before eating
> after blowing your nose, coughing or sneezing, or wiping a nose
> after touching an animal, animal food or animal waste
> when hands are visibly soiled. - Access to clean running water and soap is necessary. Any kind of soap should suffice.
- Handwashing should be continuous for at least 20 seconds, with the user covering all parts of hands, fingers, nails initially with water, then the introduction of soap, rubbing the lather repeatedly across all areas of the hand.
- After handwashing, hands should be rinsed and dried with a clean towel.
- If a non-alcohol-based gel is used for hand hygiene, it should contain polymeric biocide and virucides.
- If any type of gel is used (alcohol, ethanol or non-alcohol), the amount used should cover the hands and fingers entirely and be rubbed in until dry, usually a minimum of 30 seconds.
- If gloves are being used after handwashing, hand lotion that does not compromise the integrity of the gloves can be used twice daily to minimise skin irritation.
- Fingernails should be kept short and trimmed.
- Hands should be washed more frequently during an epidemic or pandemic to help prevent transmission.
- Dispose of dressings, bandages, sharps, gloves and soiled clothing safely and correctly, while continuing to cover your hands (e.g. use gloves or banana leaves). Wash your hands immediately afterwards.
- When soap and water are not available to wash hands, ash might be used to clean hands.
Education considerations
Context considerations
- There are large parts of the world where soap, clean water, hand sanitiser or other hand hygiene options may be unavailable (Tharaldson and Moore, 2017). Discuss considering the use of ash or other rinse-free methods to clean one’s hands (Paludan-Müller 2020; Munn, 2020).
- Community-based learning, hand hygiene strategies may be effective, particularly when combined with sanitation programmes (De Buck, 2017).
- During an epidemic or Pandemic, frequent hand washing is essential to curb the transmission of the virus. Discuss with learners how this can best be communicated and implemented in their context and what barriers and challenges need to be considered.
Learner considerations
- Parents, caregivers and community health workers are important learner audiences for this topic due to their contact and influence in the home and amongst family members.
To promote handwashing as a good health behaviour beyond first aid education:
- Consider developing motivational handwashing messages and activities to make handwashing appealing to young children (Watsonl, 2019). Test the messages with the target group for more likely behaviour change. Posters and stickers with messages can also be effective (Appiah-Brempong, 2018).
- Handwashing campaigns and promotions in schools can be effective. Consider using Peer learning to develop sustainability and culture change, and to promote self-efficacy amongst children (Appiah-Brempong, 2018).
- Children are the best behaviour change agents in every community. Develop school programming that teaches the children and allows them to bring messages and content to share at home.
Facilitation tips
- Encourage learners to wash their hands and use hand sanitiser at the beginning of a first aid course. This reflects good practice and can be a good way to start a discussion on the topic.
- If appropriate, encourage learners to wash hands every time there is a practical session – do it rather than just talk about it.
- Highlight the importance of hand hygiene as an effective way to prevent the spread of infection.
- Discuss what to include in a first aid kit with regards to hand hygiene. Kits should have an ethanol-based product of 70% ethanol, or an alcohol-based product of 60% (e.g., N-propanol, isopropanol), or more. If non-alcohol-based sanitisers are used because of the context, they must contain polymeric biocide and virucides.
Facilitation tools
- Get learners to develop visual cues such as posters to support good hygiene practices.
- Use songs or rhymes to help people experience how long 20 seconds is.
- Identify appropriate locations for posters and other media which promote hand hygiene, such as washrooms (Hamilton, 2019).
- WHO provide a range of information on their Save Lives: Wash your hands campaign page. They also have a range of promotion materials including: WHO hand hygiene brochure, WHO How to handwash poster, and WHO how to handrub poster.
- Use videos to show how appropriate handwashing ensures that viruses can be washed away and keep us safe. Videos can be found online or made in the local language using smartphones.
Scientific foundation
Systematic reviews
We used five systematic reviews as the scientific foundation for this topic.
Hand hygiene interventions
Jefferson et al. (2020) completed a Cochrane systematic review showing moderate-certainty evidence from seven studies involving 44,129 participants for the probable benefit of hand hygiene to decrease the number of people catching acute respiratory infection. Low-certainty evidence was found for the more strictly defined outcomes of influenza-like illness (ten studies) and lab-confirmed influenza (eight studies), suggesting that hand hygiene makes little or no difference. When pooling all the 16 studies for the composite outcome of acute respiratory infection or influenza-like illness or lab-confirmed influenza, low-certainty evidence showed that hand hygiene may offer a benefit with an 11% relative reduction of respiratory illness. Few studies measured and reported harms; skin irritation in people using hand sanitiser was mentioned.
