Status of Hand Hygiene Implementation in Public Hospitals of Ethiopia: A Multi-Center Study

Status of Hand Hygiene Implementation in Public Hospitals of Ethiopia: A Multi-Center Study | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Status of Hand Hygiene Implementation in Public Hospitals of Ethiopia: A Multi-Center Study Feyissa Regassa Senbato, Zelalem Bonger, Kibrewossen Aklilu Kifle, and 25 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7923983/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background: Healthcare-associated infections (HAIs) are a major threat to patient safety, especially in low-resource settings. Hand hygiene (HH) is the most crucial pillar of infection prevention and control (IPC), yet its multimodal improvement strategy (MMIS) implementation in Ethiopian hospitals remains uninvestigated. This study assessed HH MMIS implementation using the World Health Organization (WHO) Hand Hygiene Self-Assessment Framework (HHSAF) across public hospitals in Ethiopia. Methods: A cross-sectional study was conducted from January 1 to March 30, 2025, in twenty public hospitals designated as national sites for HAIs surveillance. The study adopted the WHO HHSAF, covering five components and twenty-seven indicators; MMIS elements (system change, training and education, evaluation and feedback, reminders in the workplace, and institutional safety climate). The assessment was completed by the IPC focal of each participating hospital and validated by external senior IPC officers. Facilities’ implementation level was then categorized as inadequate, basic, intermediate, or advanced. Descriptive statistical and subgroup analyses were performed using SPSS v.25. Findings were summarized using medians and interquartile ranges (IQRs). Results: Overall, the median HHSAF score was 203.75 (IQR: 153.75–233.75), indicating a basic level of implementation. Four hospitals (20%) achieved an intermediate level, while two were inadequate. Tertiary hospitals scored slightly higher, with a median of 210 (IQR: 152.5–225), compared to secondary hospitals at178.75 (IQR: 155–197.5). Across all hospitals, the highest average scores were observed for reminders in the workplace (median: 63.75 in secondary hospitals; 52.5 in tertiary hospitals), while system change registered the lowest score (median: 20). A strong positive correlation (r=0.98) was observed between institutional safety climate (ISC) and overall HHSAF score. HH compliance was found to be poor, with 75% of the facilities demonstrating below 50% of compliance rate. Conclusion: The study revealed significant variability and unsatisfactory level implementation of MMIS public across hospitals. Hence, poor hand hygiene compliance was observed in studied facilities. Policymakers and healthcare leaders should prioritize embedding HH with routine clinical activities, supported by dedicated budgets and accountability structures. Such comprehensive and sustained efforts are crucial to enhance the compliance, reducing HAIs, and promoting patient safety. Hand Hygiene Multimodal Improvement Strategy Figures Figure 1 Figure 2 1. Introduction The consistent emerging of multidrug resistance organisms (MDROs) accompanied by healthcare-associated infections (HAIs) pose a significant threat to patient safety, contributing to increased morbidity, mortality, and healthcare costs (World Health Organization, 2024). Although data on HAIs in low-and middle-income countries (LMICs) remains limited, available evidence indicates a higher prevalence, resulting in a substantial health and economic burdens (Adal et al., 2025 ; Allegranzi et al., 2011 ; Ling et al., 2015 ; Loftus et al., 2019 ). Hand hygiene a cornerstone of IPC, plays a crucial role in reducing HAIs by preventing the transmission of infectious pathogens through the hands of healthcare workers (HCWs), which—harboring resident and transient flora frequently come into contact with patients, medical equipment, and the healthcare environment during routine clinical activities (Borodova et al., 2025 ; Sax et al., 2007 ; Steere & Mallison, 2016 ). Evidence indicates that MMIS significantly reduces HAIs and mitigates AMR, with a well-structured HH improvement program capable of preventing up to 50% of avoidable infections and yielding economic benefits estimated to be 16 times greater than its implementation cost (WHO, 2025 ). A 2019 global survey using the HHSAF revealed that most healthcare facilities achieved an intermediate level of HH implementation with a median score of 350/500 points, while in a study from Sierra Leone the mean score was 273 and inadequate budgets for HH resources and lack of stronger institutional safety climate were identified as major gaps (De Kraker et al., 2022 ; Lakoh et al., 2022 ). Despite global development, HH