Original Investigation 

Infectious Diseases

World Health Organization Multimodal Improvement Strategy for Hand Hygiene: A Stepped-Wedge Cluster Randomized Trial

Emma Nyawere, Hiroki Saito, Robinah Ajok, et al

JAMA Netw Open 2026;9;(7):e2625250. doi:10.1001/jamanetworkopen.2026.25250

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.

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