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. 2026 Jul 27;9(7):e2625250. doi: 10.1001/jamanetworkopen.2026.25250

World Health Organization Multimodal Improvement Strategy for Hand Hygiene

A Stepped-Wedge Cluster Randomized Trial

Emma Nyawere 1, Hiroki Saito 2,3,✉, Robinah Ajok 4, Beryl Aber 1, Francis Owori 5, Didier Pittet 6
PMCID: PMC13409013  PMID: 42507443

Key Points

Question

What is the long-term impact of the World Health Organization (WHO) multimodal improvement strategy (MMIS) for hand hygiene, combined with locally manufactured alcohol-based handrub (ABHR), in resource-limited settings?

Findings

In this stepped-wedge cluster randomized trial with 27 895 hand hygiene opportunities observed across 8 health care facilities in eastern Uganda, hand hygiene adherence among health care workers increased by more than 50% during the intervention phase and remained high during the follow-up phase, compared with baseline.

Meaning

These findings support the scalability of the WHO MMIS approach for hand hygiene with locally manufactured ABHR at regional and national levels in resource-limited health care settings.

This stepped-wedge cluster randomized trial evaluates the effectiveness and sustainability of the World Health Organization multimodal improvement strategy for hand hygiene in Ugandan health care facilities.

Abstract

Importance

Evidence on hand hygiene promotion in resource-limited settings remains sparse, and its generalizability and long-term sustainability are poorly understood. Previous studies have predominantly relied on single-center, short-duration, before-and-after interventional designs.

Objective

To assess the long-term impact of the World Health Organization (WHO) multimodal improvement strategy (MMIS) supported by locally manufactured alcohol-based handrub (ABHR) on hand hygiene performance across multiple health care facilities in Uganda.

Design, Setting, and Participants

This stepped-wedge cluster randomized trial was conducted at 8 health care facilities across 4 districts in eastern Uganda from November 1, 2020, to July 31, 2024 (45 months). Participants included all health care workers at the participating sites.

Intervention

Following a baseline phase of 12 to 21 months, the WHO MMIS combined with locally manufactured ABHR was sequentially introduced in each district at 3-month intervals and implemented for 12 to 21 months (ie, the intervention phase), followed by a 12-month follow-up period without additional intervention.

Main Outcomes and Measures

The primary outcome was hand hygiene adherence among health care workers. Secondary outcomes included scores on the WHO Hand Hygiene Self-Assessment Framework (HHSAF) and the Infection Prevention and Control Assessment Framework (IPCAF).

Results

A total of 27 895 hand hygiene opportunities were observed. Hand hygiene adherence increased from 22.1% (95% CI, 11.4%-32.8%) at baseline to 79.2% (95% CI, 67.2%-91.2%; P < .001) during the intervention phase and remained high at 72.7% (95% CI, 57.8%-87.6%; P < .001) during follow-up. Median HHSAF scores improved significantly from 145.00 (IQR, 52.50-202.50) at baseline to 383.75 (IQR, 367.50-417.50 [P = .008]) during the intervention phase and 366.25 (IQR, 316.25-380.00 [P = .008]) during follow-up. Median IPCAF scores followed a similar pattern, from 335.00 (IQR, 235.00-520.25) at baseline to 657.50 (IQR, 648.75-705.00) (P = .008) during the intervention phase and 676.25 (IQR, 656.25-705.00) (P = .008) during follow-up. ABHR accounted for more than 99% of observed hand hygiene actions during the intervention and follow-up phases.

Conclusions and Relevance

In this study of hand hygiene promotion in eastern Uganda, the WHO MMIS supported by locally produced ABHR led to substantial and sustained improvements in hand hygiene adherence. This stepped-wedge cluster randomized trial provides robust evidence supporting the scalability of this approach at regional and national levels in resource-limited settings.