compliance remains suboptimal, (Lambe et al., 2019 ), especially in low resource settings where barriers such as inadequate infrastructure, resource limitations, and lack training persist (Didier Pittet, 2001 ). In developing countries, including Ethiopia, where the burden of HAIs is disproportionately high, improving HH in healthcare facilities is critical for patient safety (Allegranzi et al., 2017 ). In this study, a baseline assessment was conducted in twenty public hospitals across Ethiopia, to identify existing gaps, assess facility readiness, and generate evidence to guide targeted interventions for improvements of HH promotion and practices across the country. Furthermore, conducting this study is timely and strategically aligned with the Ethiopian Federal Ministry of Health (FMOH) efforts to initiate HAIs surveillance in twenty selected public hospitals. 2. Methods Context of study settings Ethiopia has a population of over 105 million (2021), and administratively divided into 11 regions and two city administrations. The country has a three-tier healthcare delivery system with more than 353 public hospitals, 3,706 public health centers, and 17,561 health posts. (Alemu et al., 2025 ). The country is currently advancing efforts to strengthen the capacity of healthcare facilities and the quality of care, with a particular focus on HAIs caused by MDROs. To this effect, the FMOH is planning to piloting an HAI surveillance program across the country. As part of this initiative, the Ministry conducted a series of capacity assessments covering overall IPC and microbiology service using a tool adapted from CDC. The purpose was to identify healthcare facilities with acceptable adherence to IPC standards were considered essential for rolling out an HAI surveillance program. Based on the results, twenty public hospitals were selected to serve as national HAIs surveillance sentinel sites. The current study was conducted in these 20 HAIs surveillance sites to evaluate the HH MMIS implementation status of each facility before commencement of HAIs surveillance. Hence, FMOH to make informed decision to initiate the surveillance. Study design A multicenter, cross-sectional study design was conducted over the twenty public hospitals from eight of the 14 regions in Ethiopia. Thus, the study covered approximately 72% of the regions in the country. Data collection was conducted from January 1 to March 30, 2025. Data collection tool, procedure, and quality assurance. As a part HH development approaches, the WHO prepared the MMIS, consisting of five key components: system change, training and education, monitoring and feedback, workplace reminders/communications, and institutional safety climate/culture change (WHO, 2009 ). The framework consists of 27 indicators, each having values ranging from 5 to 50 points, distributed across five MMIS components, each worth 100 points. According to the WHO HHSAF user guide, the assessment should be completed by IPC professionals directly responsible for implementing HH improvement strategies at the facility level. Thus, one IPC focal person fully dedicated to IPC was recruited from each of the twenty selected hospitals and completed the standardized questionnaires. Furthermore, three senior external IPC officers were employed to ensure data quality and consistency during the data collection process. The officers carried out a comprehensive assessment of filled HHSAF tools and verified the information through planned interviews with each facility focal persons. The study assigned levels for each of the five MMIS elements according to the WHO assessment, categorizing facilities into four groups: inadequate (≤ 25), basic (26–50), intermediate (51–75), and advanced (> 75). Moreover, based on the overall score of a facility, an HH implementation level was assigned as inadequate (0-125 points), basic (126–250 points), intermediate (251–375 points), or advanced (376–500 points) (WHO, 2010a ). Data analysis Data was entered, cleaned, and analyzed using SPSS version 25. The key indicators in each domain were summarized using basic descriptive analysis, and aggregated data were examined independently for each facility. Descriptive statistics were initially used to summarize HHSAF scores and categorize hospitals into implementation levels. Subgroup analysis was also carried out using component-specific scores, calculating the median and interquartile ranges for each core components. The median and interquartile range were used to summarize the HHSAF results and scores for each of the MMIS elements. The correlation between HHSAF component scores and overall HH was assessed using the Pearson correlation coefficient (r). 