Longitudinal Evaluation of a Multimodal Hand Hygiene Intervention in Improving Healthcare Worker Compliance: A Three-Year Quasi-Experimental Study at a Cardiac Specialty Hospital in Karachi, Pakistan

doi:10.21203/rs.3.rs-7201329/v1

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Longitudinal Evaluation of a Multimodal Hand Hygiene Intervention in Improving Healthcare Worker Compliance: A Three-Year Quasi-Experimental Study at a Cardiac Specialty Hospital in Karachi, Pakistan

https://doi.org/10.21203/rs.3.rs-7201329/v1

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BACKGROUND

Healthcare-associated infections pose a major challenge in developing countries, with hand hygiene (HH) compliance being the most critical preventive measure. Despite WHO recommendations, HH compliance in Pakistani healthcare settings remains suboptimal. This study aimed to evaluate the effectiveness of a WHO-based multimodal HH improvement intervention in enhancing compliance among healthcare workers at Tabba Heart Institute, Karachi, from 2022 to 2024.

METHODS

A quasi-experimental before-and-after study was conducted in three phases: baseline assessment (Jan–Dec 2022), intervention implementation (Jan–Dec 2023), and post-intervention evaluation (Jan–Jun 2024). The multimodal intervention included system changes, educational training, monitoring with feedback, workplace reminders, and institutional safety climate enhancement. Trained observers used the WHO HH observation tool to record 9,460 HH opportunities across physicians, nurses, and allied healthcare staff.

RESULTS

HH compliance improved significantly from 68.0% in 2022 to 71.0% in 2023, with sustained improvement reaching 85.5% in 2024. Compliant HH actions increased from 3,082/4,532 opportunities in 2022 to 1,150/1,344 in 2024. Monthly compliance rates showed consistent upward trends, peaking in early 2024. Nurses demonstrated the highest compliance, followed by physicians and allied staff.

CONCLUSION

The WHO multimodal HH strategy effectively and sustainably improved HH compliance at our institution, achieving a 17.5% increase over three years. This demonstrates the feasibility and impact of systematic quality improvement interventions in resource-limited healthcare settings.

Hand hygiene compliance

Multimodal intervention

Healthcare-associated infections

WHO guidelines

Quality improvement

Pakistan

Infection prevention

Patient safety

Healthcare-associated infections (HAIs) represent one of the most significant challenges to patient safety globally, affecting millions of patients annually and contributing substantially to morbidity, mortality, and healthcare costs.¹ In developing countries, the burden of HAIs is particularly pronounced, with prevalence rates often exceeding those observed in high-income nations due to resource limitations, inadequate infection prevention infrastructure, and suboptimal compliance with evidence-based practices.² Pakistan, as a lower-middle-income country, faces considerable challenges in implementing effective infection prevention and control measures, with studies indicating HAI prevalence rates as high as 8.4% in hospitalized patients.³

Hand hygiene (HH) represents the single most effective intervention for preventing the transmission of pathogenic microorganisms in healthcare settings, yet compliance rates remain disappointingly low worldwide.⁴ The World Health Organization's (WHO) comprehensive review of global HH practices revealed average compliance levels of only 59.6% in intensive care units (ICU), with stark disparities between high-income countries (64.5%) and low- and middle-income countries (9.1%).⁵ These findings underscore the urgent need for targeted interventions specifically designed for resource-limited settings, where traditional approaches may be insufficient or inappropriate.

The WHO's multimodal improvement strategy, first introduced in 2009 as part of the "Clean Care is Safer Care" initiative, has emerged as the gold standard for HH improvement interventions.⁶ This evidence-based approach encompasses five core components: system change to ensure access to alcohol-based hand rub (ABHR) at the point of care, training and education of healthcare workers, monitoring of practices with performance feedback, workplace reminders, and creation of an institutional safety climate that prioritizes patient safety.⁶ Multiple studies have demonstrated the effectiveness of this approach, with interventions showing compliance improvements ranging from 30% to over 80% across diverse healthcare settings.^7,8

In the Pakistani context, limited research has been conducted on HH compliance improvement initiatives, despite the recognized burden of HAIs and the potential for cost-effective interventions.⁹ The unique challenges faced by Pakistani healthcare facilities, including resource constraints, high patient-to-staff ratios, and varying levels of infrastructure development, necessitate careful adaptation of international guidelines to local contexts.⁹ Furthermore, the sustainability of improvement initiatives remains a critical concern, as many quality improvement projects fail to maintain gains over extended periods without ongoing support and reinforcement.