Trial Registration

University Hospital Medical Information Network Clinical Trials Identifier: UMIN000039483

Introduction

Infection prevention and control (IPC) is essential for patient safety and reduces health care–associated infections worldwide.1,2 Hand hygiene is central to IPC.3 However, hand hygiene adherence rates as low as 10% have been reported in Africa.4,5 Adoption of alcohol-based handrub (ABHR) as the preferred method for routine hand hygiene has substantially improved hand hygiene practices worldwide6 and led to its inclusion in the World Health Organization (WHO) Essential Medicines List.7 The WHO promotes hand hygiene through its multimodal improvement strategy (MMIS), a 5-element approach.8 System change, one of the elements, begins with ensuring access to ABHR, water, and soap. In 2021, the WHO and UNICEF reported that approximately half of health care facilities in sub-Saharan Africa lacked basic water services, highlighting persistent water, sanitation, hygiene, health care waste management, and cleaning (WASH) challenges in resource-limited settings.9,10 In Uganda, ABHR is included in the National Medical Stores essential medicines list and supplied to public health care facilities. However, facility-level access often remains limited owing to supply interruptions and logistical constraints.11 Accordingly, the WHO identified interventions to facilitate sustained system change as a priority in its 2023-2030 hand hygiene research agenda.12,13

Local ABHR production may facilitate sustained system change.14,15,16 Using locally produced ABHR, the 2014-2015 WardGel study in eastern Uganda improved hand hygiene adherence from 9.2% to 56.4% with associated reduction in health care–associated infections.5 However, findings from this short-term single-center study require confirmation in broader settings. We therefore evaluated the effectiveness and sustainability of the WHO hand hygiene MMIS in Ugandan health care facilities.

Methods

This cluster randomized trial was approved by the Research Ethics Committee of Mbale Regional Referral Hospital, which waived the need for informed consent because the WHO MMIS was implemented at the facility level and hand hygiene is considered standard of care. The study protocol is found in Supplement 1. We adhered to the Consolidated Standards of Reporting Trials (CONSORT) reporting guideline extension for stepped-wedge cluster randomized trials.

Study Design and Setting

The MIKONO study was a 45-month stepped-wedge cluster randomized trial conducted in 8 health care facilities across 4 districts of eastern Uganda between November 1, 2020, and July 30, 2024. The study districts—Mbale, Tororo, Kumi, and Busia—were selected because they form a referral network served by Mbale Regional Referral Hospital, the region’s tertiary referral facility. Two health care facilities were selected from each district. To enhance generalizability, facilities of different types were included. Characteristics of the participating sites are summarized in eTable 1 and eFigure 1 in Supplement 2.

Cluster randomization was used to minimize cross-contamination of hand hygiene behaviors among health care workers within the same facility.17 A stepped-wedge design was chosen to facilitate intervention implementation given the limited human resources of the trained research team.18 The sequence of intervention rollout was randomly assigned at the district level, with the 2 participating sites within each district receiving the interventions simultaneously. Because of the nature of the intervention, blinding of the research team, research assistants, and health care workers was not feasible. The study timeline is presented in Figure 1.

Figure 1. Chart Showing Study Schedule and Activities.

Two-panel timeline chart of study schedule and activities across four districts. Panel A labeled Study schedule. A grid-style timeline with a leftmost column labeled District and four rows labeled Mbale, Tororo, Kumi, and Busia. Across the top, years labeled 2020, 2021, 2022, 2023, and 2024, each subdivided into months labeled with numbers. Under 2020, month labels 11 and 12. Under 2021, month labels 1 through 12. Under 2022, month labels 1 through 12. Under 2023, month labels 1 through 12. Under 2024, month labels 1 through 7. Each district row contains colored blocks aligned to the month grid. A medium blue block spans the earlier months for each district, ending at different times by row. A single orange block appears at the transition point for each district, staggered by district: Mbale at 2021 month 11, Tororo at 2022 month 2, Kumi at 2022 month 5, and Busia at 2022 month 8. After the orange block, a pale yellow block continues through 2023 month 7 for all districts. A light green block begins at 2023 month 8 and continues through 2024 month 7 for all districts. Panel B labeled Study activities. Four separate labeled boxes arranged left to right. The first box titled Baseline phase contains three stacked blue rows labeled Hand hygiene adherence, H H S A F, and I P C A F. The second box titled Initiation of intervention contains three stacked orange rows labeled Installation of dispensers, A B H R supply, and Training and education. The third box titled Intervention phase contains five stacked pale yellow rows labeled A B H R supply, Evaluation and feedback, Reminder, W H O campaign promotion, and Baseline activities. The fourth box titled Follow-up phase contains three stacked green rows labeled Hand hygiene compliance, H H S A F, and I P C A F.

