Eng et al - 2021 - Did you wash your hands a prospective study of

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2021, Vol. 22(5) 195 –202
https://doi.org/10.1177/17571774211012767
Journal of Infection Prevention
 
© The Author(s) 2021 
Article reuse guidelines: 
sagepub.com/journals-permissions
DOI: 10.1177/17571774211012767
jip.sagepub.com
Journal of 
Infection 
Prevention
Background
The importance of hand hygiene on preventing the spread 
of healthcare-associated infections (HAIs) is well docu-
mented in the healthcare field, particularly by the World 
Health Organization (WHO) and the Centers for Disease 
Control and Prevention (CDC) hand hygiene task force, 
who participate in updating quality control standards (CDC, 
2002; Peters et al, 2019; Pittet et al, 2009; WHO, 2009). 
Despite widely available information and easily accessible 
hand hygiene devices in healthcare settings, compliance 
“Did you wash your hands?”: 
a prospective study of patient 
empowerment to prompt hand washing 
by healthcare providers
Tony Y Eng1 , Nina L Eng2, Carol A Jenkins3 and Patti G Grota4
Abstract
Background: Hand hygiene is paramount in preventing the spread of healthcare-associated infections especially during 
disease epidemics. Compliance rates with hand hygiene policies remain below 50% internationally and may be lower 
in the outpatient care setting. This study assessed the impact of the patient empowerment model on hand hygiene 
compliance among healthcare providers.
Methods: From October 2016 to May 2017, patients from a large ambulatory oncology centre were prospectively 
enrolled. Patients were instructed to observe healthcare providers for hand hygiene compliance and to remind healthcare 
providers where it was not observed during at least three consecutive encounters. Healthcare provider reactions to 
this intervention were rated by patients. Patients’ hand hygiene knowledge and beliefs were objectively elicited pre and 
post-study.
Results: Thirty patients with a median age of 52 years (range 5–91) completed the study for a total of 190 healthcare 
provider encounters. When initial hand hygiene was not observed, patients offered a reminder in 71 (37.4%) encounters, 
did not offer a reminder in 73 (38.4%) encounters and forgot to offer a reminder in 24 (14.2%) encounters. Patients 
perceived positive or neutral reactions in 76.8% of encounters and negative or surprised reactions in 23.2% of encounters. 
Healthcare provider compliance improved from 11.6% to 48.9% with intervention. Patient hand hygiene knowledge 
improved by 16% following the study.
Conclusions: Patient-empowered hand hygiene may be a useful adjunct for improving hand hygiene compliance among 
healthcare providers and improving patient hand hygiene knowledge, although it may confer an emotional burden on 
patients.
Keywords
Patient empowerment, hand hygiene, hand washing, healthcare providers
Date received: 4 October 2020; accepted: 6 April 2021
1 Department of Radiation Oncology, Winship Cancer Institute of Emory 
University, Atlanta, USA
2School of Medicine, Emory University, Atlanta, USA
3 Department of Radiation Oncology, UT Health San Antonio MD 
Anderson Cancer Center, San Antonio, USA
4 Office of Faculty Excellence, School of Nursing, UT Health San 
Antonio, San Antonio, USA
Corresponding author:
Tony Y Eng, Department of Radiation Oncology, Winship Cancer 
Institute of Emory University, 1365 Clifton Road, NE Atlanta, GA 
30345, USA. 
Email: t.y.eng@emory.edu
1012767 BJI Journal of Infection PreventionEng et al
Original Article
https://doi.org/10.1177/1757177420973763
Journal of Infection Prevention
2021, Vol. 22(3) 111 –118
© The Author(s) 2020 
Article reuse guidelines: 
sagepub.com/journals-permissions
DOI: 10.1177/1757177420973763
jip.sagepub.com
Journal of 
Infection 
Prevention
Background
Gram-negative bloodstream infection (GNBSI) contributed 
to an estimated 5500 patient deaths in 2015 (Public Health 
England, 2017b). There were 70.7 cases per 100,000 peo-
ple of Escherichia coli bacteraemia in 2018 in England, 
Wales and Northern Ireland, a 28% rise from 2014 (Public 
Health England, 2019). It is estimated that by 2050, GNBSI 
will contribute to 10 million deaths globally and cost £66 
trillion to the global economy in lost productivity (Review 
An analysis of the incidence, 
causes and preventative approaches to 
gram-negative bloodstream infections 
of hepatopancreatobiliary origin
Mustafa Majeed1 , Harry Ward1, Cian Wade2, Lisa Butcher2, 
Zahir Soonawalla3 and Giles Bond-Smith3
Abstract
Background: Gram-negative bloodstream infection (GNBSI) is a threat to public health in terms of mortality and 
antibiotic resistance. The hepatopancreatobiliary (HPB) cohort accounts for 15%–20% of GNBSI, yet few strategies have 
been explored to reduce HPB GNBSI.
Aim: To identify clinical factors contributing to HPB GNBSI and strategies for its prevention.
Methods: We performed a retrospective analysis of 433 cases of HPB GNBSI presenting to four hospitals between April 
2015 and May 2019. We extracted key data from hospital and primary care records including: the underlying source of 
GNBSI; previous documentation of biliary disease; and any previous surgical or non-surgical management.
Findings: Out of 433 cases of HPB GNBSI, 388 had clear evidence of HPB origin. The source of GNBSI was related to 
gallstone disease in 282 of the 388 cases (73%) and to HPB malignancy in 70 cases (18%). Of the gallstone-related cases, 
117 had previously been diagnosed with symptomatic gallstones. Of the 117 with a previous presentation, 93 could have 
been prevented with a laparoscopic cholecystectomy at the first presentation of gallstones, while 18 could have been 
prevented if intraoperative biliary tract imaging had been performed during a prior cholecystectomy. Of the 70 malignant 
cases, five could have been prevented through earlier biliary stenting, use of metal stents instead of plastic stents or 
earlier pancreaticoduodenectomy.
Discussion: The incidence of HPB GNBSI could be reduced by up to 30% by the implementation of alternative 
management strategies in this cohort.
Keywords
Gram-negative, bloodstream infection, infection prevention, hepatopancreatobiliary, gallstones, malignancy
Date received: 2 May 2020; accepted: 18 October 2020
1Medical Sciences Division, University of Oxford, Oxford, UK
2Oxford University Hospitals NHS Foundation Trust, Oxford, UK
3 Nuffield Department of Surgical Sciences, Oxford University Hospitals 
NHS Foundation Trust, Oxford, UK
Corresponding author:
Giles Bond-Smith, Nuffield Department of Surgical Sciences, Oxford 
University Hospitals NHS Foundation Trust, SEU Secretaries Office, 
John Radcliffe Hospital, Headley Way, Headington, Oxford OX3 9DU, 
UK. 
Email: giles.bond-smith@ouh.nhs.uk
973763 BJI Journal of Infection PreventionMajeed et al.
Original Article
02_JIP973763.indd 111 27/04/2021 11:57:31 AM
196 Journal of Infection Prevention 22(5)
Structured observation has been found to be the best indicator 
to assess handwashing practices in Indian households (Biran 
et al., 2008).
Outcome variable
The outcome variable considered for the analysis was ‘the 
use of soap/detergent and water for handwashing’. It is 
defined as the presence of soap/detergent along with water 
in the usual place of handwashing among the households, 
where the place of handwashing was observed.
Predictor variables
The predictor variables used in the analysis were chosen 
based on the extensive literature review and available infor-
mation in the NFHS-4. Specifically, the predictor variables 
used were the schooling of the household head (< 5 years 
including the illiterates, 5–9 years, 10–11 years, ⩾ 12 
years), sex of the household head (male, female), religion 
of the household head (Hindu, Muslim, Christian and 
Others), caste/tribe of the household head (scheduled caste 
[SC], scheduled tribe [ST], other backward classes [OBC] 
or non-SC/ST/OBC), household size (< 5 members, ⩾ 5 
members), house type (kuccha, semi-pucca, pucca), loca-
tion of water source (in own dwelling, elsewhere),owner-
ship of the house (not own house, own house), wealth index 
(poorest, poorer, middle, richer, richest), place of residence 
(urban, rural) and region (north, central, east, northeast, 
west, south).
Statistical analysis
In the present study, cross-tabulations between the outcome 
and predictor variables were done using the appropriate 
sample weights. The binary logistic regression was carried 
out to understand the predictors of handwashing practices. 
For this regression analysis, the dependent variable ‘Soap/
detergent and water used for handwashing’ was categorised 
into two, i.e. 1 = yes, 0 = no. The variables ‘house type’ 
and ‘ownership of house’ were dropped from the regression 
analysis to avoid multicollinearity. The Statistical Package 
for Social Sciences (SPSS-25, IBM Corp., Armonk, NY, 
USA) was used for analysis. The choropleth map was pre-
pared at the district level using the ArcMap (version 10.4) 
to assess the regional scenario. The local indicators of spa-
tial association (LISA) cluster map and Moran’s I scatter 
plot were calculated through GeoDa (version 1.14) to 
understand the spatial clustering in the use of soap/deter-
gent and water for handwashing.
