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. 2025 Mar 2:17571774251324373. Online ahead of print. doi: 10.1177/17571774251324373

Hand hygiene compliance among hospital visitors: A systematic review and meta-analysis of observational studies

Gaviota Khalish 1, Made Satya Nugraha Gautama 2,✉
PMCID: PMC11873859  PMID: 40041664

Abstract

Background

Hand hygiene is a crucial measure for preventing the spread of healthcare-associated infections. While healthcare workers receive emphasis, hospital visitor hand hygiene compliance is limited.

Aim

To investigate hand hygiene compliance among hospital visitors.

Methods

A comprehensive search of four databases (PubMed, Embase, Scopus, ScienceDirect) and a hand search were performed from inception to October 2023. Observational studies in hospital settings were included if estimates for adult hospital visitors’ observation were reported. Joanna Briggs Institute critical appraisal checklist was used to assess the risk of bias in the included studies. Meta-analysis was conducted using STATA software version 17 to estimate a weighted pooled compliance rate with a 95% confidence interval.

Results

17 studies were included in this study. The pooled hand hygiene compliance among hospital visitors was 37% (95% CI: 25 – 49). Subgroup analysis revealed that in low-middle-income countries, covert observation, ICU and various ward studies, longer observation durations, measuring hand hygiene at entrance and exit points, and smaller sample sizes were all associated with higher visitor hand hygiene compliance rates.

Discussion

The visitor hand hygiene compliance rate was notably low, much lower than that reported for doctors and nurses. This significant difference highlights the urgent need for focused attention and interventions to improve visitor hand hygiene practices.

Keywords: visitors, hand hygiene, handwashing, compliance

Background

Healthcare-associated infections (HAIs) represent a significant global concern, contributing to prolonged hospitalizations, increasing morbidity and mortality rates, and increasing healthcare costs (Liu et al., 2022; Loftus et al., 2019). Hand hygiene is known as one of the most important and effective infection control for reducing HAIs transmission (Boora et al., 2021; Mouajou et al., 2022). Hand hygiene involves the act of cleaning hands to remove pathogens, achieved through either hand washing with water and soap or hand rubbing with alcohol-based hand rub (WHO, 2009). The fact that hand hygiene is important for reducing HAIs is well-documented among healthcare workers (Van Niekerk et al., 2021), yet the study and guideline of hand hygiene practices among visitors remains comparatively limited (Gaube et al., 2021). Visitors are equally crucial as healthcare workers in infection prevention, as they can transmit pathogens to patients or become ill due to infections transmitted from patients (Bayhan et al., 2022).

Visitors are defined as individuals entering the hospital who are not hospital employees, patients, contractors, or delivery drivers who may enter the hospital (Hobbs et al., 2016). Despite playing a vital role in the care of hospitalized patients, visitors may inadvertently expose patients to infections (Altowijri et al., 2020; Hei et al., 2018). Visitor’s hand hygiene compliance is a fundamental measure for reducing the risk of acquiring and transmitting pathogens (Wong et al., 2020). Evidences indicate that visitors who neglect hand hygiene practices can acquire pathogenic microorganisms associated with HAIs including methicillin-resistant S. aureus, Clostridium difficile, and respiratory virus infections (Altowijri et al., 2020; Birnbach et al., 2015). Visitors who fail to comply with hand hygiene appropriately (Randle et al., 2010) yet frequently come into contact with the patient’s skin and bodily fluids, posing a potential risk of infection (Cohen et al., 2012). Therefore, ensuring visitor compliance with hand hygiene is crucial to prevent the transfer of pathogenic microorganisms between healthcare institutions and the community (Kaya et al., 2023).