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ABHR indicates alcohol-based handrub; HHSAF, Hand Hygiene Self-Assessment Framework; IPCAF, Infection Prevention and Control Assessment Framework; and WHO, World Health Organization.

Interventions

The study consisted of 3 phases: baseline, intervention, and follow-up. During the baseline phase (ranging from 12 to 21 months, depending on intervention allocation), hand hygiene adherence among health care workers was observed by trained research assistants at each participating site. At study initiation, research assistants were selected from within each facility; all had prior basic IPC knowledge and served as local IPC focal points. They received standardized training to conduct direct hand hygiene observation according to the WHO My Five Moments for Hand Hygiene framework.19 Observations consisted of anonymous recording of each hand hygiene opportunity and the corresponding action (hand rubbing with ABHR and handwashing with soap and water) or no action. Observation sessions were conducted in accordance with WHO-recommended procedures. In addition, the WHO Hand Hygiene Self-Assessment Framework (HHSAF)20 and the Infection Prevention and Control Assessment Framework (IPCAF)21—validated tools for assessing facility-level hand hygiene promotion and IPC capacity—were completed at baseline by the research team in collaboration with local IPC focal points.22,23,24,25,26,27

At the start of the intervention phase, the research team delivered a 1-day training session on hand hygiene and IPC to health care workers at each facility (training and education). This was accompanied by the provision of 1-L bottles of ABHR and installation of wall-mounted dispensers (system change). The locations of the installation were determined by the research team to ensure point-of-care ABHR availability. The study ABHR (Alsoft V; Saraya East Africa Co Ltd) was locally manufactured in Uganda from sugar cane, contained 80% (volume to volume ratio) ethanol, and complied with international Good Manufacturing Practice standards. Health care workers were permitted to continue using other ABHR products supplied by government sources when available.

Throughout the intervention phase (12 to 21 months), the research team conducted site visits every 3 to 6 months to ensure continuity of ABHR supply, monitor implementation, and provide feedback to local IPC focal points and health care workers (evaluation and feedback). During these visits, hand hygiene adherence data were compiled, and HHSAF and IPCAF assessments repeated. WHO My Five Moments for Hand Hygiene posters were displayed as appropriate (reminders in the workplace). Facilities were encouraged to participate in the annual WHO World Hand Hygiene Day campaign,3,28,29,30 and facility leadership was engaged by promoting hand hygiene adherence as a quality indicator, raising patient safety awareness, and seeking support from district health authorities (institutional safety climate).

During the follow-up phase (12 months), hand hygiene observations by site-based research assistants continued, along with periodic site visits by the research team to reassess HHSAF and IPCAF scores. In December 2023, during the follow-up phase and outside the original study protocol, the research team conducted a national 3-day train-the-trainers course in hand hygiene.31,32,33 Research assistants from participating sites were invited to attend and received advanced training in hand hygiene and IPC.

Outcomes

The primary outcome was hand hygiene adherence among health care workers, calculated as the proportion of observed hand hygiene opportunities for which hand hygiene was performed (ie, hand hygiene actions of hand hygiene opportunities). Each opportunity was treated as a binary event—hand hygiene performed or not performed—defined according to the WHO My Five Moments for Hand Hygiene framework.8,34

Secondary outcomes were facility-level WHO HHSAF and IPCAF scores. The HHSAF and IPCAF consist of 27 and 81 indicators, respectively, covering the 5 elements of the WHO hand hygiene MMIS and the 8 IPC core components defined by the WHO. Maximum possible scores were 500 for the HHSAF and 800 for the IPCAF. HHSAF and IPCAF scores were categorized into 4 performance levels—inadequate, basic, intermediate, and advanced—according to WHO-defined thresholds, with higher scores indicating more advanced.