3. Results 3.1. Workforce and bed capacity of facilities involved in the study The finding shows that tertiary hospitals have many beds (median = 326.5) and staff (median = 711.5) compared to secondary hospitals (median = 578.5 for beds and 908 for staff). (Fig. 1 ). All studied facilities have an IPC program and dedicated full-time IPC officers. 3.2. HHSAF Scores Assessment of Twenty Public Hospitals in Ethiopia The overall median HHSAF score was 203.75(IQR: 153.75-233.75), categorizing it within the basic HH implementation level. A marginally elevated score was noted in tertiary hospitals (210; IQR: 152–225) in comparison to secondary hospitals (178; IQR: 155-197.5). Four out of the twenty public hospitals achieved intermediate-level performance. Three of these intermediate performing facilities are among the secondary hospitals, and one of them is among the tertiary hospitals. The MMIS of the majority of hospitals is at a basic level, while two hospitals attained an inadequate hand hygiene level (Fig. 1 ). In secondary hospitals, reminders in the workplace (RW) had the highest median score of 63.75. Institutional Safety Climate (ISC) lagged behind with a median of 45, highlighting a weaker organizational culture and commitment to safety practices. In tertiary hospitals, reminders in the Workplace (RW) remained the strongest domain, with a median of 52.5, indicating that visible reminders continue to be more consistently implemented than systemic changes. System Change (SC) scored the lowest with a median of 20 (Table 1). Table 2: HHSAF Assessment Scores of Twenty Public Hospitals in Ethiopia, 2025 3.3. The scores of public hospitals across each domain of the HHSAF There are notable variations in domain-specific scores across the five thematic areas. System change has the lowest weighted score both at secondary hospitals (20:00 (IQR: 13.75)) and at tertiary hospitals 20:00 (IQR: 12.50). None of the hospitals had alcohol-based hand rub (ABHR) continuously available at each point of care, with only 2 (10%) ensuring facility-wide and point-of-care access in majority of wards. Half of the hospitals had a constant supply of clean water, although soap was consistently accessible at sinks in only 6 (30%) and single use towel were universally absent. Furthermore, 95% of hospitals reported the absence of a dedicated budget for hand hygiene products, however, 50% of the hospitals had realistic plan to improve the HH in their respective facilities. The median score for Training and Education (TE) was 35.0 (IQR: 17.50) for secondary and 32.5 (IQR: 18.13) for tertiary hospitals. Gaps in training and education in the study hospitals were evident. Half of hospitals (50%) provided regular HH training for all professional categories at least annually, while the remaining half offered no consistent or structured training. Only 8 hospitals had a process in place to confirm that all healthcare workers completed the training, indicating limited follow-up and accountability mechanisms. Access to WHO hand hygiene resources was inconsistent: ten hospitals had the WHO Guidelines summary, none had the Technical Reference Manual, 11 provided the “Why, How, and When” brochure, and three had the Glove Use Information Leaflet. A majority of hospitals 65% had no professionals with adequate skills designated to train HCWs on HH practice and 40% had structured system for training and evaluating HH compliance observers. Evaluation and Feedback (EF) scored median of 37.5 (IQR: 52.50) in secondary hospitals and median of 38.75 (IQR: 16.88) in tertiary hospitals. Fewer than one fourth conducted regular audits of HH resources and less than half routinely assessed healthcare workers knowledge of correct HH techniques. Direct observation of hand hygiene compliance using WHO’s “My 5 Moments” methodology was limited: six hospitals observed quarterly or more often, three annually, eight irregularly, and three never. Compliance rates were generally below 50% in most hospitals. Although half of the hospitals provided immediate feedback following audits and minority demonstrated regular trend analysis and data sharing. Reminders in the Workplace (RW) achieved the highest scores across both hospital levels — 56.25 (IQR: 38.13) in secondary and 57.50 (IQR: 25.00) in tertiary hospitals. Among the 20 hospitals evaluated, posters explaining indications for HH were available in most wards in 15(75%) of the facilities, while posters on correct hand rub and handwashing techniques were displayed in all wards in only 30% and 25% of hospitals, respectively. Routine audits of poster condition were uncommon, conducted only in 40% of facilities. Furthermore, fewer than half (40%) undertook additional HH promotional activities, and 45% provided information leaflets for patients or visitors. Other workplace reminders, such as screensavers or stickers, were reported in 45% of