The cardiac care setting presents particular challenges for HH compliance due to the complexity of patient care, frequent use of invasive devices, and time-sensitive clinical situations that may compromise adherence to infection prevention protocols.¹⁰ Patients in cardiac care units are often at elevated risk for HAIs due to underlying comorbidities, immunocompromised states, and the invasive nature of many cardiac interventions.¹⁰ Therefore, maintaining high standards of HH compliance in these settings is crucial for optimizing patient outcomes and minimizing the risk of preventable complications.

Our objective was to evaluate the effectiveness of a multimodal HH improvement intervention based on the WHO strategy in enhancing compliance rates among healthcare workers at Tabba Heart Institute, Karachi, Pakistan, over a three-year period from 2022 to 2024.

STUDY DESIGN AND SETTING:

This quasi-experimental before-and-after intervention study was conducted at Tabba Heart Institute, a specialized cardiac care facility in Karachi, Pakistan, from January 2022 to June 2024. The study utilized a three-phase implementation approach consistent with WHO recommendations for multimodal HH improvement initiatives.⁶ The first phase (Jan - Dec 2022) served as the baseline assessment period, during which existing HH practices were systematically observed and documented to establish pre-intervention compliance rates. The second phase (Jan - Dec 2023) constituted the active intervention period, wherein the multimodal improvement strategy was fully implemented across all participating units. The third phase (Jan - Jun 2024) represented the post-intervention evaluation period, focusing on assessing the sustainability and continued effectiveness of the implemented interventions.

The study was conducted across multiple clinical areas within the institute, including ICUs, general wards, outpatient departments, and procedural areas. All healthcare workers involved in direct patient care were eligible for inclusion in the study, including physicians, nurses, and allied healthcare professionals such as physiotherapists, technicians, and support staff.

INTERVENTION COMPONENTS:

SYSTEM CHANGE

The system change component focused on ensuring sustainable access to ABHR at all points of patient care throughout the facility. This involved conducting a comprehensive assessment of existing HH infrastructure, identifying gaps in ABHR availability, and implementing systematic improvements to ensure that HH products were accessible within arm's reach of every patient care area. New ABHR dispensers were strategically placed at the entrance and exit of patient rooms, at nursing stations, and at all critical care points where healthcare workers typically perform patient care activities. The procurement process prioritized WHO-recommended ABHR formulations with proven antimicrobial efficacy, and backup supply systems were established to prevent stockouts that could compromise compliance rates. Additionally, existing handwashing facilities were upgraded where necessary to ensure adequate soap dispensers, paper towels, and proper drainage systems were available throughout the facility.

TRAINING AND EDUCATION

A comprehensive educational program was developed and implemented targeting all categories of healthcare workers involved in direct patient care. The training curriculum was based on WHO educational materials and adapted to the local context, addressing specific challenges identified during the baseline assessment phase. Interactive training sessions were conducted in small groups to facilitate discussion and hands-on practice of proper HH techniques. The educational content covered the scientific rationale for HH, the "Five Moments for Hand Hygiene" concept, proper techniques for both alcohol-based hand rubbing and soap-and-water handwashing, and the critical role of HH in preventing HAIs.¹¹

MONITORING AND FEEDBACK

A robust monitoring and feedback system was established to provide ongoing assessment of HH compliance and deliver timely performance feedback to healthcare workers and unit managers. Trained observers were recruited from the infection prevention and control team and received extensive training on the WHO direct observation methodology to ensure standardized and reliable data collection.¹² Monthly compliance reports were generated and shared with unit managers, department heads, and individual healthcare workers to promote transparency and accountability. Feedback was provided in multiple formats, including individual coaching sessions for low-performing staff and regular presentations to hospital leadership highlighting progress and areas for continued improvement. The feedback system was designed to be constructive and supportive rather than punitive, emphasizing the collective responsibility for patient safety and quality improvement.

WORKPLACE REMINDERS

Strategic placement of visual reminders and communication materials throughout the facility served to reinforce HH messages and prompt appropriate behavior at critical moments. Colorful posters depicting the "Five Moments for Hand Hygiene" were displayed in high-visibility locations such as nursing stations and patient rooms.¹¹ Special attention was paid to placing reminders at decision points where healthcare workers transition between patient care activities, as these moments represent critical opportunities for HH compliance.