Previous research, as outlined by Compton and Davenport (2018) in a scoping review, has revealed significant disparities in hand hygiene compliance rates across various hospital settings. Compliance rates have ranged from as low as 0.5% to 11% at hospital main entrances, 9% to 35% in general and surgical units, 11% in isolation rooms, 39% in pediatric wards, 3.95% to 49.1% at the bedside, and 7% to 94% in the Intensive Care Unit (ICU). Despite existing research, a comprehensive understanding of visitor hand hygiene compliance remains elusive. To address this gap, rigorous review methodologies such as systematic reviews and meta-analyses are essential for synthesizing data and providing pooled estimates of compliance rates. Therefore, this study aims to review observational studies investigating hand hygiene compliance among hospital visitors.

Method

This review is reported according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines (Page et al., 2021). The review protocol was prospectively registered with the International Prospective Register of Systematic Reviews (PROSPERO) database under the following registration number: CRD42023474432

Search strategy

A comprehensive search was conducted on PubMed, Embase, Scopus, and ScienceDirect databases, and a hand search was performed on October 31, 2023. Controlled vocabulary and text terms related to visitors were combined with those for “hand hygiene” OR “handwashing” OR “hand rubbing.” No date or language restrictions were applied. Details of the search strategy are presented in Supplement 1.

Inclusion and exclusion criteria

Peer-reviewed articles that met the following criteria were included in the study: (1) included adult persons who entered the hospital either as visitors to specific patients or as general visitors within the hospital setting; (2) reported hand hygiene compliance including any form of hand hygiene performed by visitors, including both handwashing and hand rubbing; (3) written in English or Indonesian. Studies were excluded if they were not observational studies, or if the individual compliance of visitors was not specified or reported

Data extraction, analysis, and statistical methods

Two reviewers (GK and MSG) independently screened titles, abstracts, and full texts using the Rayyan web application, resolving discrepancies through discussion and consensus. The primary data extracted from the studies were author and publication year, country, setting, type of visitor, observation method, compliance measurement, duration, sample size, and compliance rates. Hand hygiene compliance was the main focus, using baseline data from reported estimates. Compliance referred to the percentage of opportunities where visitors actually performed hand hygiene actions.

A meta-analysis was conducted using STATA software version 17 to estimate a weighted pooled compliance rate with a 95% confidence interval. A p-value of ≤0.05 was considered statistically significant. The I2 statistic assessed heterogeneity among the analyzed studies. An I2> 50% or p < .1 indicated heterogeneity, for which the random-effects model was utilized. In addition, publication bias was evaluated through visual inspections of funnel plots and Egger’s test, with a value of less than 0.05 as a cut-off point to declare the presence of publication bias. Moreover, to minimize random variations between the point estimates of the primary study, subgroup analysis was performed based on World Bank countries classification, study setting, type of visitor, total samples, observational methods, compliance measurement, and duration of observation.

Study risk of bias assessment

Two reviewers (GK and MSG) independently evaluated the risk of bias and methodological quality of the included studies. Any disagreements were resolved through discussion and consensus. The JBI Critical Appraisal Checklist for Analytical Cross-Sectional Studies was used for this assessment (Moola et al., 2017). This checklist comprises several criteria designed to evaluate the methodological quality of studies, including the clarity of the research objectives, the appropriateness of the study design, the reliability and validity of the measurement tools used, and the extent to which the results and analyses address potential biases and confounding factors. By using this comprehensive tool, we ensured a rigorous evaluation of each study’s methodological quality and risk of bias.

Results

Characteristics of included studies and study quality assessment

A search identified 1332 publications. After removing duplicates, 1193 underwent screening. Following the removal of 1141 records, 52 articles remained for full-text screening. Ultimately, 17 studies that met all eligibility criteria were included for analysis. A flow diagram illustrating the study selection process is presented in Figure 1. Moreover, among the 17 included studies, 41% of the studies had a low risk of bias according to our assessment, while the remaining 59% of the included studies had a moderate risk of bias (Table 1).

Figure 1.

Figure 1.

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Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) flow diagram for selection of studies.

Table 1.

Risk of bias of included studies.