Results
Type of handwashing elements observed 
at the usual place of handwashing
Soap/detergent and water were observed in the usual place 
of handwashing in three-fifths (60%) of the households 
(Figure 1). In 16% of the households, only water was 
observed in the usual place of handwashing. Seven out of 
every ten households were observed to have water and any 
cleansing element in their regular handwashing place. Nine 
percent of the households were found to have no water, no 
soap or any other cleansing agent at their usual place for 
handwashing.
Handwashing through soap and water 
by background characteristics of the 
households
Table 1 presents the bivariate analyses to understand the 
individual association between the predictors and outcome 
variable. Of the male-headed households, 61% use soap 
and water for handwashing compared with 55% of the 
female-headed households. Use of soap and water for hand-
washing was found to increase with increasing education of 
Figure 1. Type of cleansing element for handwashing observed at the usual place of handwashing, among households in which the 
place for hand washing was observed, India, 2015–2016.
01_JIP973754.indd 104 27/04/2021 5:36:51 PM
2 Journal of Infection Prevention 00(0)
rates among healthcare providers (HCPs) consistently 
remain below 50% (Erasmus et al, 2010; Muller et al, 2014; 
Vaidotas et al, 2015). Disease epidemics, including severe 
acute respiratory syndrome-associated coronavirus (SARS-
CoV) in 2002 and influenza H1N1 in 2009, have histori-
cally renewed focus on the importance of hand hygiene 
among HCPs and the general public, and the ongoing 
2019–2020 coronavirus disease 2019 (COVID-19) pan-
demic has been no different (Fung and Cairncross, 2006; 
Madani et al, 2014; Seto et al, 2003; Updegraff et al, 2011).
Multiple interventions have been implemented interna-
tionally to improve hand hygiene compliance rates, 
including the implementation of doorway signage and 
education programmes for HCPs and trainees, although 
most have reported minimal sustained success at best 
(Vander Weg et al, 2019; Updegraff et al, 2011; Wearn 
et al, 2015). One strategy that has gained popularity over 
the past couple of decades is the “audit and feedback” 
method, in which providers are observed and counselled 
verbally and/or in written form. A 2012 Cochrane review 
of randomised trials assessing this strategy reported a 
small improvement in hand hygiene practices when a 
HCP is counselled multiple times, especially by a supervi-
sor (Ivers et al, 2012).
While reminding a fellow colleague or subordinate is an 
achievable task for most people, the practice of “upward 
feedback”, in which an actual or perceived subordinate pro-
vides feedback to the supervisor, is less comfortable due to 
fears of a negative reaction or repercussions (Schwappach 
and Gehring, 2014; van Dierendonck et al, 2007). A 2017 
web-based cross-sectional survey reported only 28.7% of 
patients were willing to ask their HCPs to wash their hands 
before examination (Vijayalakshmi et al, 2017). However, 
several small studies have demonstrated that patients are 
often willing to be empowered to remind their HCPs when 
it is actively encouraged by the healthcare organisation 
(McGuckin and Govednik, 2013).
Hand hygiene is especially important among providers 
who interact with oncology patients, many of whom are 
considered immunocompromised due to their ongoing 
chemotherapy, radiation and surgical treatments (Morrison, 
2014; Shankar et al, 2020). This study was performed just 
prior to the COVID-19 pandemic to contribute to the lim-
ited existing data on patient empowerment and hand 
hygiene compliance among oncology providers.
Methods
Setting and population
Between October 2016 and May 2017, patients undergoing 
cancer treatments were enrolled by the study authors at a 
large, ambulatory cancer treatment centre in San Antonio, 
Texas, USA. All patients, including children with consent-
ing parents, seen in one of two oncology clinics were 
eligible for enrollment. Informed consent was obtained by 
the primary HCP. Given the pilot nature of this study, a 
power calculation for sample size was impractical, and the 
authors sought to enroll as many participants as possible 
during the given time frame based on available funding. 
The study was approved by the University of Texas Hospital 
System at San Antonio (UTHSCSA) institutional review 
board (IRB) prior to implementation.
Intervention
Intervention instructions were provided verbally and in 
writing by the primary HCP who obtained informed con-
sent. Participants were instructed to observe all HCPs they 
interacted with during at least three subsequent, consecu-
tive clinic encounters for appropriate hand hygiene prior to 
initiating physical contact. When the action was not 
observed, patients were instructed to remind the HCP to 
perform the task, then document their perceptions of the 
providers’ reactions to the reminder, as well as their per-
sonal reactions to providing the reminder. To assess patient 
knowledge throughout the study time period, patients’ base 
hand hygiene knowledge and beliefs were acquired and 
compared pre and post-study using a nominal scale survey 
developed and published previously by the study authors 
(Grota et al, 2020) (see Table 1).
The primary outcomes included the frequency of patient 
observed provider hand hygiene, frequency of patient insti-
gated provider hand hygiene and types of patient perceived 
personal and provider reactions during the interaction. 
Secondary outcomes included changes in patient hand 
hygiene knowledge and beliefs as well as factors that influ-
enced successful intervention implementation throughout 
the course of the study.
Definitions
Definitions of terms utilised in this study are defined in 
Appendix 1. All definitions were agreed on by all study 
authors, and equivocal cases were reviewed by at least two 
authors.
Analysis
Data were analysed utilising Microsoft Excel and the statis-
tical package SPSS (Software version 26.0 for Mac OS; 
IBM Corp., Armonk, NY, USA). Descriptive and frequency 
analysis was performed for all variables. Continuous vari-
ables are reported utilising median and range. Categorical 
variables are reported utilising raw numbers and percentage 
of the total. Due to the small population size, univariate 
analysis was performed over multivariate analysis includ-
ing the independent t-test analysis for continuous variables 
and Pearson chi-square analysis for categorical variables. 
For qualitative data analysis, key words, as defined in 
Eng et al 197 
2015). Globally, only 19% of people wash their hands after 
contact with excreta (Freeman et al., 2014).
Handwashing is practised by washing hands using theseveral combinations of water, solid or liquid soap, sani-
tiser, alcohol-based components, sand, ash and mud. 
Although mostly water is used for handwashing, water 
alone is an inefficient skin cleanser because fats and pro-
teins are not readily dissolved in water. People in low-
income countries such as India, Bangladesh and sub-Saharan 
Africa use ash, mud or sand for handwashing as zero-cost 
alternatives to soap (Bloomfield and Nath, 2009). Although 
there is potential for infection transmission by using con-
taminated soil/mud/ash for handwashing, ash or mud is 
perceived to clean hands as effectively as soap (Nizame 
et al., 2015). Handwashing with soap can dramatically 
reduce the rates of common diseases, including pneumonia 
and diarrhoea, two of the leading causes of deaths in chil-
dren. Handwashing with soap and water is a simple and 
efficient method for reducing the risk of infectious diseases 
(Burton et al., 2011). Handwashing with soap can reduce 
childhood mortality rates related to respiratory and diar-
rheal diseases by almost 50% in developing countries 
(Curtis and Cairncross, 2003). Handwashing with soap pre-
vents the two clinical syndromes that cause the most sig-
nificant number of childhood deaths globally; namely, 
diarrhoea and acute lower respiratory infections (Luby 
et al., 2005).
Effective national programs for changes in handwashing 
behaviour can be expected to reduce diarrhoea and pneu-
monia caused by lack of handwashing by 25% (Townsend 
et al., 2017). A large number of people do not wash their 
hands regularly or do not know how to wash their hands 
properly (Ali et al., 2014). Education, socioeconomic sta-
tus, availability of a water source in the house, ownership 
of the house and rural residence are associated with hand-
washing (Al-Khatib et al., 2015; Halder et al., 2010; Kumar 
et al., 2017; Ray et al., 2010; Schmidt et al., 2009; 
Ssemugabo et al., 2020). Handwashing is also related to 
knowledge of hand hygiene and non-availability of hand-
washing spaces or soap among school children (Mane 
et al., 2016).
India, with a cumulative number of 2,905,823 cases of 
COVID-19, is the third-worst affected country after the 
USA and Brazil as of 21 August 2020 (WHO, 2020b). 
Experts differ on the future trend of the COVID-19 in the 
country, amid rapidly growing cases across the states 
(Application Programming Interface, 2020), and the disease 
transmission stage being classified as ‘cluster of cases’ 
(WHO, 2020b). Appropriate handwashing (handwashing 
with alcohol-based agent or soap and water for a minimum 
of 20 s) is recommended as one of the most important ways 
to prevent person-to-person transmission of COVID 19. 