INSTITUTIONAL SAFETY CLIMATE

Creating and sustaining an institutional safety climate that prioritizes HH required engagement from senior leadership and the development of organizational policies that support and reinforce desired behaviors. Role modeling by senior physicians and nursing leaders helped establish HH as a professional expectation. Recognition programs were implemented to celebrate units and individuals who demonstrated exemplary HH compliance, fostering a culture of positive reinforcement and peer motivation. Integration of HH expectations into job descriptions, performance evaluations, and orientation programs for new employees ensured that the importance of compliance was communicated consistently throughout the organization.

DATA COLLECTION:

Data collection was conducted using the WHO standardized direct observation method, employing the "Five Moments for Hand Hygiene" framework as the primary assessment tool.^11,12 Trained observers, consisting of infection prevention and control practitioners and specially trained nursing staff, conducted systematic observations during randomly selected time periods across all shifts and days of the week to ensure representative sampling of HH practices. Each observation session lasted approximately 20 minutes, during which observers documented all HH opportunities and corresponding actions taken by healthcare workers using standardized data collection forms provided in the WHO implementation toolkit.¹²

The five moments observed included: before touching a patient, before performing aseptic procedures, after exposure to body fluids, after touching a patient, and after touching patient surroundings. For each observed opportunity, data collectors recorded whether appropriate HH was performed, the method used (ABHR or soap and water), the professional category of the healthcare worker (physician, nurse, or other), and any relevant contextual factors that might influence compliance behavior. Observers maintained a discrete presence to minimize the Hawthorne effect while ensuring accurate documentation of actual practices rather than ideal behaviors.

STATISTICAL ANALYSIS:

Statistical analysis was conducted to assess changes in HH compliance over time and identify factors associated with compliance behavior. Descriptive statistics were calculated for all study variables, including mean compliance rates, standard deviations, and confidence intervals for each study phase and professional category. Compliance rates were calculated as the proportion of HH opportunities in which appropriate action was taken, expressed as percentages for ease of interpretation. All data was entered in Microsoft Excel software (Microsoft Excel 2013 {15.0.5553.1000} 32-bit) for the purpose of descriptive analysis.

Furthermore, interrupted time series analysis was performed to assess the impact of interventions, employing a segmented regression model to assess intervention effects while controlling for underlying trends. Monthly compliance rates were calculated from numerator-denominator pairs (compliant actions/total opportunities) across 30 observation points (Jan 2022 - Jun 2024). The intervention period commencing January 2023 divided the series into pre-intervention (12 months) and post-intervention (18 months) phases, with six months of post-implementation data excluded for latency period analysis. A p value of < 0.05 was considered as significant.

Subgroup analyses were also conducted to examine compliance patterns by professional category, clinical unit, time of day, and specific HH moments to identify areas of particular strength or concern.

OVERALL COMPLIANCE TRENDS:

The implementation of the multimodal HH improvement intervention resulted in substantial and sustained improvements in compliance rates across the three-year study period. Baseline compliance in 2022 was measured at 68.0% (3,082 compliant actions out of 4,532 observed opportunities), representing the pre-intervention performance level. Following the implementation of the interventions in 2023, compliance rates increased to 71.0% (2,532 compliant actions out of 3,584 opportunities). The most significant improvements were observed in 2024, when compliance rates reached 85.5% (1,150 compliant actions out of 1,344 opportunities), representing a 17.5% improvement from baseline levels (Table 1 & Fig. 1).

Table 1
Annual Hand Hygiene compliance data in terms of number of opportunities, compliance events and compliance rate
Year	Opportunities (n)	Compliance (n)	Compliance Rate (%)
2022	4532	3082	68%
2023	3584	2532	71%
2024	1344	1150	85.5%

INTERRUPTED TIME SERIES ANALYSIS:

Segmented regression revealed three distinct phases: a stable pre-intervention baseline (68.0% mean compliance, 95% CI:66.8–69.2), immediate post-intervention improvement (+ 8.7%, p < 0.001), and sustained monthly gains (+ 1.2%/month vs pre-intervention + 0.4%, p = 0.003). By June 2024, compliance reached 87.5% (95% CI:85.1–89.9), representing a 28.7% relative improvement from baseline (Fig. 2). The model explained 91% of variance (R²=0.91) with adequate error structure (p = 0.41). Had pre-intervention trends continued, projected compliance would have reached 72.4% by June 2024 versus observed 87.5%, a 15.1% divergence. Cumulative prevented non-compliance events totaled 1,142 (95% CI:887-1,397) based on opportunity-adjusted calculations.