Alcohol-based solutions
A systematic review about the use of alcohol-based solutions in hospitals as an option for hand hygiene (Picheansathian, 2004) included 26 studies that looked at effectiveness in reducing microorganisms and 14 that looked at adverse events (skin problems). In summary, it was demonstrated that alcohol-based hand rubs remove bacteria, viruses, fungi and multiple drug resistance microorganisms more effectively than non-medicated soap or other antiseptic agents and water, from the hands of health care workers. At equal concentrations, N-propanol was shown to be the most effective alcohol (of those commonly used) and ethanol the least effective. Six of the 26 studies looked at various concentrations of alcohol-based solutions and isopropanol 90% was shown to be as effective in antimicrobial activity as N-propanol 60%, and ethanol-based solutions were most effective if they contained at least 70% ethanol. When it concerns skin irritation it was shown that alcohol-based solutions are less irritating on skin than soap and water or other antiseptic detergents, however frequent use of alcohol can dry the skin.
Hand cleaning with ash
The Cochrane systematic review by Paludan-Müller et al. (2020) addressed using ash for cleaning one’s hands. The review was uncertain whether cleaning the hands with ash effectively reduces the spread of viral or bacterial infections or causes harm compared to using soap or other well-known materials. Studies show that using ash when soap and water are not available to wash hands has been effective in removing some types of bacteria.
Education interventions
The Cochrane systematic review of Gould et al. (2017) concluded there was limited evidence in favour of hand hygiene education to healthcare workers to produce a statistically significant decrease in respiratory outbreaks, MRSA infections requiring hospitalisation, MRSA acquisitions, primary bloodstream infections and MRSA colonisations. Additionally, a statistically significant decrease in the presence of MRSA, the number of MRSA infections, the period of healthcare-associated infections and MRSA colonisations could not be demonstrated.
Promotional approaches
The Campbell systematic review of De Buck et al. (2017) explored promotional approaches and their effectiveness in changing handwashing and sanitation behaviour (see Education reviews).
Non-systematic reviews
A cohort study showed that, for those who handle food, the best practices for fingernail sanitation include maintaining short fingernails and scrubbing them with soap and a nail brush when washing one’s hands (Lin et al., 2003).
White et al. (2003) completed a non-randomised study in university dormitories. The study demonstrated that an increase in awareness of the importance of hand hygiene caused an increase in the frequency of handwashing and the use of alcohol gel hand sanitizer. This led to improved hand-hygiene practices overall.
Using literature data, Montiville et al. (2002) completed a risk assessment and observed that soap with an antimicrobial agent (specifically CHG) was more effective than regular soap. Hot air drying could increase the amount of bacterial contamination on hands, while paper towel drying caused a slight decrease in contamination. There was little difference in the efficacy of alcohol and alcohol-free sanitisers. Wearing a ring caused a slight decrease in the efficacy of handwashing.
Research at the University of Birmingham showed a correlation between the countries with high adherence to frequent and appropriate handwashing at critical times to a lower COVID-19 exposure (Pogrebna, 2020).
Education review
Insight for this review was drawn from The State of Handwashing in 2017 report by the Global Handwashing Partnership. This review highlights disparities in access to water and soap for handwashing in households in low and middle-income countries as a key vector for disease transmission. An analysis from 51 low and middle-income countries showed large variations in the proportion of households with soap available at the handwashing place (i.e., from <0.1% in Ethiopia to 91.5% in Iraq). Within almost every country, households with higher wealth were more likely to have soap available than households with lower wealth. Rural healthcare facilities are also reported to have low availability of water, soap, and hand-drying materials. People in urban areas had greater access to handwashing facilities than rural areas, where access was close to zero in many countries.
The report also draws heavily on an extensive Campbell Systematic Review (De Buck et al., 2017) which explores promotional approaches and their effectiveness in changing handwashing and sanitation behaviour. This review finds that community-based approaches to promote handwashing and sanitation efforts appeared to work better than social marketing approaches, sanitation & hygiene messaging, and elements of a psychosocial theory. Programmes that combine hygiene and sanitation measures tend to show a greater impact than either one alone. Studies using a community-based approach which include sanitation were shown to increase handwashing at key times, as well as the use of latrines and safe disposal of faeces, and reduction of open defecation.
Studies cited in the State of Handwashing 2017 review include a study by Appiah-Brempong et al. (2017) to design a hand hygiene intervention framework for schools. It considers that self-efficacy and enhancement of behavioural cues could bridge the intention-behaviour gap for handwashing in schools. They conclude that peer-led educational campaigns are a promising strategy for improving self-efficacy, while cues to action, including posters and stickers, can trigger proper hand hygiene practices.
Studies in the State of Handwashing review which identify barriers faced in some contexts include one by Odu et al. (2019) which reveals that among mothers, caregivers and school children in Nigeria, the availability of handwashing facilities with a reliable water source and soap influences handwashing practice. Even when caregivers have sufficient knowledge and positive attitudes regarding handwashing, these structural inadequacies can be barriers to proper hand hygiene.
Watson et al. (2019) considered children in an internally displaced person’s camp in Iraqi Kurdistan concerning hand hygiene. Children in intervention households received transparent soaps with embedded toys, delivered within a short, fun, and interactive household session with minimal, non-health-based, messaging. The control group received plain soap delivered in a short standard, health-based, hygiene promotion session. After four weeks, children in the intervention group were more likely to wash their hands with soap after key handwashing occasions than expected in the counterfactual (if there had been no intervention) based on the comparison to children in the control group.
