Table 1.

Characteristics of included studies (n = 17).

Author, Country, (Year)	Design	Interventions	Sample	Hand Hygiene Compliance	Main Results	LE/GR
		Educational strategies
Fisher et al., Singapore, (2013) [12]	Randomized controlled trial	HH compliance using ultrasound + audio reminders	n = 72 ICU nurses	-	Higher HH compliance after intervention of 6.8% (95% CI, 2.5–9.5)	1a/A
Ho et al., China, (2012) [13]	Randomized controlled trial by groups	CG: reception of intervention package (posters, talks, hydroalcoholic solution)IG 1: same + glove pack slightlypowderedIG 2: same + powderless gloves	n = 612 geriatric nurses CG n = 189 IG1 n = 180 IG2 n = 243	CG = 19.5% IG1 = 27% IG2 = 22%	Increase in HH compliance 1 month/4 months after interventionCG = 19.8%/21.6% IG1 = 59.2%/60.6% IG2 = 59.9%/48.6%	1a/A
Huis et al., Netherlands, (2013a) [14]	Randomized controlled trial	Adherence to two improvement strategies of HH Group led by leaders (GLD) (classic education) State-of-the-art strategy group (SASG): education, reminders, feedback, facilities and products, establishment of norms and objectives, social influence, and leadership	n = 67 nurses GLD: n = 20 SASG: n = 47	GLD: 19.1% SASG: 21.8%	Increase of HH adherence through social influence and enhanced leadership in HH improvement strategies Postintervention/follow-up (at 6 months): GLD: 34%/33% SASG: 18.6%/24.1%	1a/A
Huis et al., Netherlands, (2013b) [15]	Randomized controlled trial by groups	Strategy of HH compliance that was leader-directed CG: education, reminders, feedback, and orientation (led by leaders) IG: same as the last group + social influence and leadership (state-of-the-art wards)	n = 914 nurses, 67 wards CG: n = 402 IG: n = 512	CG: 20% IG: 22%	HH compliance rates improved from 22% (just before implementing strategies) to 47% (after the intervention) and to 48% (six months after). The vanguard group improved from 23% to 42% in the short term and 46% in the long term. Compliance in CG increased from 20% to 53% (short term) and remained at 53% in the long term	1a/A
Kukanich et al., United States, (2013) [16]	Randomized controlled trial	Improved HH in two outpatient healthcare clinics Outpatient clinic oncology (G1) Gastrointestinal specialist outpatient clinic (G2)Disinfectant gel and informational signs were introduced together as an intervention	n = 56 nurses G1: n = 41 G2: n = 15	G1: 11% G2: 21%	The frequency of HH improved significantly after intervention G1: 36% G2: 54%	1a/A
Martín-Madrazo et al., Spain, (2012) [17]	Cluster randomized controlled trial	5MHH to evaluate HH CG: - IG: training of HWs through teaching sessions, the implementation of hydroalcoholic preparations, and the installation of reminder posters	n = 198 nurses CG n = 99 IG n = 99		Overall baseline compliance level: 8.1% Increased adherence to HH: 21.6% At 6 months: CG: 3.6%IG: 16.1%	1a/A
Rodríguez et al., Argentina, (2015) [18]	Conglomerate randomized controlled trial	Improving HWs compliance with HH Shipping one time per month of an intervention: (i) leadership commitment, (ii) surveillance of materials necessary to comply with hand hygiene and alcohol consumption, (iii) use of reminders, (iv) a screenplay of the project, and (v) feedback	n = 468 ICU nurses	50%	A multimodal strategy was effective for HH compliance Handwashing after interventions was 70%	1a/A
Rupp et al., United States, (2008) [19]	Randomized clinical trial	Adherence in the use of alcohol-based hand gel Unit A: educational program, reminders of handwashing, and leaflets with questionnaires. After 12 months, introduction of hydroalcoholic gel Unit B: installation of hydroalcoholic solution containers inside and outside of each patient care room	n = 174 ICU nurses	Unit A: 47% Unit B: 38%	Increase in the use of alcohol-based hand gel at 31% in both units Unit A: ● After the educational program: 62% ● With hand gel available: 66% Unit B: ● Hand gel available: 74%	1a/A
Stewardson et al., Switzerland, (2016) [20]	Conglomerate randomized controlled trial	Control group (G1): observation of participants Improved performance feedback group (G2): observation + feedback (verbal comments, reminder of 5MHH) Improved performance feedback and participation group (G3): observation + feedback + reports and posters every 3 months	n = 67 nurses G1 = 21 G2 = 24 G3 = 22	G1: 66% G2: 65% G3: 66%	HH compliance increase from 65% to 77% G1: 73% G2: 75% G3: 77% Effect of the intervention: G1 = OR, 1.41 CI (1.21–1.63) G2 = OR, 1.61 CI (1.41–1.84) G3 = OR, 1.73 CI (1.51–1.98)	1a/A