hospitals. Institutional Safety Climate (ISC) had median scores of 45.0 (IQR: 17.50) for secondary and 47.5 (IQR: 30.00) for tertiary hospitals, suggesting moderate but uneven leadership engagement and safety culture. Only seven hospitals had a dedicated hand hygiene team, all of which met monthly, but only five allocated time for active promotion activities, including teaching, monitoring, and organizing events. Leadership support was strong, with commitment from Chief Executive Officers, Medical Directors, and Directors of Nursing reported in 17 hospitals each. Facility-wide plans for the 5 May “Save Lives: Clean Your Hands” initiative existed in 10 hospitals. Systems to designate hand hygiene champions were in place in nine hospitals, and recognition of role models in seven hospitals. Patient engagement was reported in thirteen hospitals, though only seven had formalized programs. Continuous improvement initiatives were inconsistently applied: three hospitals used e-learning tools, eight set annual institutional targets, four shared tested local innovations, seven included hand hygiene in regular communications, three had personal accountability systems, and nine implemented a buddy system for new employees. 3.4. Overall HHSAF and Institutional safety climate There is a very strong positive correlation (r = 0.98) between the institutional safety climate score and the overall HHSAF score across the twenty hospitals. Facilities with higher safety climate scores consistently attained higher overall HHSAF scores. Conversely, hospitals with weaker safety climates performed poorly overall (Fig. 2 ) 4. Discussion According to this study, the HHSAF score of the public hospitals that were evaluated indicates that most of them operate at a fundamental level of HH implementation. The findings reveal substantial gaps across nearly all components, highlighting persistent challenges to achieving effective and sustainable HH programs in the study hospitals. The lowest median scores in system change at both secondary and tertiary hospitals indicates substantial deficiencies in the supplies and infrastructure required for effective hand hygiene. None of the hospitals had continuous availability of ABHR at point of care, only 2(10%) ensured widespread access in most wards. Although half of the hospitals maintained a regular water supply, 30% access to soap, and none of the facilities access the single use towels. Furthermore, 95% lacked a dedicated for hand hygiene products. These findings are consistent with studies from Low-and Middle-income countries such as Nigeria, Kenya, and India which reported similar infrastructure and resource limitations affecting HH implementation. The low scores observed here suggests persistent barriers to basic resource provision, which is a critical prerequisite for any hand hygiene improvement(De Kraker et al., 2022 ). The absence of soap at every point-of-care sink in most facilities, the universal lack of single-use towels, and the absence of dedicated procurement budgets further undermine the ability to maintain effective hand hygiene practices. These infrastructural gaps are consistent with observations in both high and low resource settings, where suboptimal ABHR and soap availability are associated with lower hand hygiene compliance and increased risk of healthcare-associated infections (Tantum et al., 2021 ). In contrast, system change typically scores much higher especially in high-income settings, due to well-established infrastructure and continuous ABHR availability and reduced HAIs(De Kraker et al., 2022 ; van der Kooi et al., 2022 ). Median scores of education and training were 35.0 (IQR 17.50) in secondary and 32.5 (IQR 18.13) in tertiary hospitals reflecting inadequate and inconsistent capacity building for HCWs. Only half of the hospitals provided regular training to all professionals categories at least once per year, and eight hospitals-maintained mechanisms to verify that all staff completed the training. These findings align with evidence from other LMICs, where training on HH often lacks structure, follow-up, and sustainability (Allegranzi et al., 2013 ; Irek et al., 2019 ). Limited access to WHO resources such as the technical reference manual and glove use guidelines further constraints the effectiveness of educational interventions. WHO emphasizes that regular, structured education tailored to professional roles is cornerstone sustainable improvement (WHO, 2009 , 2010b ). The limited availability of skilled trainers and compliance observers, as well as the absence of dedicated training budgets in most hospitals, are barriers that have been identified in the literature as contributing to poor hand hygiene performance and sustainability of interventions (Tantum et al., 2021 ). The