Statistical Analysis

Continuous variables were analyzed using mean (SD) when normally distributed or median (IQR) otherwise. Categorical variables were analyzed by frequencies and proportions.

For the primary outcome, we used a multilevel generalized linear mixed-effects model with nested random effects for districts and facilities. Fixed effects included study phase (baseline, intervention, and follow-up) and calendar month indicators to adjust for secular trends. Random effects consisted of district-level random intercepts, facility-level random intercepts, and random slopes for phase, allowing the intervention effect to vary across facilities.18,35,36,37,38 Site-specific estimates of hand hygiene adherence were derived using generalized linear models. In each model, mean estimated values were reported for hand hygiene adherence and its 95% CI. For the secondary outcomes, the Wilcoxon signed rank test was used to compare each phase of HHSAF and IPCAF scores. The proportions of hand rubbing with ABHR vs hand washing with soap and water were analyzed across study phases using the χ2 test.

The number of participating sites and the study duration were mainly determined by available resources and study feasibility. Therefore, a formal sample size calculation was not performed. All statistical analyses were made using Stata, version 18.0 (StataCorp LLC) with statistical significance indicated by 2-sided P < .05.

Results

Hand Hygiene Adherence Overall Model and by Facility

A total of 27 895 hand hygiene opportunities were observed across 8 health care facilities in 4 districts during the 45 months of the study. In the primary analysis using a multilevel generalized linear mixed-effects model, the baseline overall hand hygiene adherence was 22.1% (95% CI, 11.4%-32.8%). Adherence increased significantly to 79.2% (95% CI, 67.2%-91.2%) during the intervention phase; absolute increase was 57.1% (95% CI, 44.8%-69.4%) (P < .001). The increase was sustained at 72.7% (95% CI, 57.8%-87.6%) during the follow-up phase; absolute increase was 50.6% (95% CI, 36.3%-64.8%) (P < .001) (Figure 2).

Figure 2. Line Graph Showing Overall Hand Hygiene Adherence Across Study Phases.

Line graph of adherence percent by study phase with error bars and rising then slight decline. Single line graph with three teal circular markers connected by a thin black line, each marker accompanied by a vertical black error bar with horizontal caps. The horizontal axis label reads Study phase. Three category labels appear along the axis from left to right: Baseline, Intervention, and Follow-up. The vertical axis label reads Marginal estimated mean adherence, percent. The vertical scale runs from 0 at the bottom to 100 at the top, with labeled ticks at 0, 20, 40, 60, 80, and 100, and light gray horizontal gridlines aligned to these ticks. At Baseline, the marker lies slightly above the 20 percent gridline, approximately 22 percent, with an error bar extending from roughly 12 percent to roughly 33 percent. At Intervention, the marker lies near the 80 percent gridline, approximately 80 percent, with an error bar extending from roughly 68 percent to roughly 92 percent. At Follow-up, the marker lies between the 60 and 80 percent gridlines, closer to 70, approximately 73 percent, with an error bar extending from roughly 58 percent to roughly 88 percent. The connecting line rises steeply from Baseline to Intervention and then slopes slightly downward from Intervention to Follow-up. No legend is present.

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Error bars indicate 95% CIs.

Longitudinal facility-level adherence is shown in Figure 3. Mt Elgon Hospital consistently demonstrated the highest adherence across all study phases, whereas the Tororo and Atutur district hospitals showed the lowest baseline adherence (≤10.0%) (Table). Mbale Regional Referral Hospital demonstrated improvements in hand hygiene adherence from 26.9% to 76.9%. Most facilities maintained adherence levels greater than 60.0% during follow-up, although Tororo and Atutur district hospitals declined to less than 50.0%. Masafu District Hospital and Busia Health Center IV showed increasing adherence toward the end of the baseline phase (Figure 3D).

Figure 3. Line Graphs Showing Hand Hygiene Adherence of 8 Health Facilities in 4 Ugandan Districts.