Author (years) Q1 Q2 Q3 Q4 Q5 Q6 Q7 Q8 % Yes Risk*
Nishimura et al. (1999) No Yes Yes Yes No No Yes Yes 62% Moderate
Biswal et al. (2020) No Yes Yes Yes No No Yes Yes 62% Moderate
Birnbach et al. (2015) No Yes Yes No No No Yes Yes 50% Moderate
Savage et al. (2011) No Yes Yes Yes No No Yes Yes 62% Moderate
Randle et al. (2010) No Yes Yes No Yes Yes Yes Yes 75% Low
Filion et al. (2011) Yes Yes Yes No No No No Yes 50% Moderate
Hobbs et al. (2016) No Yes Yes Yes No No Yes Yes 62% Moderate
Jung and Kang (2019) No Yes Yes Yes No No Yes Yes 62% Moderate
Birnbach et al. (2015) No Yes Yes Yes No No Yes Yes 62% Moderate
Lee et al. (2021) No Yes Yes Yes No No Yes Yes 62% Moderate
Kaya et al. (2023) Yes Yes Yes Yes No No Yes Yes 75% Low
Randle et al. (2014) No Yes Yes Yes No No Yes Yes 62% Moderate
Patarakul et al. (2005) Yes Yes Yes Yes No No Yes Yes 75% Low
Vaidotas et al. (2015) Yes Yes Yes Yes No No Yes Yes 75% Low
Altowijri et al. (2020) Yes Yes Yes Yes No No Yes Yes 75% Low
Davis (2010) Yes Yes Yes Yes No No Yes Yes 75% Low
Theresia (2018) Yes Yes Yes Yes No No Yes Yes 75% Low
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*The risk of bias was ranked as high when the study reached up to 49% of yes scores, moderate when reached 50 to 69% of yes scores, and low when the study reached more than 70% of yes.

The included studies represented 11 countries categorized by the World Bank, including 29% from High-Income Countries (HIC) and 71% from Low-Middle Income Countries (LMIC), published between 1999 and 2023. The analysis encompassed a wide array of hospital settings, with a total sample size of 104,859 visitor HH opportunities ranging from n = 26 to n = 91,724, reflecting significant diversity in participant counts. 13 studies examined patient visitors (Altowijri et al., 2020; Birnbach et al., 2015; Biswal et al., 2020; Davis, 2010; Jung and Kang, 2019; Kaya et al., 2023; Lee et al., 2021; Nishimura et al., 1999; Patarakul et al., 2005; Randle et al., 2010, 2014; Savage et al., 2011; Theresia, 2018), defined as individuals who enter hospitals to provide care for their loved ones undergoing medical treatment, while four studies focused on hospital visitors (Birnbach et al., 2020; Filion et al., 2011; Hobbs et al., 2016; Vaidotas et al., 2015), comprising individuals who enter hospitals but are not employees, patients, contractors, or delivery drivers. The majority of research studies employed observation of hand hygiene at entrances to assess compliance, with observation durations ranging from 1 day to 5 years. Table 2 delineates the key characteristics of the included studies.

Table 2.

Characteristics of included studies.

