ECJ EUROPEAN Cleaning Journal

Study after study reveals that too few people are washing their hands when they need to – even in hygiene-critical environments such as healthcare. So, what are the barriers to optimum hand hygiene, asks Ann Laffeaty? 

The World Health Organization and UNICEF have launched what they describe as being the first global guidelines for hand hygiene in community settings. Issued on Global Handwashing Day, the guidelines call for governments to promote good hand hygiene practices by ensuring that everyone has access to soap and water or an alcohol-based hand rub.

Authorities should also provide clear information on when and how to wash their hands, according to WHO. The five key moments for handwashing are: before preparing food, before eating, after using the toilet, after coughing, sneezing, or nose-blowing and when the hands are visibly dirty.

The US-based National Foundation for Infectious Diseases claims that handwashing can help to prevent around 80 per cent of infectious diseases, which means it plays a critical role in 
public health.

Healthcare workers are at the front line of infection control which means hand washing is particularly crucial in hospitals. However according to various studies, hand hygiene compliance rates among healthcare workers vary significantly from country to country but average out at between around 40 and 70 per cent.

Hospital visitors are even less likely to wash their hands than staff members. An observational study published in the Journal of Infection Prevention in March this year revealed that healthcare visitors have an average hand washing compliance rate of 37 per cent worldwide, with significant variations from country to country.

Meta-analysis of the study, which pooled the results from 17 surveys, revealed that hospital visitors in Japan had the highest compliance rate at 94 per cent whereas the lowest rate – a mere four per cent – was recorded in the UK.

This is despite the fact that hospital visitors will potentially be spending long periods at the bedside of their vulnerable loved ones. The act of washing the hands is key for infection control because it physically removes any harmful viruses or bacteria from the skin, effectively breaking the chain of infection. It also prevents germs from being transferred to the eyes, nose, mouth or on to food where they could lead to illnesses such as food poisoning, flu and healthcare-associated infections.

Poor comprehension

Why, then, are so few people washing their hands – particularly in hygiene-critical environments such as healthcare?

A systematic review published in April this year, which pooled the results of 28 studies worldwide, identified four main barriers to good hand hygiene. These were: behavioural, societal, physical and organisational barriers.

Behavioural barriers stem from a poor comprehension of the importance and techniques of hand hygiene alongside a lack of understanding as to how infections are transmitted. Societal barriers are more complex, sometimes stemming from poor hand washing habits developed in childhood. Some healthcare workers may feel that washing their hands before or after an examination might offend the patient, giving the impression that the patient is a source of contamination. Others claim to have been deterred from washing their hands by senior colleagues who may have had been dismissive about the need for hand hygiene.

Physical barriers to hand washing occur when soap and hand-drying products are unavailable or are inconveniently placed. And organisational barriers refer to outside factors such as a high workload where overburdened staff – who might have been given no hand hygiene training – are working in a fast-paced environment.

Kimberly-Clark’s category and product manager of skincare and dispensers Hannah Lloyd agrees that a range of behavioural, environmental and organisational factors make hand hygiene compliance a challenge in hygiene-critical environments.

“Time constraints, skin irritation and poor accessibility to hygiene stations often lead to missed opportunities, even among trained professionals,” she said. “Studies have shown that forgetfulness, a lack of perceived risk and inconsistent reinforcement all contribute to low adherence rates. However, these barriers can be addressed through thoughtful design and a supportive infrastructure.”

Compliance can be significantly impacted in cases where hand hygiene products are lacking or are not placed where they are most needed, she said. “Research shows that when dispensers are missing, empty or inconveniently located, even well-trained individuals may skip handwashing opportunities,” said Lloyd. “Accessibility is critical - products should be positioned at key hygiene moments such as near patient bedsides, in food preparation areas and in high-traffic zones to make hand hygiene effortless and intuitive.”

Multifaceted approach

Educational programmes and visual reminders can help to encourage hand hygiene, she said. However, improving compliance requires a multifaceted approach. “Research highlights the importance of ergonomic dispenser design, strategic placement and skin-friendly formulations to reduce irritation and encourage frequent use,” said Lloyd. “Visual cues such as posters can increase compliance by more than 16 per cent.”