COMPLIANCE BY PROFESSIONAL CATEGORY:

Analysis of compliance patterns by professional category revealed important insights into the differential response to the intervention across healthcare worker groups. Nurses consistently demonstrated the highest compliance rates throughout the study period, with performance improving from baseline levels to exceed 80% by the final assessment period. Physicians showed moderate baseline compliance rates that improved significantly following the intervention, though their compliance levels remained relatively lower than the nursing staff. Allied healthcare professionals, including physiotherapists, respiratory therapists, and patient care technicians, demonstrated variable compliance patterns, with some categories showing substantial improvements while others required additional targeted interventions to achieve desired performance levels.

INDICATION-SPECIFIC COMPLIANCE:

Examination of compliance patterns across the five WHO-defined moments for HH revealed significant variations in adherence to different types of HH opportunities. Compliance rates were consistently higher for "after" moments (after touching patients, after exposure to body fluids, and after touching patient surroundings) compared to "before" moments (before touching patients and before aseptic procedures). The highest compliance rates were observed for moments involving potential exposure to body fluids. Compliance with HH before aseptic procedures showed the greatest improvement over the study period, suggesting that educational interventions successfully enhanced understanding of the importance of preventing HAIs through proper preparation for invasive procedures. The lowest compliance rates throughout the study period were observed for HH after touching patient surroundings.

The findings of this three-year quality improvement study demonstrate the substantial impact that systematic, evidence-based interventions can have on HH compliance in healthcare settings, even in resource-limited environments. The 17.5% rise in compliance rates exceeds the improvement reported in some of the international studies and provides compelling evidence for the effectiveness of the WHO multimodal improvement strategy when properly adapted to local contexts.^13–15 Our results are particularly significant given the challenges associated with implementing quality improvement initiatives in developing countries, where competing priorities, resource constraints, and infrastructure limitations often impede the success of such programs. The sustained improvement observed through 2024 suggests that the intervention components were successfully integrated into the organizational culture and operational systems of the institution, addressing one of the most common criticisms of healthcare quality improvement initiatives i.e., their tendency to achieve short-term gains that are not maintained over time.

Our results are in line with similar studies conducted in other low- and middle-income countries. A study conducted in Saudi Arabia using similar methodology achieved compliance improvements from 30.7–45.5%, representing a 14.8% increase that was considered highly successful in that context.¹⁵ Another intervention study in China reported improvements from 37.8–75.9%, achieving a 38.1% increase but starting from a much lower baseline.¹⁶ Furthermore, another study demonstrated that a targeted hand hygiene training intervention made a significant improvement in the compliance rate of HH protocols from 66.0–88.3%, highlighting the importance of regular education to enhance infection control in healthcare settings.⁹

The differential response patterns observed among professional categories align closely with findings from the international literature and provide important insights for future intervention design.^17,18 The higher performance of nursing staff throughout the study period reflects patterns consistently reported across diverse healthcare settings and cultural contexts. This phenomenon likely results from multiple factors, including the more frequent and direct patient contact characteristic of nursing practice, the greater emphasis on infection prevention in nursing education curricula, and the hierarchical dynamics within healthcare teams that often position nurses as primary advocates for patient safety protocols. The moderate but significant improvements observed among physicians, mirror findings from other studies and highlight the ongoing challenge of engaging this professional group in HH improvement initiatives.^17,18

The success of our interventions can be attributed in large part to the comprehensive nature of the multimodal approach. Unlike single-component interventions that often fail to achieve sustainable improvements, the multimodal strategy addresses the multiple barriers to HH compliance simultaneously, creating synergistic effects that amplify the impact of individual components.¹⁹ The system change component ensured that environmental barriers to compliance were removed, while the educational component addressed knowledge gaps and misconceptions about HH practices. The monitoring and feedback system provided ongoing reinforcement and accountability, while workplace reminders served as cognitive aids during busy clinical periods. Perhaps most importantly, the institutional safety climate component ensured that HH improvement was positioned as an organizational priority supported by senior leadership and integrated into the cultural fabric of the institution.