Author Country Countries Classification Setting Type of Visitor Total Samples Observational Methods Compliance Measurement Duration of observation HH compliance (%)
Nishimura et al. (1999) Japan HIC ICU Patient visitor 127 Covert Entrance 1 week 94
Biswal et al. (2020) India LMIC ICU and various ward Patient visitor 868 Covert Five moments 5 years 46
Birnbach et al. (2015) USA HIC Hospital-wide Hospital visitor 2.100 Covert Entrance 2 weeks 5
Savage et al. (2011) UK HIC Medical or surgical ward Patient visitor 121 Not describe Five moments 6 weeks 57
Randle et al. (2010) UK HIC Medical or surgical ward Patient visitor 89 Overt Five moments 1 day 4
Filion et al. (2011) USA HIC Hospital-wide Hospital visitor 963 Covert Not describe 9 days 20
Hobbs et al. (2016) USA HIC Hospital-wide Hospital visitor 6.603 Covert Entrance 3 weeks 64
Jung and Kang (2019) Korea HIC Medical or surgical ward Patient visitor 766 Covert Four moments 7 weeks 11
Birnbach et al. (2015) USA HIC ICU Patient visitor 55 Covert Entrance 4 weeks 35
Lee et al. (2021) Canada HIC Medical or surgical ward Patient visitor 196 Covert Four moments 2 months 11
Kaya et al. (2023) Turkey LMIC Medical or surgical ward Patient visitor 209 Covert Four moments 6 Months 56
Randle et al. (2014) UK HIC Medical or surgical ward Patient visitor 369 Overt Five moments 9 Months 26
Patarakul et al. (2005) Thailand LMIC ICU Patient visitor 26 Covert Before contact with patient 8 Hours 12
Vaidotas et al. (2015) Brazil LMIC Hospital-wide Hospital visitor 91.724 Covert Entrance 33 weeks 56
Altowijri et al. (2020) Saudi Arabia HIC ICU Patient visitor 356 Not describe Entrance 1 month 26
Davis (2010) UK HIC Medical or surgical ward Patient visitor 58 Covert Entrance 12 Months 34
Theresia (2018) Indonesia LMIC ICU and various ward Patient visitor 229 Not describe Entrance and exit 24 months 59
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HIC: High-Income Countries, LMIC: Low-Middle Income Countries, five moments: WHO five moments of HH, four moments: Based on WHO five moments but excluding after a procedure or exposure to body fluid.

Hand hygiene (HH) compliance among hospital visitors

The random-effects model yielded a pooled HH compliance rate of 37% (95% CI: 25 – 49) among hospital visitors. The forest plot examined in this study displayed a high level of heterogeneity (I2 = 99.88, p < .001), as illustrated in Figure 2. According to the meta-analysis, the lowest reported hand hygiene compliance was observed in a study conducted in the UK (4%), while the highest compliance rate was reported in a study conducted in Japan (94%).

Figure 2.

Figure 2.

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Forest plot of the pooled level of hand hygiene compliance among hospital visitors.

The visual examination of the funnel plot showed an asymmetric distribution of studies, indicating no publication bias (Figure 3). Furthermore, Egger’s tests for detecting publication bias found no statistically significant evidence of bias in assessing hand hygiene compliance among healthcare workers, with p-values of 0.93.

Figure 3.

Figure 3.

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Funnel plot to assess publication bias among included studies.

Subgroup analysis

Subgroup analysis showed that low-middle-income countries had the highest hand hygiene compliance compared to high-income countries (Table 3). Covert observation methods also reported higher compliance rates than overt methods. Studies in ICUs and various wards demonstrated better compliance compared to other settings. Additionally, higher HH compliance was associated with observation periods longer than 12 months, measuring HH at both entrance and exit points, and sample sizes below 500.

Table 3.

Subgroup analysis compares the pooled level of hand hygiene compliance among hospital visitors.

Variables Subgroup Number of Studies Included Level of HH compliance (95% CI) Heterogeneity across the studies
I2 (%) p-value
World Bank Ccountries classification Low-Middle Income Countries (LMIC) 5 53 (47 – 59) 97.64 <0.001
High-Income Countries (HIC) 12 32 (17 – 47) 98.82 <0.001
Study setting Hospital-wide 4 35 (8 – 62) 98.39 <0.001
ICU 4 43 (8 – 78) 97.02 <0.001
ICU and various ward 2 51 (39 – 64) 74.51 0.05
Medical/surgical ward 7 29 (12 – 46) 99.09 <0.001
Type of visitor Hospital visitor 4 35 (8 – 62) 98.39 <0.001
Patient visitor 13 37 (23 – 51) 99.34 <0.001
Observational methods Covert 12 38 (23 – 53) 99.84 <0.001
Overt 2 14 (8 – 37) 94.26 <0.001
Not reported 3 47 (25 – 69) 86.3 <0.001
Compliance measurement Entrance 7 44 (23 – 66) 98.53 <0.001
Five moments 4 32 (9 – 55) 99.24 <0.001
Four moments 3 28 (3 – 60) 97.75 <0.001
Before contact with the patient 1 12 (27 – 50) - -
Entrance and exit 1 59 (46 – 72) - -
Not reported 1 20 (14 – 26) - -
Duration of observation <1 month 7 32 (6 – 57) 98.21 <0.001
1 – 12 months 7 38 (23 – 53) 99.82 <0.001
>12 months 3 49 (38 – 59) 57.86 0.09
Total samples <500 10 40 (22 – 58) 91.19 <0.001
>500 7 33 (17 – 49) 99.89 <0.001
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Discussion