Four-panel line charts of hand hygiene adherence percent over time by facility. Four time-series panels labeled A through D. All panels share a vertical axis labeled Hand hygiene adherence, percent, ranging from 0 to 100, and a horizontal axis labeled Study month and year with ticks at July 2020, July 2021, July 2022, July 2023, and July 2024. Each panel contains two facility series with circular markers connected by lines, one dark teal and one orange, plus vertical dashed reference lines. Panel A title Mbale district. Legend at lower right: dark teal Mbale Regional Hospital; orange Mt Elgon Hospital. Values in 2020 to mid 2021 fluctuate roughly from 10 to 60, including a dark teal point near 0 around mid 2021. After a dashed line near late 2021, both series rise sharply to about 90 to 100; orange remains near 95 to 100 through 2022 to 2024 with small dips, while dark teal varies about 65 to 100. A second dashed line appears near July 2023. Panel B title Tororo district. Legend at lower right: dark teal Tororo District Hospital; orange Nagongera Health Center I V. Dark teal begins around 5 to 15 in 2020 to 2021, reaches near 0 around late 2021, then climbs steeply after a dashed line near early 2022 to peaks near 90, followed by wide swings from about 35 to 95 and later values around 20 to 60 after a dashed line near July 2023. Orange starts around 30 to 55, increases after early 2022 to about 70 to 100, then fluctuates mostly 60 to 95 through 2024 with a dip near the mid 50s. Panel C title Kumi district. Legend near upper left: dark teal Atutur District hospital; orange Kumi Ongino Hospital. Early values are low, with dark teal mostly 0 to 10 and orange about 10 to 35 through 2021. After a dashed line near mid 2022, both increase to roughly 40 to 95 with frequent oscillations; dark teal includes a peak near 100 around 2023 and a late drop near 5 to 15 close to 2024, while orange ranges about 50 to 90 and ends near 60. A second dashed line appears near July 2023. Panel D title Busia district. Legend at lower right: dark teal Masafu District Hospital; orange Busia Health Center I V. Both series rise from low values in 2020 to 2021, then after a dashed line near mid 2022 increase to about 75 to 100. Dark teal varies around 60 to 98 with a late sharp dip near 35 and recovery near 70 by 2024. Orange stays mostly 80 to 100 with intermittent dips near 70. A second dashed line appears near July 2023.

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Dashed lines indicate the start of the intervention and follow-up phases.

Table. Hand Hygiene Adherence at Participating Sites.

District and hospitals Adherence by phase, mean (95% CI), %
Baseline Intervention Follow-up
Mbale
Mbale Regional Referral Hospital 26.9 (19.7-34.0) 76.9 (71.5-82.3) 85.6 (78.5-92.8)
Mt Elgon Hospital 42.1 (35.7-48.5) 91.3 (86.4-96.1) 95.7 (89.2-100)
Tororo
Tororo District Hospital 10.0 (3.4-16.5) 65.6 (59.7-71.6) 33.8 (26.5-41.1)
Nagongera Health Center IV 41.0 (35.7-46.2) 83.4 (78.5-88.3) 74.7 (70.8-82.5)
Kumi
Atutur District Hospital 9.7 (8.7-18.5) 55.0 (45.4-64.7) 43.5 (32.7-54.3)
Kumi Ongino Hospital 23.6 (17.7-29.4) 72.7 (66.5-78.9) 65.5 (58.6-72.5)
Busia
Masafu District Hospital 26.0 (16.4-35.5) 66.3 (53.5-79.1) 79.4 (67.7-91.1)
Busia Health Center IV 38.7 (29.1-48.3) 82.6 (69.7-95.6) 91.0 (78.0-100)
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Hand Hygiene Adherence According to the WHO Framework

Adherence improved significantly across all WHO My Five Moments for Hand Hygiene framework during the intervention and follow-up phases (eTable 2 in Supplement 2). Moment 3 (after body fluid exposure risk) showed the highest adherence at baseline and during intervention, whereas moment 4 (after touching a patient) exceeded 80% during the follow-up.