Kimberly-Clark offers Icon touchless dispensers, gentle soaps, soft paper towels and moisturisers to help repair the skin’s barrier when washing the hands frequently. Icon dispensers also incorporate customisable faceplates which may be used for displaying hand hygiene reminders to improve compliance.

Time pressures on staff and the adverse effects of disinfectants on the skin are among the main barriers to hand hygiene in healthcare, says Hagleitner’s senior product manager for disinfection Kerstin Heine. “Hand hygiene needs to be quick and easy which means the soap, paper towel dispensers and warm water all need to be available where the hands are going to be washed,” she said. “People will also be keener to use mild soaps than more aggressive products.”

Clearly visible

Poorly-positioned dispensers can also have an impact on hand hygiene compliance, she says. “People are more likely to practise hand hygiene if they feel as though they’re being watched,” she said. “So dispensers should be situated in clearly visible locations rather than hiding them behind closed doors. Where hand hygiene is both accessible and observable, it is more likely to be performed.”

She added that dispensers should also be easy to spot. “For example, brightly coloured dispensers are often used in healthcare,” said Heine. New from Hagleitner is septDES MED 365, a virucidal hand disinfectant designed for use in the healthcare sector. It is designed to be kind to the skin and will disinfect the hands in 90 seconds, which the company claims is 25 per cent faster than most alternative products.

People who have never directly experienced the consequences of poor hand hygiene may underestimate the importance of thorough hand washing, according to Principle Cleaning Services’ head of safety and compliance Ian Sinclair. “Complacency or a lack of reminders can lead to lapses in habits,” he said.

He believes some people may feel that being “too clean” can prevent the immune system from developing properly. “This makes them avoid frequent handwashing or exposure to cleaning products in order to build immunity,” he said.

According to Sinclair, this mindset stems from the “hygiene hypothesis” which suggests that people might become more susceptible to allergies and autoimmune conditions if they have had limited exposure to microbes during childhood.

“However, experts agree that avoiding basic hygiene practices such as handwashing doesn’t actually build immunity,” he said. “Handwashing, particularly after using the washroom or before eating, is crucial for preventing the spread of infectious diseases."

He adds that a misunderstanding about the effectiveness of hand sanitisers is another barrier to handwashing for some. “Many people believe hand sanitisers are a suitable alternative to hand washing, but they are not as thorough a method of cleansing as soap and water and washing for at least 40 seconds,” he said.

Essity’s communications director Jenny Turner agrees that time pressures are a major factor in suboptimal hand hygiene compliance among healthcare staff. “In high-pressure environments such as healthcare and hospitality, professionals may feel too busy to wash their hands as frequently as required or for as long as it is recommended,” she said. “A lack of awareness is another issue. Some people outside of specialist settings may not fully understand the importance of hand hygiene or the correct techniques.”

Poor placement of dispensers or a lack of access to hygiene products can also hinder compliance, she says.  “For example, if dispensers are not within easy reach or are placed in inconvenient locations, people are less likely to use them,” said Turner.

Skin conditions and other physical issues such as arthritis could lead to poor hand hygiene compliance if the wrong products are supplied, she said. “Harsh, fragranced soaps can aggravate skin sensitivities or chronic conditions such as eczema, particularly when hand washing is carried out frequently,” said Turner. “And people with arthritis or limited mobility may find it difficult to use dispensers that require strength or fine motor control.”

Tork offers a range of ECARF-certified, fragrance-free sensitive soaps while its dispensers are said to be the first in the world to be certified according to the Design for All standard (EN 17161).

Reinforce behaviour

Education, training and behavioural prompts are all key to ensuring better practices, says Turner. “Posters and digital reminders will help to reinforce good behaviour,” she said. Tork provides training materials, poster and digital tools through its Clean Care programme to reinforce the importance of hand hygiene. The company also offers Tork VR hand hygiene training for healthcare workers where trainees follow the WHO moments of hand hygiene in an interactive world.

Hand hygiene practices will inevitably be improved where people are given the right products in dispensers that are easy to use and conveniently placed, she adds.

“Soaps with gentle formulations and soft towels will be less of an aggravant to the skin, and all dispensers should be intuitive and require minimal effort to use,” she said. “These should be strategically placed, visible and accessible - particularly in healthcare and hospitality settings. And dispensers should also have an inclusive design, one that considers the needs of a full spectrum of people including those with physical, sensory or cognitive conditions.”