To our knowledge, this is the first systematic review and meta-analysis that examined hand hygiene compliance in hospital visitors. Results showed wide variation in compliance, with the highest rates in low-middle-income countries and lower rates in high-income countries. Covert observation methods and studies in ICUs or various wards reported better compliance. Higher compliance rates were also associated with longer observation periods, monitoring at both entrance and exit points, and smaller sample sizes. These findings emphasize the need for targeted strategies to improve hand hygiene compliance among hospital visitors.

The estimated hand hygiene compliance across the 17 studies revealed a concerningly low rate among hospital visitors at just 37%. This figure is markedly lower than the compliance rates reported for healthcare professionals, with doctors ranging from 43.7% to 45% and nurses from 52% to 54.9% (Allegranzi et al., 2013; Bredin et al., 2022). This stark disparity underscores a critical gap in infection control strategies within healthcare settings. While healthcare workers have been the primary focus of hand hygiene initiatives, the significantly lower compliance among visitors represents a potential weak link in the chain of infection prevention.

The World Health Organization (WHO) has rightfully prioritized the evaluation of various hand hygiene training and educational strategies for healthcare workers in its research agenda for 2023-2030 (WHO, 2023). However, our findings suggest that this focus may need to be broadened to include hospital visitors and caregivers. The role of visitors in the transmission of HAIs has been historically underappreciated, yet they represent a significant population moving between healthcare institutions and the community. This bidirectional movement of visitors creates a potential conduit for the transfer of pathogenic microorganisms, potentially exacerbating the already significant burden of HAIs (Kaya et al., 2023). Moreover, the low compliance rate among visitors may indicate a lack of awareness, inadequate education, or insufficient emphasis on the importance of hand hygiene for non-healthcare workers within hospital settings (El et al., 2020). This gap not only poses a risk to patient safety but also to the broader community, as visitors can inadvertently become vectors for the spread of infections beyond hospital walls.

The low hand hygiene compliance among visitors can be attributed to insufficient knowledge (Bayhan et al., 2022; Bellissimo-Rodrigues et al., 2016), This inadequacy is often compounded by a lack of education on hand hygiene practices (Kaya et al., 2023; Lee et al., 2021). Providing education alone may not be enough; it is crucial to also enhance visitor motivation for consistent hand hygiene practice (Khalish et al., 2021; Lee et al., 2021). This can be achieved through repetitive education and reminders (Khalish et al., 2021; Lee et al., 2021), providing engaging media content related to hand hygiene, and ensuring visible placement of hand hygiene stations (Hansen et al., 2021).

The subgroup analysis of the study reveals low hand hygiene compliance among both patient visitors and hospital visitors, emphasizing the necessity for comprehensive attention and intervention regardless of visitor type. The results highlight better compliance scores in the ICU setting, consistent with Compton and Davenport’s findings (2018), suggesting that stricter regulations in ICU rooms contribute to enhanced compliance. Additionally, covert observation methods yielded higher hand hygiene compliance rates compared to overt methods, recommending their use for providing a more accurate estimate of hand hygiene compliance (Purssell et al., 2020).