Hand Rubbing With ABHR vs Handwashing With Soap and Water

Of all observed hand hygiene actions (ie, performed hand hygiene), the proportion of performed hand hygiene actions using ABHR hand-rubbing increased from 1235 of 1343 observations (92.0% [95% CI, 90.4%-93.4%) at baseline to 9045 of 9076 (99.7% [95% CI, 99.5%-99.8%) during the intervention and 7360 of 7432 (99.0% [95% CI, 98.8%-99.2%]) during follow-up (P < .001 for all) (eFigure 2 in Supplement 2).

WHO HHSAF and IPCAF Scores

Results of the WHO HHSAF and IPCAF across the 3 study phases are summarized in Figure 4 and eTables 3 to 5 in Supplement 2. Median HHSAF scores increased significantly from 145.00 (IQR, 52.50-202.50) at baseline to 383.75 (IQR, 367.50-417.50) (P = .008) during the intervention and 366.25 (IQR, 316.25-380.00) (P = .008) during follow-up. Median IPCAF scores increased significantly from 335.00 (IQR, 235.00-520.25) at baseline to 657.50 (IQR, 648.75-705.00) (P = .008) during the intervention and 676.25 (IQR, 656.25-705.00) (P = .008) during follow-up (Figure 4). According to WHO-defined performance categories, all participating sites were classified as inadequate or basic at baseline and improved to intermediate or advanced levels during the intervention and follow-up phases, with the exception of HHSAF score at Busia Health Center IV, which reverted to the basic level during follow-up (eTable 3 in Supplement 2).

Figure 4. Box and Whisker Plots Showing Scores of Hand Hygiene Self-Assessment Framework (HHSAF) and Infection Prevention and Control Assessment Framework (IPCAF) Across Study Phases.

Two-panel box plots of H H S A F and I P C A F scores by study phase. Two side-by-side panels labeled A and B. Panel A title at upper left: H H S A F scores. Panel B title at upper left: I P C A F scores. Each panel contains three vertical box-and-whisker plots aligned over the same horizontal categories labeled Baseline, Intervention, and Follow-up. In both panels, the horizontal axis label reads Study phase. In panel A, the vertical axis label reads Median score, with tick marks from 0 to 500 in steps of 100. The Baseline box spans roughly 50 to 200 with a median line near 145; whiskers extend to about 30 and 230. The Intervention box spans about 365 to 410 with a median near 380; whiskers extend to about 325 and 445. The Follow-up box spans about 315 to 375 with a median near 360; whiskers extend to about 295 and 382. In panel B, the vertical axis label reads Median score, with tick marks from 0 to 800 in steps of 200. The Baseline box spans roughly 230 to 520 with a median near 330; whiskers extend to about 110 and 550. The Intervention box spans about 650 to 705 with a median near 660; whiskers extend to about 610 and 770. The Follow-up box spans about 660 to 705 with a median near 680; whiskers extend to about 650 and 750. Boxes are filled with muted blue-gray, with black median lines and black whiskers.

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Maximum possible scores were 500 for the HHSAF and 800 for the IPCAF, with higher scores indicating more advanced performance of hand hygiene. Boxes indicate IQRs; horizontal lines, medians; and error bars, furthest data points no more than 1.5 times below the 25th percentile or above the 75th percentile.

Discussion

In this stepped-wedge cluster randomized trial conducted across 8 health care facilities in eastern Uganda for nearly 4 years, implementation of the WHO MMIS was associated with increased hand hygiene adherence by more than 50 percentage points. The MIKONO study is, to our knowledge, the largest hand hygiene intervention study conducted in African health care settings.4,5,11,39,40,41,42,43,44 High adherence was sustained for at least 1 year after the intervention.