The indication-specific patterns observed in our study provide valuable insights into the psychological and behavioral factors that influence HH compliance in clinical practice. The consistently higher compliance rates for "after" moments compared to "before" moments reflect the self-protection bias that is well-documented in literature, where healthcare workers are more motivated to protect themselves from contamination than to protect patients.^20–22 This pattern suggests that future educational interventions should place greater emphasis on the patient protection benefits of HH, potentially through narrative approaches that help healthcare workers understand the patient perspective and the devastating consequences that HAIs can have on individual patients and their families. The particularly low compliance rates observed for HH after touching patient surroundings highlight an important knowledge gap that persists even after comprehensive educational interventions, suggesting the need for more innovative educational approaches that effectively communicate the role of environmental contamination in pathogen transmission.

The economic implications of our findings warrant careful consideration, particularly in resource-limited settings where the cost-effectiveness of quality improvement initiatives is a critical factor in their adoption and sustainability. While comprehensive economic analysis was beyond the scope of this study, WHO has estimated that HH improvement programs can prevent up to 50% of avoidable HAIs and generate economic savings averaging 16 times the cost of implementation.²³ Future research should include comprehensive economic evaluations to quantify these benefits and provide additional evidence for the value proposition of HH improvement initiatives in developing country contexts. Such analyses would be particularly valuable for hospital administrators and policymakers who must make difficult decisions about resource allocation in settings where competing healthcare priorities may appear more urgent or visible than infection prevention activities.

The study has several limitations that must be acknowledged when interpreting the findings and considering their generalizability to other settings. Firstly, the quasi-experimental design without a control group limits our ability to definitively attribute the observed improvements to the intervention rather than to secular trends or other concurrent initiatives that may have influenced HH practices during the study period. Secondly, the potential for observation bias represents another significant limitation, as healthcare workers may have modified their behavior when they knew they were being observed, potentially leading to overestimation of true compliance rates. Additionally, the study was conducted at a single institution with strong leadership commitment to quality improvement, which may limit the generalizability of findings to facilities with different organizational cultures or resource constraints. The focus on a cardiac care facility may also limit applicability to other clinical specialties where patient populations, workflow patterns, and infection risks may differ substantially. Finally, the study did not include measurement of clinical outcomes such as HAI rates or patient safety indicators, which would provide additional evidence for the ultimate impact of improved HH compliance on patient outcomes. In this regard, the authors aim to conduct a more comprehensive quality improvement study in the future that would address the above limitations and would be applicable to the wider population of Pakistan.

Our study demonstrates that substantial and sustained improvements in HH compliance can be achieved in healthcare settings through the systematic implementation of evidence-based interventions. The 17.5% improvement in compliance rates achieved at our institute through a multimodal quality improvement strategy places this initiative among one of the most successful reported in the international literature and provides compelling evidence for the feasibility of achieving excellence in HH compliance in resource-limited environments.

The sustained nature of the improvements observed through 2024 suggests that the intervention components were successfully integrated into the organizational culture and operational systems of the institution, addressing one of the most significant challenges in healthcare quality improvement. The differential response patterns among professional categories provide important insights for future intervention design and highlight the need for tailored approaches that address the specific challenges and motivational factors affecting different healthcare worker groups.

ETHICS APPROVAL AND CONSENT TO PARTICIPATE

The study was approved by the Institutional Review Board of the Tabba Heart Institute, Karachi, Pakistan (Ref # THI/IRB/SQ/11-10-2024/111). This quality improvement study did not involve human patients or animals directly; therefore, individual consent to participate was not applicable.

CONSENT FOR PUBLICATION

Not applicable

AVAILABILITY OF DATA MATERIALS

All data generated during the course of this study has been included in this published article.

FUNDING

The authors did not receive any funding for this work.

COMPETING INTERESTS

The authors declare no conflict of interests.

ACKNOWLEDGEMENTS

None

AUTHOR CONTRIBUTIONS

SA – Conceptualization, Methodology, Project Administration, Supervision, Validation and Writing – review & editing

MAK – Formal analysis, Software, Validation, Visualization and Writing – original draft

VB, MP & NS - Data curation, Investigation, Validation and Writing – review & editing

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No competing interests reported.

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You are reading this latest preprint version

Longitudinal Evaluation of a Multimodal Hand Hygiene Intervention in Improving Healthcare Worker Compliance: A Three-Year Quasi-Experimental Study at a Cardiac Specialty Hospital in Karachi, Pakistan

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Abstract

BACKGROUND

METHODS

RESULTS

CONCLUSION

Figures

INTRODUCTION

METHODS

STATISTICAL ANALYSIS:

RESULTS

DISCUSSION

CONCLUSIONS

Declarations

References

Additional Declarations

Status:

Version 1