In this study, it was found that Low-Middle-Income Countries demonstrated the highest hand hygiene compliance compared to High-Income Countries. This finding contrasts with the disparities observed in healthcare worker hand hygiene compliance between high-income and low-income countries, which were reported to be 64% and 9%, respectively (WHO, 2023). The differences in compliance were attributed to the various settings and measurement methods used across the studies included in the analysis (Valim et al., 2019). Notably, five different measures of hand hygiene compliance were identified, although one study did not report its results. This variability may arise from a lack of standardized recommendations on the frequency and specific situations requiring hand hygiene (Bayhan et al., 2022). The differences in visitor hand hygiene compliance may be also influenced by a low perceived risk of infection and lack of public health campaigns in Low-Middle-Income Countries (Loftus et al., 2019), which emphasize and promote proper hand hygiene practices. These campaigns play a crucial role in raising awareness and educating the public on the significance of maintaining good hand hygiene as a preventive measure (Seimetz et al., 2016). Public health campaigns help bridge this gap by providing guidance and reinforcing the necessity of hand hygiene in reducing infection risks (Aboul-Enein et al., 2024).

The WHO introduced guidelines on hand hygiene in healthcare in 2009 (WHO, 2009), which have since supported a notable increase in promotional campaigns aimed at promoting hand hygiene to reduce HAIs (Compton and Davenport, 2018). However, it is regrettable that these guidelines do not include specific recommendations for hospital visitors or individuals entering healthcare environments. As a result, research and efforts to improve hand hygiene compliance among hospital visitors are often limited and less focused compared to those aimed at healthcare workers. This highlights the need for further research and the development of specific guidelines to enhance hand hygiene compliance among hospital visitors, thereby strengthening infection prevention efforts in healthcare settings.

There are several limitations in this study. Firstly, the heterogeneity was high (I2 = 99.76%), and the subsequent Q-test was significant (p < .001), suggesting that the variation in the results was primarily due to study heterogeneity rather than sample variance. Secondly, as in observational studies, confounding factors were not accounted for, and the use of varying measurements, sampling methods, and settings further contributed to the heterogeneity of results.

In conclusion, this systematic review underscores the low compliance of visitor hand hygiene, posing a risk for increased HAIs. However, attention and research on this population remain limited. Potential areas of interest include developing guidelines for the moments visitors have to hand hygiene, identifying effective intervention strategies to enhance hand hygiene compliance, and assessing the impact of hand hygiene compliance on the incidence of HAIs. Future research addressing these questions and fostering stakeholder involvement among hospital visitors in controlling infectious diseases could lead to improved health outcomes for patients.

Supplemental Material

Supplemental Material - Hand hygiene compliance among hospital visitors: A systematic review and meta-analysis of observational studies
sj-pdf-1-bji-10.1177_17571774251324373.pdf (624.8KB, pdf)

Supplemental Material for Hand hygiene compliance among hospital visitors: A systematic review and meta-analysis of observational studies by Gaviota Khalish and Made Satya Nugraha Gautama in Journal of Infection Prevention.

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding: The author(s) received no financial support for the research, authorship, and/or publication of this article.

Supplemental Material: Supplemental material for this article is available online.

Ethical statement

Ethical approval

All included studies adhered to ethical standards set by their respective institutions. The review protocol was prospectively registered with the International Prospective Register of Systematic Reviews (PROSPERO) under registration number: CRD42023474432.

ORCID iDs

Gaviota Khalish https://orcid.org/0000-0002-4000-6736

Made Satya Nugraha Gautama https://orcid.org/0000-0001-8194-9784

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Supplemental Material - Hand hygiene compliance among hospital visitors: A systematic review and meta-analysis of observational studies
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Supplemental Material for Hand hygiene compliance among hospital visitors: A systematic review and meta-analysis of observational studies by Gaviota Khalish and Made Satya Nugraha Gautama in Journal of Infection Prevention.

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