The need for cluster randomized trials, including stepped-wedge designs, to evaluate hand hygiene promotion strategies has previously been highlighted.26,45 The MIKONO study, which incorporated sustained local ABHR production, was larger in scale than previous hand hygiene studies conducted in Africa and was implemented using a stepped-wedge design, while maintaining the methodologic rigor and validity of a cluster randomized trial. Notably, the proportion of hand rubbing with ABHR exceeded 90% during the baseline phase, despite overall low hand hygiene adherence. This finding suggests that health care workers at participating sites were already familiar with ABHR use and/or that access to soap and water or basic handwashing infrastructure, such as sinks, was limited at the point of care. This interpretation is supported by low baseline scores for the HHSAF system change component (10 to 45 of 100), which were lower than those reported in the HHSAF global survey, including African facilities.24 The intervention further increased ABHR use, resulting in near-complete replacement of soap-and-water handwashing during intervention and follow-up. Preferential use of ABHR is widely recognized as a marker of successful system change and hand hygiene excellence across health care settings.46

Local production of ABHR can strengthen basic hand hygiene services by enabling system change and thereby facilitate the WHO MMIS implementation.47 In the present study, all 5 HHSAF components improved, suggesting successful development of facility-level capacity for hand hygiene promotion and broader benefits of system change enabled by locally produced ABHR. However, the HHSAF subscore for system change declined across all participating sites during follow-up, indicating that long-term self-sustainment of ABHR supply may remain challenging (eTable 4 in Supplement 2). Despite this decline, overall HHSAF scores were largely maintained, suggesting that training, evaluation and feedback, and institutional safety climate can be sustained even with limited ongoing resources. Similarly, IPCAF scores improved and remained high over time. Previous WHO global surveys have demonstrated a correlation between HHSAF and IPCAF scores,24,25 and the present findings further support this association, highlighting the close interconnection between implementation of the WHO MMIS and broader IPC activities, including monitoring systems and infrastructure.

Although the intervention achieved marked and sustained overall effects, its impact varied across sites. In particular, the Tororo and Atutur district hospitals demonstrated lower baseline hand hygiene adherence, and maintaining high adherence at these facilities remained challenging during follow-up. These facilities were part of the public sector and may have had more limited access to ABHR outside the study and/or a weaker institutional culture of hand hygiene at baseline, compared with better-resourced facilities such as Mbale Regional Referral Hospital (tertiary), Mt Elgon Hospital (private), and Kumi Ongino Hospital (private not-for-profit). Notably, Mbale Regional Referral Hospital—where the WardGel study had previously been conducted5—demonstrated comparable or greater improvements in hand hygiene adherence following the intervention than in the earlier study (from 26.9% to 76.9% in the MIKONO study, compared with 9.2% to 56.4% in the WardGel study), and achieved its highest adherence level during follow-up. The baseline adherence observed at Mbale Regional Referral Hospital in the MIKONO study suggests that gains achieved during the WardGel study were not fully sustained several years after the intervention ended. This finding suggests that repeated exposure to hand hygiene interventions may enhance facility readiness and capacity to sustain hand hygiene promotion over time.

With regard to HHSAF scores, only Busia Health Center IV reverted to the basic level during follow-up, with a marked decline in the training and education component. Busia Health Center IV was 1 of the 2 participating public sector health centers, whereas the remaining sites were hospitals, which generally benefit from greater staffing levels and institutional resources. These findings suggest that smaller health centers may require additional, targeted support to sustain hand hygiene and broader IPC activities over time.40,48