Nevertheless, evidence suggests poor hand hygiene in hos-
pitals /healthcare providers (Mani et al., 2010; Sureshkumar 
et al., 2011; Tyagi et al., 2018) and the role of hands in 
spreading infections in the country (Taneja et al., 2003). 
Handwashing through alcohol-based agent/soap and water 
at the household level again seems not universal, as millions 
of Indians do not have access to basic amenities (Kumar, 
2015). With several parts of India being water-stressed, and 
as much as 70% of the surface water resources being con-
taminated (Niti Aayog, 2019), is further perceived to worsen 
the recommended handwashing practices. Empirical evi-
dence on existing handwashing practices is crucial to com-
bat infectious diseases like COVID-19. There is, however, 
no scientific study exploring handwashing practices, spatial 
clustering and its determinants at the household level using 
the nationally representative sample in India. The aims of 
the present study were to: (1) understand the pattern and 
predictors of handwashing using soap/detergent and water; 
and (2) assess the spatial clustering of handwashing through 
soap/detergent and water at the district level in India.
Methods
Data
The study used data from the fourth round of the National 
Family Health Survey (NFHS), 2015–2016. The NFHS-4 is 
a nationally representative survey of 601,509 households 
that provides information for a wide range of monitoring 
and impact evaluation indicators of health, nutrition and 
women’s empowerment. The sampling design of the 
NFHS-4 is a stratified two-stage sample with an overall 
response rate of 98%. The Primary Sampling Unit (PSUs), 
i.e. the survey villages in rural areas and Census Enumeration 
Blocks (CEBs) in urban areas, were selected using probabil-
ity proportional to size (PPS) sampling. Data collection was 
conducted in two phases from January 2015 to December 
2016. The data were gathered using computer-assisted per-
sonal interviewing (CAPI) by trained research investigators. 
Only those respondents who gave oral/written consent were 
interviewed in the survey. A more detailed description of 
survey design, questionnaire and quality control measures 
can be obtained elsewhere (Paswan et al., 2017).
The NFHS-4 asked a specific question: ‘Please show me 
where members of your household most often wash their 
hands’. In the households where the place of handwashing 
was observed, research investigators were instructed to 
observe the presence of water, soap/detergent (bar, liquid, 
powder, paste) or other cleansing agents (ash, mud, sand) or 
absence of any cleansing agent. The present analysis is 
restricted to 582,064 households where the usual place for 
handwashing was observed. The availability of specific hand-
washing materials at the usual place of handwashing is 
assumed to be used by the household for handwashing. There 
is no consensus on a gold standard for identifying handwash-
ing behaviour (Manun’Ebo et al., 1997), though handwashing 
behaviour can be assessed using questionnaires, by hand-
washing demonstration and by direct/indirect observation. 
01_JIP973754.indd 103 27/04/2021 5:36:51 PM
Eng et al 3
Appendix 1, were identified from patient interview tran-
scripts to categorise trends and patterns.
Results
Patient demographics
Thirty patients (29 adults, one paediatric) were enrolled 
between October 2016 and May 2017. The median age was 
53 years (range 5–91) and 90% (n=27) of the patients were 
female. Fifty per cent of patients (n=15) identified as 
Hispanic, and the remainder identified as non-Hispanic. 
Most of the patients (n=24) preferred English as their first 
language, while the remaining patients preferred Spanish 
(n=1) or either English or Spanish (n=5). With regard to 
education level, 7% (n=2) of patients did not graduate high 
school, 60% (n=18) of patients possessed a high school 
degree and 33% (n=10) of patients possessed a college and/
or other advanced degree. Fifty per cent of patients (n=15) 
were undergoing long-term treatment for endometrial can-
cer, with the remaining patients undergoing treatment for a 
variety of other cancers. All demographics are delineated in 
Table 2.
Hand hygiene intervention frequency
Among all 30 study participants, there was a total of 202 HCP 
scheduled encounters at the treatment centre. Of the 202 
scheduled encounters, 12 encounters were not completed 
secondary to patient cancellation or missed appointment. Of 
the 190 completed encounters, HCPs were noted initially to 
complete hand hygiene without a reminder prior to initiating 
physical contact in 11.6% (n=22) of encounters. HCPs were 
not observed performing hand hygiene prior to physical con-
tact in the remaining 88.4% (n=168) of encounters. Of the 
168 encounters in which the intervention was warranted, 
patients reminded the HCP in 37.4% (n=71) of encounters, 
failed to remind the HCP in 38.4% (n=73) of encounters and 
either forgot to remind or could not find the opportunity to 
remind the HCP in 12.6% (n=24) of encounters. These results 
are delineated in Table 3. All HCPs who received a reminder 
subsequently performed appropriate hand hygiene, represent-
ing an increase in the compliance rate from 11.6% to 48.9%.
The majority of patients (n=26; 86.7%) completed the 
interventionduring at least one encounter and 46.7% 
(n=14) of patients completed the intervention during half or 
more of their scheduled encounters. Forty per cent (n=12) 
of patients forgot to complete the intervention during at 
Table 1. Survey questions of knowledge and beliefs of hand 
hygiene administered to study participants pre and post-study.
Question
1 Have I ever asked my doctor or nurse to clean their 
hands?
2 Does washing my hands stop the spread of infection?
3 Does using alcohol hand sanitiser/hand rub stop the 
spread of infections?
4 If I can see dirt on my hands, should I wash my hands 
with soap and water?
5 Should I clean my hands after blowing my nose?
6 Should I clean my hands after using the restroom?
7 Should I clean my hands before I eat?
8 Should my doctor or nurse clean their hands prior to 
touching me?
9 Should my doctor or nurse clean their hands prior to 
doing a procedure on me?
10 Do I feel comfortable asking a doctor or nurse to 
clean their hands?
Source: Grota et al (2020).
Table 2. Patient demographics.
Variable N (range or %) (n=30)
Gender 
 Female 27 (90)
 Male 3 (10)
Average age, years 53 (2–91)
Highest level of education completed 
 <High school 2 (6.7)
 High school 18 (60)
 College or other advanced degree 10 (33.3)
Preferred language 
 English 24 (80)
 Spanish 1 (3.3)
 English or Spanish 5 (16.7)
Ethnicity 
Hispanic 15 (50)
Non-Hispanic 15 (50)
Cancer subtype 
 Endometrial 15 (50)
 Cervical 5 (16.7)
 Skin 3 (10)
 Brain 2 (6.7)
 Vulva 2 (6.7)
 Desmoid 1 (3.3)
 Ovarian 1 (3.3)
 Nasopharyngeal 1 (3.3)
All continuous variables are presented as median (range), and all 
categorical variables are presented as n (%).
198 Journal of Infection Prevention 22(5)
Structured observation has been found to be the best indicator 
to assess handwashing practices in Indian households (Biran 
et al., 2008).
Outcome variable
The outcome variable considered for the analysis was ‘the 
use of soap/detergent and water for handwashing’. It is 
defined as the presence of soap/detergent along with water 
in the usual place of handwashing among the households, 
where the place of handwashing was observed.
Predictor variables
The predictor variables used in the analysis were chosen 
based on the extensive literature review and available infor-
mation in the NFHS-4. Specifically, the predictor variables 
used were the schooling of the household head (< 5 years 
including the illiterates, 5–9 years, 10–11 years, ⩾ 12 
years), sex of the household head (male, female), religion 
of the household head (Hindu, Muslim, Christian and 
Others), caste/tribe of the household head (scheduled caste 
[SC], scheduled tribe [ST], other backward classes [OBC] 
or non-SC/ST/OBC), household size (< 5 members, ⩾ 5 
members), house type (kuccha, semi-pucca, pucca), loca-
tion of water source (in own dwelling, elsewhere), owner-
ship of the house (not own house, own house), wealth index 
(poorest, poorer, middle, richer, richest), place of residence 
(urban, rural) and region (north, central, east, northeast, 
west, south).
Statistical analysis
In the present study, cross-tabulations between the outcome 
and predictor variables were done using the appropriate 
sample weights. The binary logistic regression was carried 
out to understand the predictors of handwashing practices. 
For this regression analysis, the dependent variable ‘Soap/
detergent and water used for handwashing’ was categorised 
into two, i.e. 1 = yes, 0 = no. The variables ‘house type’ 
and ‘ownership of house’ were dropped from the regression 
analysis to avoid multicollinearity. The Statistical Package 
for Social Sciences (SPSS-25, IBM Corp., Armonk, NY, 
USA) was used for analysis. The choropleth map was pre-
pared at the district level using the ArcMap (version 10.4) 
to assess the regional scenario. The local indicators of spa-
tial association (LISA) cluster map and Moran’s I scatter 
plot were calculated through GeoDa (version 1.14) to 
understand the spatial clustering in the use of soap/deter-
gent and water for handwashing.