von Lengerke et al., Germany, (2017) [21]	Randomized controlled trial	CG: training measures on “clean hands action” (adaptation of World Health Organization’s (WHO’s) “Cleaner Care Is Safer Care” program) IG: application of 29 patterns of behavior change	n = 572 ICU nurses CG: n = 367 IG: n = 205	CG: 55% IG: 54% (compliance with HH in 2013)	Increased adherence to HH through behavioral interventions in 2013 vs 2015 CG: +9% (95% CI, 5.1–11.8) IG: +16% (95% CI, 11.9–18.9)	1a/A
Xiong et al., China, (2017) [22]	Randomized controlled trial	CG: self-directed readings IG: education sessions, with lectures, videos, role play + 15–20 min of individual online supervision and feedback sessions after each class	n = 84 nursing students (n = 42 in each group)		The level of knowledge about HH increased by 15% in the intervention group	1a/A
		Effectiveness of Different Methods
Chow et al., Singapore, (2012) [23]	Randomized controlled trial	Compared the effectiveness of 3 HH protocols Protocol 1 (P1): hand rubbing with alcohol covering all hand surfaces in no particular order Protocol 2 (P2): manual scraping with alcohol using the standard seven-step technique Protocol 3 (P3): washing hands with chlorhexidine using the standard seven-step technique	n = 60 nurses		In terms of daily care, alcohol hand rubbing covering all hand surfaces was the most effective intervention The effectiveness of the three interventions was shown to be equally effective Time spent on chlorhexidine HH was 79.7 s vs alcohol HH at 26 s	1a/A
Sharma et al., India, (2013) [24]	Randomized controlled trial	Comparison of 3 HH methods ● Group hand washing soap (G1) ● Alcohol solution group (G2) ● Povidone iodine group (G3)	n = 105 NICU nurses		Povidone–iodine scrub and alcohol hand rubbing were superior to plain soap hand washing In the groups using alcoholic solution and povidone, the measurement of colony-forming units was lower than in the group using soap. Mean reduction was 38.6%.	1a/A
		Prevention-Focused Training
Dulon et al., Germany, (2009) [25]	Randomized controlled trial	Increase protective behavior through a skincare program reducing skin disease CG: training seminar IG: training seminar + advice on interventions and protection of the skin by instructors	n = 388 geriatric nurses CG: n = 242IG: n = 146	CG: 19% IG: 26%	No differences between groups in work behavior (prevalence post-intervention= 17% in both groups). In IG, increase in the use of moisturizers and hand disinfection instead of hand washing.	1a/A
Van der Meer et al., Netherlands, (2014) [26]	Randomized controlled trial	Effects of a multifaceted implementation strategy on behavior, behavioral determinants, knowledge, and awareness of HWs regarding the use of recommendations to prevent hand eczema CG: only brochure IG: education, participatory work groups, and role models	n = 1649 nurses CG: n = 773 IG: n = 876	CG: 10.3% IG: 7.3%	IG group was significantly more likely to report hand eczema CG: 9.7% IG: 11.3% The intervention had a positive effect on the frequency of HH, the use of a moisturizer, and wearing cotton gloves	1a/A
		Training with Audiovisual Media
Bloomfield et al., UK, (2010) [27]	Randomized controlled trial	Effects of a computer-assisted learning module (IG) vs conventional face-to-face classroom teaching (CG)	n = 231 nursing students CG: n = 113 IG: n = 118	-	Computer-assisted learning was effective in teaching both the theory and the skill of knowledge of hand washing	1a/A
Jansson et al., Finland, (2016) [28]	Randomized controlled trial follow-up study	Four phases: (1) Simulation; (2) Orientation to mannequin capabilities; (3) Practical scenario; (4) Post-scenario debriefing session.	n = 30 ICU nurses IG: n = 15 CG: n = 15	IG = 40.8%	HH adherence in IG increased to 59.2% (6 months after the intervention) and decreased to 50.8% (24 months after)	1a/A

Note: CG = control group; GR = grade of recommendation; HH = hand hygiene; HWs = health workers; ICU = intensive care unit; IG = intervention group; LE = level of evidence; NICU = neonatal intensive care unit; 5MHH = five moments for hand hygiene.