Limitations

This study has several limitations. First, outcome measures directly related to patient safety, such as the incidence of health care–associated infections, were not included. Reliable health care–associated infection surveillance remains challenging in resource-limited settings, particularly in general hospitals and health centers. Nevertheless, substantial evidence demonstrates that improvements in hand hygiene in health care settings are associated with reductions in health care–associated infections.5,6,49,50,51,52,53 Given these constraints, and to ensure study feasibility, the MIKONO study prioritized comprehensive implementation of the WHO MMIS—including sustained availability of ABHR at the point of care—and a longer study duration to assess long-term and sustained impact. Second, although the research team ensured training of research assistants at each participating site, health care workers —particularly in the public sector—were frequently reassigned during the study period. This resulted in turnover among research assistants requiring repeated training at some sites and potentially contributing to variability in observations. However, members of the research team had extensive experience in hand hygiene training across multiple countries in accordance with the WHO MMIS13,31,32,47,54 and ensured that all research assistants were trained to assess hand hygiene adherence using standardized methods across sites. Third, due to the nature of the intervention, neither research assistants nor health care workers at participating sites could be blinded. As a result, measurement bias and/or a Hawthorne effect cannot be fully excluded. Fourth, the study was conducted during the COVID-19 pandemic, which may have influenced ABHR availability and hand hygiene practices independently of the intervention. For example, the increase in hand hygiene adherence observed toward the end of the baseline phase in Busia district (Figure 3D) may reflect ongoing hand hygiene initiatives external to the MIKONO study. Similarly, the generally higher adherence with WHO moments 3 and 4 may have been reinforced by heightened IPC behaviors during the pandemic (eTable 2 in Supplement 2). Fifth, although the study used a stepped-wedge design, it was not intended to evaluate the individual contribution of each component of the WHO MMIS. The intervention was delivered as an integrated package reflecting conditions in a clinical setting. Sixth, given the stepped-wedge study design with 2 health facilities nested within each district, district-specific secular trends were not fully distinguished from intervention effects. Finally, the quality of each hand hygiene action was not systematically assessed.

Conclusions

In this stepped-wedge cluster randomized trial conducted in 8 health care facilities in eastern Uganda, the WHO MMIS for hand hygiene supported by locally manufactured ABHR was associated with a substantial increase in hand hygiene adherence that was sustained beyond the intervention period. Further research should evaluate the scalability of this approach at national and regional levels to improve patient safety in resource-limited settings.

Supplement 1.

Trial Protocol

jamanetwopen-e2625250-s001.pdf (2.1MB, pdf)
Supplement 2.

eTable 1. Characteristics of Health Care Facilities (as of 2020)

eTable 2. Hand Hygiene Adherence According to the World Health Organization My Five Moments for Hand Hygiene

eTable 3. Scores of World Health Organization Hand Hygiene Self-Assessment Framework and Infection Prevention and Control Assessment Framework of Participating Sites

eTable 4. Scores of Each Element of World Health Organization Hand Hygiene Self-Assessment Framework of Participating Sites

eTable 5. Scores of Each Core Component of World Health Organization Infection Prevention and Control Assessment Framework (IPCAF) of Participating Sites

eFigure 1. Geographical Location of Participating Sites in Uganda

eFigure 2. Proportions of Hand Rubbing With Alcohol-Based Handrub vs Hand Washing With Soap and Water

jamanetwopen-e2625250-s002.pdf (501.5KB, pdf)
Supplement 3.

Data Sharing Statement

jamanetwopen-e2625250-s003.pdf (16.5KB, pdf)

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Associated Data

This section collects any data citations, data availability statements, or supplementary materials included in this article.

Supplementary Materials

Supplement 1.

Trial Protocol

jamanetwopen-e2625250-s001.pdf (2.1MB, pdf)
Supplement 2.

eTable 1. Characteristics of Health Care Facilities (as of 2020)

eTable 2. Hand Hygiene Adherence According to the World Health Organization My Five Moments for Hand Hygiene

eTable 3. Scores of World Health Organization Hand Hygiene Self-Assessment Framework and Infection Prevention and Control Assessment Framework of Participating Sites

eTable 4. Scores of Each Element of World Health Organization Hand Hygiene Self-Assessment Framework of Participating Sites

eTable 5. Scores of Each Core Component of World Health Organization Infection Prevention and Control Assessment Framework (IPCAF) of Participating Sites

eFigure 1. Geographical Location of Participating Sites in Uganda

eFigure 2. Proportions of Hand Rubbing With Alcohol-Based Handrub vs Hand Washing With Soap and Water

jamanetwopen-e2625250-s002.pdf (501.5KB, pdf)
Supplement 3.

Data Sharing Statement

jamanetwopen-e2625250-s003.pdf (16.5KB, pdf)

Articles from JAMA Network Open are provided here courtesy of American Medical Association

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