Results
Type of handwashing elements observed 
at the usual place of handwashing
Soap/detergent and water were observed in the usual place 
of handwashing in three-fifths (60%) of the households 
(Figure 1). In 16% of the households, only water was 
observed in the usual place of handwashing. Seven out of 
every ten households were observed to have water and any 
cleansing element in their regular handwashing place. Nine 
percent of the households were found to have no water, no 
soap or any other cleansing agent at their usual place for 
handwashing.
Handwashing through soap and water 
by background characteristics of the 
households
Table 1 presents the bivariate analyses to understand the 
individual association between the predictors and outcome 
variable. Of the male-headed households, 61% use soap 
and water for handwashing compared with 55% of the 
female-headed households. Use of soap and water for hand-
washing was found to increase with increasing education of 
Figure 1. Type of cleansing element for handwashing observed at the usual place of handwashing, among households in which the 
place for hand washing was observed, India, 2015–2016.
01_JIP973754.indd 104 27/04/2021 5:36:51 PM
4 Journal of Infection Prevention 00(0)
least one encounter. At least seven (23.3%) patients were 
unsure whether to remind HCPs who were wearing gloves 
to perform hand hygiene and two (6.7%) patients did not 
realise hand sanitiser was considered appropriate hand 
hygiene. At least 13 (43.3%) patients felt uncomfortable 
reminding the HCP to perform hand hygiene. Of these 
patients, at least five (16.7%) patients felt especially 
uncomfortable reminding a physician, citing feeling “awk-
ward” and “disrespectful”, because the physician “should 
know what [he/she] is doing”. There were no statistically 
significant differences in terms of patient demographics or 
pre-study perceptions between patients who did and did not 
complete the intervention during at least one encounter or 
during half or more of the encounters (Table 4).
Patient perceptions of provider 
response to intervention
As represented in Table 5, patients reported that HCPs 
responded positively or neutrally to the intervention in 
43.8% (n=35) and 32.5% (n=26) of encounters, respec-
tively. Patients reported a surprised reaction in 10% (n=8) 
of encounters and a negative reaction in 13.7% (n=11) of 
encounters. Patients’ perceived provider responses did not 
have a statistically significant impact on their likelihood to 
complete the intervention. In post-study interviews, at least 
two patients (6.7%) reported choosing to stop reminding 
HCPs after receiving a negative HCP reaction to the 
reminder.
Patient hand hygiene perceptions
The majority (n=21; 70.0%) patients scored 9–10 out of 10 
points on the pre-study survey, indicating accurate hand 
hygiene knowledge and relative familiarity with reminding 
HCPs to perform hand hygiene. The two most common 
questions that patients missed were “prior experience with 
asking an HCP to perform hand hygiene” (n=25; 83.3%) 
and “comfort with the task of reminding an HCP to perform 
hand hygiene” (n=5; 16.7%). Five (16.7%) patients missed 
at least one hand hygiene knowledge question, the majority 
of whom did not realise hand sanitiser use aided in stopping 
the spread of infection.
In the post-study survey, 27 (90%) of patients scored 
9–10 out of 10 points, representing an improvement of 
28.6%. All patients but one (n=29; 96.7%) correctly 
answered all of the hand hygiene knowledge questions, an 
improvement of 16%. Nineteen (63.3%) patients reported 
new experience reminding an HCP to perform hand 
hygiene. Two (6.7%) patients reported new comfort with 
reminding an HCP, although two (6.7%) patients reported a 
loss of comfort with reminding an HCP. There were no 
explanations provided for this sentiment.
Discussion
Hand hygiene is a well-documentedand widely accepted 
method for reducing HAIs. This is especially important 
among oncology patients whose immune systems are fre-
quently compromised secondary to chemotherapy and radi-
ation (Morrison, 2014; Shankar et al, 2020). This study 
sought to assess the frequency of hand hygiene and the effi-
cacy of a patient-empowered intervention for improving 
hand hygiene compliance in the setting of a large, ambula-
tory oncology centre.
This study prospectively enrolled 30 adult and paediat-
ric patients undergoing long-term cancer therapy between 
October 2016 and May 2017. On completion of the study, 
patients reported an HCP hand hygiene compliance rate of 
11.6%. This is much lower than the authors expected, as 
average hand hygiene compliance rates of 30–50% have 
been reported in the literature, although most studies con-
sist primarily of inpatient data collection (Kingston et al, 
2016; Livorsi et al, 2018). Although significantly limited in 
availability, studies specifically focusing on the outpatient 
setting have reported vastly varying hand hygiene compli-
ance rates ranging from 6% to 63% (Kato et al, 2021; 
KuKanich et al, 2013; Thompson et al, 2016). These 
reduced compliance rates may be secondary to the histori-
cal paucity of robust hand hygiene interventions, education 
and funding in the outpatient versus inpatient setting 
(Bingham et al, 2016).
The 2009 WHO hand hygiene guidelines clearly encour-
age patient empowerment as one of the strategies for 
improving HCP hand hygiene compliance (WHO, 2009). 
Despite this, there have been few data published supporting 
Table 3. Patient implementation of the study intervention.
Patient action
 
Did not 
remind the 
HCP
Reminded the 
HCP
HCP initiated 
appropriate 
hand hygiene
Forgot to 
remind the 
HCP
No opportunity 
to remind the 
HCP
Missed or 
cancelled 
appointment
Total
No. of encounters 73 71 22 21 3 12 202
Percentage 38.4 37.4 11.6 11.1 1.6 N/A 100
HCP: healthcare provider.
Eng et al 199 
2015). Globally, only 19% of people wash their hands after 
contact with excreta (Freeman et al., 2014).
Handwashing is practised by washing hands using the 
several combinations of water, solid or liquid soap, sani-
tiser, alcohol-based components, sand, ash and mud. 
Although mostly water is used for handwashing, water 
alone is an inefficient skin cleanser because fats and pro-
teins are not readily dissolved in water. People in low-
income countries such as India, Bangladesh and sub-Saharan 
Africa use ash, mud or sand for handwashing as zero-cost 
alternatives to soap (Bloomfield and Nath, 2009). Although 
there is potential for infection transmission by using con-
taminated soil/mud/ash for handwashing, ash or mud is 
perceived to clean hands as effectively as soap (Nizame 
et al., 2015). Handwashing with soap can dramatically 
reduce the rates of common diseases, including pneumonia 
and diarrhoea, two of the leading causes of deaths in chil-
dren. Handwashing with soap and water is a simple and 
efficient method for reducing the risk of infectious diseases 
(Burton et al., 2011). Handwashing with soap can reduce 
childhood mortality rates related to respiratory and diar-
rheal diseases by almost 50% in developing countries 
(Curtis and Cairncross, 2003). Handwashing with soap pre-
vents the two clinical syndromes that cause the most sig-
nificant number of childhood deaths globally; namely, 
diarrhoea and acute lower respiratory infections (Luby 
et al., 2005).
Effective national programs for changes in handwashing 
behaviour can be expected to reduce diarrhoea and pneu-
monia caused by lack of handwashing by 25% (Townsend 
et al., 2017). A large number of people do not wash their 
hands regularly or do not know how to wash their hands 
properly (Ali et al., 2014). Education, socioeconomic sta-
tus, availability of a water source in the house, ownership 
of the house and rural residence are associated with hand-
washing (Al-Khatib et al., 2015; Halder et al., 2010; Kumar 
et al., 2017; Ray et al., 2010; Schmidt et al., 2009; 
Ssemugabo et al., 2020). Handwashing is also related to 
knowledge of hand hygiene and non-availability of hand-
washing spaces or soap among school children (Mane 
et al., 2016).
India, with a cumulative number of 2,905,823 cases of 
COVID-19, is the third-worst affected country after the 
USA and Brazil as of 21 August 2020 (WHO, 2020b). 
Experts differ on the future trend of the COVID-19 in the 
country, amid rapidly growing cases across the states 
(Application Programming Interface, 2020), and the disease 
transmission stage being classified as ‘cluster of cases’ 
(WHO, 2020b). Appropriate handwashing (handwashing 
with alcohol-based agent or soap and water for a minimum 
of 20 s) is recommended as one of the most important ways 
to prevent person-to-person transmission of COVID 19. 
Nevertheless, evidence suggests poor hand hygiene in hos-
pitals /healthcare providers (Mani et al., 2010; Sureshkumar 
et al., 2011; Tyagi et al., 2018) and the role of hands in 
spreading infections in the country (Taneja et al., 2003). 