A Cochrane systematic review (Munn et al., 2020) was conducted to assess the effectiveness of rinse‐free hand washing for reducing absenteeism due to illness in preschool and school children compared to no handwashing, conventional handwashing with soap and water or other hand hygiene strategies. This review identified a small yet potentially beneficial effect of rinse‐free hand washing regimes on illness‐related absenteeism. However, the certainty of the evidence that contributed to this conclusion was low or very low.
References
Systematic reviews
De Buck, E., Van Remoortel, H., Hannes, K., Govender, T., Naidoo, S., Avau, B., … & Mosler, H. J. (2017). Approaches to promote handwashing and sanitation behaviour change in low‐and middle‐income countries: a mixed-method systematic review. Campbell Systematic Reviews, 13(1), 1-447.
Gould D. J., Moralejo D., Drey N., Chudleigh J. H., & Taljarrd, M. (2017). Interventions to improve hand hygiene compliance in patient care. Cochrane Database Syst Rev. 1(9), CD005186.
Jefferson T., Del Mar C. B., Dooley L., Ferroni E., Al-Ansary L. A., Bawazeer G. A., van Driel M. L., Jones M. A., Thorning S., Beller, E.M., Clark, J., Hoffmann, T. C., Glasziou, P. P., & Conly J. M. (2020). Physical interventions to interrupt or reduce the spread of respiratory virus. Cochrane Database of Systematic Reviews, Issue 11. Art.No.:CD006207.
Paludan-Müller, A.S., Boesen, K, Klerings, I., Jørgensen, K.J., & Munkholm, K. (2020). Hand cleaning with ash for reducing the spread of viral and bacterial infections: a rapid review. Cochrane Database of Systematic Reviews 2020, Issue 4. Art. No.: CD013597. DOI 10.1002/14651858.CD013597
Full text article
Picheansathian W., (2004). A systematic review on the effectiveness of alcohol-based solutions for hand hygiene. Int J Nurs Pract, 10(1), 3-9.
Non-systematic reviews
Lin C. M., Wu F. M,. Kim H. K., Doyle M. P., Michael B. S., Williams L.K, (2003). A comparison of hand washing techniques to remove Escherichia coli and caliciviruses under natural or artificial fingernails. Journal of Food Protection. 66(12): 2296-2301.
Montiville R, Chen Y, Schaffner DW., (2002). Risk assessment of hand washing efficacy using literature and experimental data. International Journal of Food Microbiology.72(2-3): 305-313.
Pogrebna, Ganna & Kharlamov, Alexander., (2020). The Impact of Cross-Cultural Differences in Handwashing Patterns on the COVID-19 Outbreak Magnitude. 10.13140/RG.2.2.23764.96649.
White C, Kolble R, Carlson R, et al., (2003). The effect of hand hygiene on illness rate among students in university residence halls. American Journal of Infection Control, 31(6): 364-370.
World Health Organisation, (2020). WHO Saves lives: Clean your hands in the context of COVID-19. Retrieved from https://www.who.int/infection-prevention/campaigns/clean-hands/WHO_HH-Community-Campaign_finalv3.pdf
Education references
Appiah-Brempong, E., Harris, M. J., Newton, S., & Gulis, G. (2018). A framework for designing hand hygiene educational interventions in schools. International Journal of Public Health, 63(2), 251-259.
Centers for Disease Control and Prevention (2020). Show me the Science – Why Wash Your Hands? Handwashing: Clean hands save lives. September 2020.
Full text article
Hamilton, S. N. (2019). Envisioning a Habitus of Hygiene: Hands as Disease Media in Public Health Handwashing Campaigns. Canadian Journal of Communication, 44(2). Retrieved from https://cjc-online.ca/index.php/journal/article/download/3402/3709
Munn, Z., Tufanaru, C., Lockwood, C., Stern, C., McAneney, H., & Barker, T. H. (2020). Rinse-free hand wash for reducing absenteeism among preschool and school children. Cochrane Database of Systematic Reviews, (4). Retrieved from https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD012566.pub2/full
Odu, O. O., Emmanuel, E. E., Amu, E. O., Deji, S., Dada, S. A., & Marcus, O. (2017). Practice of effective hand washing and associated factors among caregivers of infants attending infant welfare clinics in Ado-Ekiti, Ekiti State, Nigeria. Journal of Advances in Medicine and Medical Research, 1-8. Retrieved from http://www.journaljammr.com/index.php/JAMMR/article/download/11323/20519
Tharaldson J. and Moore C. (2018). The Global State of Handwashing in 2017: an Annual Research Summary; The Global Handwashing Partnership. Retrieved from https://globalhandwashing.org/wp-content/uploads/2018/05/The-State-of-Handwashing-in-2017_Final_tc.pdf
Watson, J., Dreibelbis, R., Aunger, R., Deola, C., King, K., Long, S., Chase, R., Cumming, O. (2019) Child’s play: Harnessing play and curiosity motives to improve child handwashing in a humanitarian setting, International Journal of Hygiene and Environmental Health, 222(2), 177-182, DOI https://doi.org/10.1016/j.ijheh.2018.09.002
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