Handwashing through alcohol-based agent/soap and water 
at the household level again seems not universal, as millions 
of Indians do not have access to basic amenities (Kumar, 
2015). With several parts of India being water-stressed, and 
as much as 70% of the surface water resources being con-
taminated (Niti Aayog, 2019), is further perceived to worsen 
the recommended handwashing practices. Empirical evi-
dence on existing handwashing practices is crucial to com-
bat infectious diseases like COVID-19. There is, however, 
no scientific study exploring handwashing practices, spatial 
clustering and its determinants at the household level using 
the nationally representative sample in India. The aims of 
the present study were to: (1) understand the pattern and 
predictors of handwashing using soap/detergent and water; 
and (2) assess the spatial clustering of handwashing through 
soap/detergent and water at the district level in India.
Methods
Data
The study used data from the fourth round of the National 
Family Health Survey (NFHS), 2015–2016. The NFHS-4 is 
a nationally representative survey of 601,509 households 
that provides information for a wide range of monitoring 
and impact evaluation indicators of health, nutrition and 
women’s empowerment. The sampling design of the 
NFHS-4 is a stratified two-stage sample with an overall 
response rate of 98%. The Primary Sampling Unit (PSUs), 
i.e. the survey villages in rural areas and Census Enumeration 
Blocks (CEBs) in urban areas, were selected using probabil-
ity proportional to size (PPS) sampling. Data collection was 
conducted in two phases from January 2015 to December 
2016. The data were gathered using computer-assisted per-
sonal interviewing (CAPI) by trained research investigators. 
Only those respondents who gave oral/written consent were 
interviewed in the survey. A more detailed description of 
survey design, questionnaire and quality control measures 
can be obtained elsewhere (Paswan et al., 2017).
The NFHS-4 asked a specific question: ‘Please show me 
where members of your household most often wash their 
hands’. In the households where the place of handwashing 
was observed, research investigators were instructed to 
observe the presence of water, soap/detergent (bar, liquid, 
powder, paste) or other cleansing agents (ash, mud, sand) or 
absence of any cleansing agent. The present analysis is 
restricted to 582,064 households where the usual place for 
handwashing was observed. The availability of specific hand-
washing materials at the usual place of handwashing is 
assumed to be used by the household for handwashing. There 
is no consensus on a gold standard for identifying handwash-
ing behaviour (Manun’Ebo et al., 1997), though handwashing 
behaviour can be assessed using questionnaires, by hand-
washing demonstration and by direct/indirect observation. 
01_JIP973754.indd 103 27/04/20215:36:51 PM
Eng et al 5
robust patient-centred interventions. In this study, we report 
that patients providing the reminder to HCPs to perform 
hand hygiene resulted in a compliance improvement from 
11.6% to 48.9%, as every provider who received a reminder 
complied immediately. Interestingly, one patient com-
mented that her reminder to the HCP resulted in that 
provider reminding other HCPs who interacted with her 
that day to perform hand hygiene. These data are promising 
for future, larger scaled interventions in outpatient settings 
and echo results from numerous similar pilot studies that 
have reported improvements in HCP compliance following 
the implementation of patient-driven hand hygiene inter-
ventions (Awaji and Al-Surimi, 2016; Davis et al, 2015; 
Görig et al, 2019; McLean et al, 2017).
Of the encounters when the provider neglected to per-
form hand hygiene prior to establishing physical contact 
with the patient, patients reported reminding the provider in 
37.4% of the encounters. While patients did not provide the 
reminder in 38.4% of warranted encounters, this level of 
patient participation was expected given the well-estab-
lished discomfort patients experience when confronting a 
provider. McGuckin and Govednik (2014) reported that 
17% of 1000 survey respondents asked an HCP to perform 
hand hygiene. While some patients in this study neglected 
to remind the HCP due to uncertainties regarding gloves, 
hand sanitiser and simple forgetfulness, nearly half of 
patients expressed fear or discomfort when presented with 
Table 4. Study variables and intervention completion during half or more encounters.
Variable Intervention completion, N (%) P valuea
Gender 
 Female 12 (44.4) 0.46
 Male 2 (66.7)
Age, years 
 <50 years 6 (42.9) 0.70
 ⩾50 years 8 (50.0)
Highest level of education completed 
 High school 10 (50.0) 0.61
 College or other advanced degree 4 (40.0)
Preferred language 
 English 4 (66.7) 0.27
 English/Spanish or Spanish 10 (41.7)
Ethnicity 
 Hispanic 6 (40.0) 0.46
 Non-Hispanic 8 (53.3)
Patient experience prior to study initiation 
 Reported experience with reminding HCP to perform hand hygiene 4 (80.0) 0.10
 Comfortable reminding HCP to perform hand hygiene 12 (48.0) 0.74
Patient experience during the study 
 Reported discomfort with reminding HCP to perform hand hygiene 6 (42.9) 0.70
 Positive or neutral HCP reaction to reminder 10 (45.5) 0.83
 Negative HCP reaction to reminder 4 (50.0)
aA P value of <0.05 was accepted for determination of statistical significance.
HCP: healthcare provider.
Table 5. Patient perception of healthcare provider responses 
to the intervention.
Healthcare provider response N (%)
Positive 35 (43.8)
Neutral 26 (32.5)
Negative 11 (13.7)
Surprised 8 (10.0)
Totala 80 (100)
aThe majority of encounters involved more than one healthcare 
provider.
200 Journal of Infection Prevention 22(5)
Structured observation has been found to be the best indicator 
to assess handwashing practices in Indian households (Biran 
et al., 2008).
Outcome variable
The outcome variable considered for the analysis was ‘the 
use of soap/detergent and water for handwashing’. It is 
defined as the presence of soap/detergent along with water 
in the usual place of handwashing among the households, 
where the place of handwashing was observed.
Predictor variables
The predictor variables used in the analysis were chosen 
based on the extensive literature review and available infor-
mation in the NFHS-4. Specifically, the predictor variables 
used were the schooling of the household head (< 5 years 
including the illiterates, 5–9 years, 10–11 years, ⩾ 12 
years), sex of the household head (male, female), religion 
of the household head (Hindu, Muslim, Christian and 
Others), caste/tribe of the household head (scheduled caste 
[SC], scheduled tribe [ST], other backward classes [OBC] 
or non-SC/ST/OBC), household size (< 5 members, ⩾ 5 
members), house type (kuccha, semi-pucca, pucca), loca-
tion of water source (in own dwelling, elsewhere), owner-
ship of the house (not own house, own house), wealth index 
(poorest, poorer, middle, richer, richest), place of residence 
(urban, rural) and region (north, central, east, northeast, 
west, south).
Statistical analysis
In the present study, cross-tabulations between the outcome 
and predictor variables were done using the appropriate 
sample weights. The binary logistic regression was carried 
out to understand the predictors of handwashing practices. 
For this regression analysis, the dependent variable ‘Soap/
detergent and water used for handwashing’ was categorised 
into two, i.e. 1 = yes, 0 = no. The variables ‘house type’ 
and ‘ownership of house’ were dropped from the regression 
analysis to avoid multicollinearity. The Statistical Package 
for Social Sciences (SPSS-25, IBM Corp., Armonk, NY, 
USA) was used for analysis. The choropleth map was pre-
pared at the district level using the ArcMap (version 10.4) 
to assess the regional scenario. The local indicators of spa-
tial association (LISA) cluster map and Moran’s I scatter 
plot were calculated through GeoDa (version 1.14) to 
understand the spatial clustering in the use of soap/deter-
gent and water for handwashing.
Results
Type of handwashing elements observed 
at the usual place of handwashing
Soap/detergent and water were observed in the usual place 
of handwashing in three-fifths (60%) of the households 
(Figure 1). In 16% of the households, only water was 
observed in the usual place of handwashing. Seven out of 
every ten households were observed to have water and any 
cleansing element in their regular handwashing place. Nine 
percent of the households were found to have no water, no 
soap or any other cleansing agent at their usual place for 
handwashing.
Handwashing through soap and water 
by background characteristics of the 
households
Table 1 presents the bivariate analyses to understand the 
individual association between the predictors and outcome 
variable. Of the male-headed households, 61% use soap 
and water for handwashing compared with 55% of the 
female-headed households. Use of soap and water for hand-
washing was found to increase with increasing education of 
Figure 1. Type of cleansing element for handwashing observed at the usual place of handwashing, among households in which the 
place for hand washing was observed, India, 2015–2016.
01_JIP973754.indd 104 27/04/2021 5:36:51 PM
6 Journal of Infection Prevention 00(0)
the situation. A 2012 questionnaire of 200 hospitalised 
patients reported that despite 99–100% of patients agreeing 
that HCPs should wash their hands prior to each patient 
encounter, only half responded feeling comfortable remind-
ing an HCP to do so, and fewer than 15% reported ever 
reminding an HCP in the past (Ottum et al, 2013). Similarly, 
a 2012 report found that 57% of patients interviewed as part 
of the United Kingdom “Clean Your Hands” campaign 
endorsed discomfort with asking HCPs to complete hand 
hygiene (Butenko et al, 2017). Similarly, Vijayalakshmi 
et al (2017) reported only 28.7% of respondents responded 
feeling comfortable about reminding an HCP to perform 
hand hygiene. Heightened anxiety while interacting with 
HCPs is a well-known phenomenon and has been seen 
to cause physical and psychological stress, including a 
reduced likelihood that patients will ask questions and 
voice concerns (Judson et al, 2013; Pioli et al, 2018, Tolan, 
2012).
Although statistically significant associations were not 
made in this study population, patient perceived HCP will-
ingness to receive feedback from the patient may be another 
contributor to the discomfort felt by patients. While the 
majority of patients perceived positive and/or neutral HCP 
reactions to the reminder, 13.7% of HCP responses were 
perceived as negative. At least two patients reported this 
negative response as the reason why they stopped remind-
ing subsequent HCPs they encountered,and two different 
patients reported a decrease in confidence with reminding 
an HCP after study completion. On the contrary, at least 
three patients reported being more likely to speak up when 
the reminder was regarded as appreciated and supported by 
the HCP. These responses highlight that the success of a 
patient-driven intervention depends in part on HCP percep-
tions, which historically have not always been favourable 
towards patients or patient family member involvement in 
hand hygiene interventions (Davis et al, 2014; Lastinger 
et al, 2017; Sande-Meijide et al, 2019).
A significant percentage of patients cited simply forget-
ting to remind the HCP during at least one encounter. 
Because patients only received the instruction to initiate the 
reminder at the beginning of the study, a higher percentage 
of patients may have performed the intervention if a 
reminder was offered during subsequent encounters. In 
addition, the initial instruction the patients received seemed 
also to improve general hand hygiene knowledge, as all but 
one patient correctly answered every hand hygiene knowl-
edge question on the post-study survey, an improvement of 
16%. In a study published in 2017 centred around outpa-
tient diabetes care centres, increased patient hand hygiene 
knowledge was directly correlated with an increased likeli-
hood to speak about hand hygiene to the HCP (von Lengerke 
et al, 2017). These findings suggest repetitive hand hygiene 
reminders and education directed at patients may inadvert-
ently improve HCP hand hygiene compliance rates.
The primary strength of this study is the use of patients 
to observe covertly the behaviours of multiple types of 
HCPs, as opposed to limiting the observation to physicians 
and nurses. Without the use of patients, it would be difficult 
to obtain an accurate account of HCP practices, because 
direct observation by a third party would result in the 
Hawthorne effect as well as a disruption in the privacy of 
the patient–provider interaction. Observation of HCPs from 
multiple departments allows for multidisciplinary opportu-
nities for improvement throughout the cancer treatment 
centre, as opposed to isolated future interventions.
This study has several limitations. Given the pilot nature 
of the study, the sample size was small resulting in an 
underpowered study, largely due to the limited number of 
study authors, time frame and available funding. While the 
results of this study are not generalisable to the public, the 
authors hope this initial experience may assist others in 
implementing a patient-empowered strategy for improving 
hand hygiene compliance in the ambulatory setting. The 
study is also limited by observation and recall bias due to 
its reliance on patient responses. Initial delivery of hand 
hygiene education and intervention instructions for patients 
was standardised, but it was not demonstrated or repeated 
at subsequent encounters. Given that it was not practical to 
observe the patients’ interactions with every HCP directly, 
the accuracy of responses likely fluctuated, particularly 
during later encounters. Finally, one study author was also 
involved in encounters with patients, resulting in the poten-
tial for the Hawthorne effect, although they represented an 
extreme minority of all HCPs encountered by patients.
Conclusions
Pilot results from this study suggest that a patient-empow-
ered hand hygiene strategy could improve compliance rates 
among HCPs in the outpatient setting, although higher 
powered studies are required to determine the full potential 
of this intervention. Dedication to fostering a supportive 
environment for issuing and receiving feedback between 
patients and HCPs will also be required for sustainable 
implementation to relieve the emotional burden on patients 
while maintaining a positive patient–provider relationship. 
Ultimately, while patient empowerment may be one of 
many components of improving compliance, the main bur-
den of responsibility should be shouldered by HCPs to 
ensure patient and provider safety by following the estab-
lished hand hygiene policy.
Key points
Question: What is the impact of the patient empowerment 
model on hand hygiene compliance among healthcare 
providers?
Findings: In this study of 30 patients with 190 healthcare 
provider encounters, appropriate healthcare provider hand 
hygiene was observed in 11.6% of encounters without 
intervention and improved to 48.9% with implementation 
of this intervention.
Eng et al 201 
2015). Globally, only 19% of people wash their hands after 
contact with excreta (Freeman et al., 2014).
Handwashing is practised by washing hands using the 
several combinations of water, solid or liquid soap, sani-
tiser, alcohol-based components, sand, ash and mud. 
Although mostly water is used for handwashing, water 
alone is an inefficient skin cleanser because fats and pro-
teins are not readily dissolved in water. People in low-
income countries such as India, Bangladesh and sub-Saharan 
Africa use ash, mud or sand for handwashing as zero-cost 
alternatives to soap (Bloomfield and Nath, 2009). Although 
there is potential for infection transmission by using con-
taminated soil/mud/ash for handwashing, ash or mud is 
perceived to clean hands as effectively as soap (Nizame 
et al., 2015). Handwashing with soap can dramatically 
reduce the rates of common diseases, including pneumonia 
and diarrhoea, two of the leading causes of deaths in chil-
dren. Handwashing with soap and water is a simple and 
efficient method for reducing the risk of infectious diseases 
(Burton et al., 2011). Handwashing with soap can reduce 
childhood mortality rates related to respiratory and diar-
rheal diseases by almost 50% in developing countries 
(Curtis and Cairncross, 2003). Handwashing with soap pre-
vents the two clinical syndromes that cause the most sig-
nificant number of childhood deaths globally; namely, 
diarrhoea and acute lower respiratory infections (Luby 
et al., 2005).
Effective national programs for changes in handwashing 
behaviour can be expected to reduce diarrhoea and pneu-
monia caused by lack of handwashing by 25% (Townsend 
et al., 2017). A large number of people do not wash their 
hands regularly or do not know how to wash their hands 
properly (Ali et al., 2014). Education, socioeconomic sta-
tus, availability of a water source in the house, ownership 
of the house and rural residence are associated with hand-
washing (Al-Khatib et al., 2015; Halder et al., 2010; Kumar 
et al., 2017; Ray et al., 2010; Schmidt et al., 2009; 
Ssemugabo et al., 2020). Handwashing is also related to 
knowledge of hand hygiene and non-availability of hand-
washing spaces or soap among school children (Mane 
et al., 2016).
India, with a cumulative number of 2,905,823 cases of 
COVID-19, is the third-worst affected country after the 
USA and Brazil as of 21 August 2020 (WHO, 2020b). 
Experts differ on the future trend of the COVID-19 in the 
country, amid rapidly growing cases across the states 
(Application Programming Interface, 2020), and the disease 
transmission stage being classified as ‘cluster of cases’ 
(WHO, 2020b). Appropriate handwashing (handwashing 
with alcohol-based agent or soap and water for a minimum 
of 20 s) is recommended as one of the most important ways 
to prevent person-to-person transmission of COVID 19. 
Nevertheless, evidence suggests poor hand hygiene in hos-
pitals /healthcare providers (Mani et al., 2010; Sureshkumar 
et al., 2011; Tyagi et al., 2018) and the role of hands in 
spreading infections in the country (Taneja et al., 2003). 
Handwashing through alcohol-based agent/soap and water 
at the household level again seems not universal, as millions 
of Indians do not have access to basic amenities (Kumar, 
2015). With several parts of India being water-stressed, and 
as much as 70% of the surface water resources being con-
taminated (Niti Aayog, 2019), is further perceived to worsen 
the recommended handwashingpractices. Empirical evi-
dence on existing handwashing practices is crucial to com-
bat infectious diseases like COVID-19. There is, however, 
no scientific study exploring handwashing practices, spatial 
clustering and its determinants at the household level using 
the nationally representative sample in India. The aims of 
the present study were to: (1) understand the pattern and 
predictors of handwashing using soap/detergent and water; 
and (2) assess the spatial clustering of handwashing through 
soap/detergent and water at the district level in India.
Methods
Data
The study used data from the fourth round of the National 
Family Health Survey (NFHS), 2015–2016. The NFHS-4 is 
a nationally representative survey of 601,509 households 
that provides information for a wide range of monitoring 
and impact evaluation indicators of health, nutrition and 
women’s empowerment. The sampling design of the 
NFHS-4 is a stratified two-stage sample with an overall 
response rate of 98%. The Primary Sampling Unit (PSUs), 
i.e. the survey villages in rural areas and Census Enumeration 
Blocks (CEBs) in urban areas, were selected using probabil-
ity proportional to size (PPS) sampling. Data collection was 
conducted in two phases from January 2015 to December 
2016. The data were gathered using computer-assisted per-
sonal interviewing (CAPI) by trained research investigators. 
Only those respondents who gave oral/written consent were 
interviewed in the survey. A more detailed description of 
survey design, questionnaire and quality control measures 
can be obtained elsewhere (Paswan et al., 2017).
The NFHS-4 asked a specific question: ‘Please show me 
where members of your household most often wash their 
hands’. In the households where the place of handwashing 
was observed, research investigators were instructed to 
observe the presence of water, soap/detergent (bar, liquid, 
powder, paste) or other cleansing agents (ash, mud, sand) or 
absence of any cleansing agent. The present analysis is 
restricted to 582,064 households where the usual place for 
handwashing was observed. The availability of specific hand-
washing materials at the usual place of handwashing is 
assumed to be used by the household for handwashing. There 
is no consensus on a gold standard for identifying handwash-
ing behaviour (Manun’Ebo et al., 1997), though handwashing 
behaviour can be assessed using questionnaires, by hand-
washing demonstration and by direct/indirect observation. 
01_JIP973754.indd 103 27/04/2021 5:36:51 PM
Eng et al 7
Meaning: Patient-empowered hand hygiene is a useful 
strategy for improving hand hygiene compliance among 
healthcare providers.
Authors’ contributions
Tony Eng: Corresponding author, recruiting patients, analysing 
data, writing final manuscript.
Nina Eng: Analysing the data and helping write the manuscript. 
Reviewing and editing final manuscript.
Carol Jenkins: Recruiting patients, following up on patients, 
reviewing and editing final manuscript.
Patti Grota: Senior author, interviewing patients, analysing data, 
reviewing and editing final manuscript.
Acknowledgements
A portion of these data was presented at the 59th ASTRO Annual 
Conference, San Diego, CA, USA, October 2017 and the APIC 
2018 Annual Conference, Minneapolis, MN, USA June 2018.
Declaration of conflicting interest
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) disclosed receipt of the following financial support 
for the research, authorship, and/or publication of this article: This 
work was funded by the University of Texas System Patient Safety 
Grant (2016-2018), UT Health San Antonio.
ORCID iD
Tony Y Eng https://orcid.org/0000-0002-4352-845X
Institutional review board protocol number
HSC20160369H.
Peer review statement
Not commissioned; blind peer reviewed.
References
Awaji MA and Al-Surimi K (2016) Promoting the role of patients in 
improving hand hygiene compliance amongst health care workers. 
BMJ Open Quality 5: u210787, w4336.
Bingham J, Abell G, Kienast L, Lerner L, Matuschek B, Mullins W, Parker 
A, Reynolds N, Salisbury D and Seidel J (2016) Health care worker 
hand contamination at critical moments in outpatient care settings. 
American Journal of Infection Control 44: 1198–1202.
Butenko S, Lockwood C and McArthur A (2017) Patient experiences of 
partnering with healthcare professionals for hand hygiene compli-
ance: a systematic review. JBI Evidence Synthesis 15: 1645–1670.
CDC (Centers for Disease Control and Prevention) (2002) Guideline for 
Hand Hygiene in Health-Care Settings. MMWR 25 October 2002, 
Vol. 51, No. RR-16. https://www.cdc.gov/mmwr/PDF/rr/rr5116.pdf 
(accessed 20 April 2021).
Davis R, Parand A, Pinto A and Buetow S (2015) Systematic review of the 
effectiveness of strategies to encourage patients to remind healthcare 
professionals about their hand hygiene. Journal of Hospital Infection 
89: 141–162.
Davis R, Savvopoulou M, Shergill R, Shergill S and Schwappach D 
(2014) Predictors of healthcare professionals’ attitudes towards fam-
ily involvement in safety-relevant behaviours: a cross-sectional facto-
rial survey study. BMJ Open 4.
Erasmus V, Daha TJ, Brug H, Richardus JH, Behrendt MD, Vos MC and 
Van Beeck EF (2010) Systematic review of studies on compliance 
with hand hygiene guidelines in hospital care. Infection Control and 
Hospital Epidemiology 31: 283–294.
Fung ICH and Cairncross S (2006) Effectiveness of handwashing in pre-
venting SARS: a review. Tropical Medicine and International Health 
11: 1749–1758.
Görig T, Dittmann K, Kramer A, Heidecke C-D, Diedrich S and Hübner 
N-O (2019) Active involvement of patients and relatives improves 
subjective adherence to hygienic measures, especially selfre-
ported hand hygiene: results of the AHOI pilot study. Antimicrobial 
Resistance and Infection Control 8: 1–9.
Grota PG, Eng T and Jenkins CA (2020) Patient motivational dialogue: a 
novel approach to improve hand hygiene through patient empower-
ment in ambulatory care. American Journal of Infection Control 48: 
573–574. 
Ivers N, Jamtvedt G, Flottorp S, Young JM, Odgaard-Jensen J, French 
SD, O’Brien MA, Johansen M, Grimshaw J and Oxman AD (2012) 
Audit and feedback: effects on professional practice and healthcare 
outcomes. Cochrane Database of Systematic Reviews 6: CD000259. 
Judson TJ, Detsky AS and Press MJ (2013) Encouraging patients to ask 
questions: how to overcome “white-coat silence”. JAMA 309: 2325–
2326.
Kato H, Takeda R, Ideno Y, Suzuki T, Sano K and Nakamura K (2021) 
Physicians’ compliance for hand hygiene in medical outpatient clin-
ics: automated hand-hygiene monitoring with touch sensor and wire-
less internet. American Journal of Infection Control 49: 50–54.
Kingston L, O’Connell N and Dunne C (2016) Hand hygiene-related 
clinical trials reported since 2010: a systematic review. Journal of 
Hospital Infection 92: 309–320.
Kukanich KS, Kaur R, Freeman LC and Powell DA (2013) Evaluation of 
a hand hygiene campaign in outpatient health care clinics. AJN The 
American Journal of Nursing 113: 36–42.
Lastinger A, Gomez K, Manegold E and Khakoo R (2017) Use of a patient 
empowerment tool for hand hygiene. American Journal of Infection 
Control 45: 824–829.
Livorsi DJ, Goedken CC, Sauder M, Vander Weg MW, Perencevich EN 
and Reisinger HS (2018) Evaluation of barriers to audit-and-feedback 
programs that used direct observation of hand hygiene compliance: a 
qualitative study. JAMA Network Open 1: e183344–e183344.
McGuckin M and Govednik J (2013) Patient empowerment and hand 
hygiene, 1997–2012. Journal of Hospital Infection 84: 191–199.
McGuckin M and Govednik J (2014) Patient empowerment begins with 
knowledge: consumer perceptions and knowledge sources for hand 
hygiene compliance rates. American Journal of Infection Control 42: 
1106–1108.
McLean HS, Carriker C and Bordley WC (2017) Good to great: quality-
improvementinitiative increases and sustains pediatric health care 
worker hand hygiene compliance. Hospital Pediatrics 7: 189–196.
Madani TA, Althaqafi AO and Alraddadi BM (2014) Infection prevention and 
control guidelines for patients with Middle East respiratory syndrome 
coronavirus (MERS-CoV) infection. Saudi Medical Journal 35: 897–913.
Morrison VA (2014) Immunosuppression associated with novel chemo-
therapy agents and monoclonal antibodies. Clinical Infectious 
Diseases 59 (Suppl 5): S360–S364.
Muller MP, Levchenko AI, Ing S, Pong SM and Fernie GR (2014) Electronic 
monitoring of individual healthcare workers’ hand hygiene event rate. 
Infection Control and Hospital Epidemiology 35: 1189–1192.
Ottum A, Sethi AK, Jacobs E, Zerbel S, Gaines ME and Safdar N (2013) 
Engaging patients in the prevention of health care-associated infec-
tions: a survey of patients’ awareness, knowledge, and perceptions 
regarding the risks and consequences of infection with methicillin-
resistant Staphylococcus aureus and Clostridium difficile. American 
Journal of Infection Control 41: 322–326.
202 Journal of Infection Prevention 22(5)
Structured observation has been found to be the best indicator 
to assess handwashing practices in Indian households (Biran 
et al., 2008).
Outcome variable
The outcome variable considered for the analysis was ‘the 
use of soap/detergent and water for handwashing’. It is 
defined as the presence of soap/detergent along with water 
in the usual place of handwashing among the households, 
where the place of handwashing was observed.
Predictor variables
The predictor variables used in the analysis were chosen 
based on the extensive literature review and available infor-
mation in the NFHS-4. Specifically, the predictor variables 
used were the schooling of the household head (< 5 years 
including the illiterates, 5–9 years, 10–11 years, ⩾ 12 
years), sex of the household head (male, female), religion 
of the household head (Hindu, Muslim, Christian and 
Others), caste/tribe of the household head (scheduled caste 
[SC], scheduled tribe [ST], other backward classes [OBC] 
or non-SC/ST/OBC), household size (< 5 members, ⩾ 5 
members), house type (kuccha, semi-pucca, pucca), loca-
tion of water source (in own dwelling, elsewhere), owner-
ship of the house (not own house, own house), wealth index 
(poorest, poorer, middle, richer, richest), place of residence 
(urban, rural) and region (north, central, east, northeast, 
west, south).
Statistical analysis
In the present study, cross-tabulations between the outcome 
and predictor variables were done using the appropriate 
sample weights. The binary logistic regression was carried 
out to understand the predictors of handwashing practices. 
For this regression analysis, the dependent variable ‘Soap/
detergent and water used for handwashing’ was categorised 
into two, i.e. 1 = yes, 0 = no. The variables ‘house type’ 
and ‘ownership of house’ were dropped from the regression 
analysis to avoid multicollinearity. The Statistical Package 
for Social Sciences (SPSS-25, IBM Corp., Armonk, NY, 
USA) was used for analysis. The choropleth map was pre-
pared at the district level using the ArcMap (version 10.4) 
to assess the regional scenario. The local indicators of spa-
tial association (LISA) cluster map and Moran’s I scatter 
plot were calculated through GeoDa (version 1.14) to 
understand the spatial clustering in the use of soap/deter-
gent and water for handwashing.
Results
Type of handwashing elements observed 
at the usual place of handwashing
Soap/detergent and water were observed in the usual place 
of handwashing in three-fifths (60%) of the households 
(Figure 1). In 16% of the households, only water was 
observed in the usual place of handwashing. Seven out of 
every ten households were observed to have water and any 
cleansing element in their regular handwashing place. Nine 
percent of the households were found to have no water, no 
soap or any other cleansing agent at their usual place for 
handwashing.
Handwashing through soap and water 
by background characteristics of the 
households
Table 1 presents the bivariate analyses to understand the 
individual association between the predictors and outcome 
variable. Of the male-headed households, 61% use soap 
and water for handwashing compared with 55% of the 
female-headed households. Use of soap and water for hand-
washing was found to increase with increasing education of 
Figure 1. Type of cleansing element for handwashing observed at the usual place of handwashing, among households in which the 
place for hand washing was observed, India, 2015–2016.
01_JIP973754.indd 104 27/04/2021 5:36:51 PM
8 Journal of Infection Prevention 00(0)
Peters A, Borzykowski T, Tartari E, Kilpatrick C, Mai SHC, Allegranzi B 
and Pittet D (2019) “Clean Care for All – It’s in Your Hands”: the 5th 
of May 2019 World Health Organization SAVE LIVES: Clean Your 
Hands Campaign. Journal of Infectious Diseases 82: 135–136. 
Pioli MR, Ritter AM, De Faria AP and Modolo R (2018) White coat syn-
drome and its variations: differences and clinical impact. Integrated 
Blood Press Control 11: 73–79.
Pittet D, Allegranzi B and Boyce J (2009) The World Health Organization 
guidelines on hand hygiene in health care and their consensus recom-
mendations. Infection Control and Hospital Epidemiology 30: 611–622.
Sande-Meijide M, Lorenzo-González M, Mori-Gamarra F, Cortés-Gago 
I, González-Vázquez A, Moure-Rodríguez L and Herranz-Urbasos M 
(2019) Perceptions and attitudes of patients and health care workers 
toward patient empowerment in promoting hand hygiene. American 
Journal of Infection Control 47: 45–50.
Schwappach DL and Gehring K (2014) Silence that can be dangerous: a 
vignette study to assess healthcare professionals’ likelihood of speak-
ing up about safety concerns. PLoS One 9: e104720.
Seto W, Tsang D, Yung R, Ching T, Ng T, Ho M, Ho L, Peiris J and Advisors 
of Expert SARS group of Hospital Authority (2003) Effectiveness of 
precautions against droplets and contact in prevention of nosocomial 
transmission of severe acute respiratory syndrome (SARS). Lancet 
361: 1519–1520.
Shankar A, Saini D, Roy S, Mosavi Jarrahi A, Chakraborty A, Bharti SJ 
and Taghizadeh-Hesary F (2020) Cancer care delivery challenges 
amidst coronavirus disease-19 (COVID-19) outbreak: specific pre-
cautions for cancer patients and cancer care providers to prevent 
spread. Asian Pacific Journal of Cancer Prevention 21: 569–573.
Thompson D, Bowdey L, Brett M and Cheek J (2016) Using medical 
student observers of infection prevention, hand hygiene, and injec-
tion safety in outpatient settings: a cross-sectional survey. American 
Journal of Infection Control 44: 374–380.
Tolan T (2012) Dealing with ‘white coat syndrome’. Healthcare 
Innovation 29: 48.
Updegraff JA, Emanuel AS, Gallagher KM and Steinman CT (2011) 
Framing flu prevention – An experimental field test of signs promot-
ing hand hygiene during the 2009–2010 H1N1 pandemic. Health 
Psychology, 30, 295.
Vaidotas M, Yokota PK, Marra AR, Camargo TZ, Victor EA, Gysi DM, 
Leal F, Santos OF and Edmond MB (2015) Measuring hand hygiene 
compliance rates at hospital entrances. American Journal of Infection 
Control 43: 694–696.
Vander Weg MW, Perencevich EN, O’Shea AM, Jones MP, Sarrazin MSV, 
Franciscus CL, Goedken CC, Baracco GJ, Bradley SF and Cadena J 
(2019) Effect of frequency of changing point-of-use reminder signs 
on health care worker hand hygiene adherence: a cluster randomized 
clinical trial. JAMA Network Open 2: e1913823–e1913823.
Van Dierendonck D, Haynes C, Borrill C and Stride C (2007) Effects 
of upward feedback on leadership behaviour toward subordinates. 
Journal of Management Development 26: 228–238. 
Vijayalakshmi S, Ramkumar S, Narayan KA and Vaithiyanathan P (2017) 
A goal unrealized: patient empowerment on hand hygiene – a web-
based survey from India. Journal of Clinical and Diagnostic Research 
11: LC12–LC16.
Von Lengerke T, KröningB and Lange K and Lower Saxon Diabetes 
Outpatient Centres Study Group (2017) Patients’ intention to speak 
up for health care providers’ hand hygiene in inpatient diabetic foot 
wound treatment: a cross-sectional survey in diabetes outpatient cen-
tres in Lower Saxony, Germany. Psychology, Health and Medicine 
22: 1137–1148.
Wearn A, Bhoopatkar H and Nakatsuji M (2015) Evaluation of the effect of 
hand hygiene reminder signs on the use of antimicrobial hand gel in a 
clinical skills center. Journal of Infection and Public Health 8: 425–431.
WHO (World Health Organization) (2009) WHO guidelines on hand 
hygiene in health care. https://www.who.int/publications/i/
item/9789241597906 (accessed 20 April 2021).
Appendix 1: Glossary of terms 
and definitions
Appropriate hand hygiene
Definition: Observed hand washing with soap and water or 
use of the clinic’s waterless alcohol-based, antiseptic scrub.
One encounter
Definition: One scheduled patient visit. The authors note 
that patients interact with a vastly varying number of 
healthcare providers (HCPs) during each encounter. 
Individual interactions were not quantified by the authors 
or the patients. Examples of encounters include the 
following:
•• Visit with a physician
•• Visit with a nurse, nurse practitioner, or physician 
assistant
•• Visit with a radiation oncology therapist
•• Visit with a phlebotomist in the laboratory
•• Visit with a radiology or radiation oncology 
technician
Intervention completion
Definition: One or more patient-initiated reminders to the 
HCP to complete hand hygiene when it was not initially 
observed during one given encounter. The number of times 
the patient initiated the reminder during one individual 
encounter was not quantified, as the number of HCP inter-
actions per encounter was not quantifiable.
Patient reported HCPs’ reactions
Definition: Categorised as positive, neutral, negative or sur-
prised. The following keywords were agreed upon and 
identified from the patient interview transcripts for 
categorization:
•• Positive: happy, glad, thank you, thank(ed), 
laugh(ed), smile(d)
•• Neutral: absence of positive, negative, or surprised 
keywords
•• Negative: angry, irritate(d), not happy, bother(ed), 
upset, rude, strange
•• Surprised: surprise(d), never asked me before, 
unusual
Patient discomfort
Definition: Presence of the following keywords identified 
in the patient interview transcripts: awkward, discomfort, 
uncomfortable, intimidate(d), difficult, hard, scare(d), 
scary, offend(ed), bother(ed).