literature underscores that regular, comprehensive training is essential for sustained compliance and is a key driver of higher overall hand hygiene performance (De Kraker et al., 2022 ). Moreover, continuous professional development, practical demonstrations, and simulation-based training have significantly improved compliance and reduced HAIs Click or tap here to enter text. The Evaluation and Feedback Scores determined to be 37.5 (IQR 52.50) in secondary and 38.75 (IQR 16.88) in tertiary hospitals, with a particularly wide IQR in secondary facilities, point to inconsistent monitoring and feedback mechanisms. Fewer than one-fourth hospitals conducted regular audits of HH resources, and less than half evaluated HCWs knowledge. The infrequent ward-based audits, with only four hospitals conducting annual assessments, and the lack of regular monitoring of ABHR and soap consumption, indicate that most facilities lack robust systems for tracking and improving hand hygiene resource availability and use. Direct observation of hand hygiene compliance using the WHO “My 5 Moments” methodology was irregular or absent in the majority of hospitals, and compliance rates were generally below 50%. Immediate feedback to staff was inconsistently provided, and systematic feedback to staff and leadership was not universal. These findings are in line with multicenter surveys demonstrating that inconsistent monitoring and feedback are associated with lower compliance and ineffective hand hygiene programs (Loftus et al., 2019 ; Tantum et al., 2021 ). The reminders in the workplace domain achieved the highest scores 56.25 (IQR 38.13) in secondary and 57.50 (IQR 25.00) in tertiary hospitals indicating widespread use of visual cues such as posters and signage. The available literatures consistently demonstrate that visual cues especially those explaining indications, demonstrating correct handrub use, and illustrating handwashing technique can modestly improve hand hygiene compliance, particularly when combined with other interventions (Gould et al., 2017a ). However, the sustainability and effectiveness of these reminders are highly variable. Audits for poster maintenance are infrequent, and materials are often not regularly updated or replaced, leading to diminished impact over time. Studies have shown that the presence of both visual and verbal reminders is associated with higher compliance rates, but the effect is attenuated when reminders are not actively maintained or when staff become habituated to static cues (Gould et al., 2017b ). Additional promotional materials, such as leaflets and digital reminders, can reinforce key messages, but their reach and influence depend on integration into broader educational and feedback systems (Drey et al., 2020 ). Median scores of 45.0 (IQR 17.50) for secondary and 47.5 (IQR 30.00) for tertiary hospitals in institutional safety climate suggest a moderate but uneven commitment to safety culture and leadership engagement. The global survey found that Institutional Safety Climate often lags behind other domains, and the current findings are consistent with this trend. Leadership support and a strong safety culture are recognized as essential for sustaining hand hygiene improvements, but these elements remain underdeveloped in many settings Facility-wide plans for initiatives such as the 5 May “Save Lives: Clean Your Hands” campaign can galvanize attention and foster a culture of safety, but their impact is contingent on ongoing leadership involvement and integration with continuous improvement activities (De Kraker et al., 2022 ; Glowicz et al., 2023 ). Systems for designating hand hygiene champions and recognizing role models are variably implemented. Recognition and reward mechanisms, including formal acknowledgment of high-performing wards or individuals, have been shown to motivate staff and reinforce positive behaviors (Ssekamatte et al., 2024 ). Patient engagement, through formalized programs that encourage patients to remind healthcare workers about hand hygiene, is recommended and can further enhance accountability, though uptake remains inconsistent (De Kraker et al., 2022 ). Continuous improvement initiatives such as e-learning tools, annual institutional targets, sharing local innovations, regular communications, personal accountability systems, and buddy systems for new employees are variably adopted and often limited by resource constraints and competing priorities (De Kraker et al., 2022 ; Glowicz et al., 2023 ). In addition, embedding hand hygiene into broader patient safety and quality improvement frameworks, with regular feedback and adaptation to local context, is essential for long-term success (Allegranzi et al., 2013 ). Strength and limitations This is a multicentered study and the first of its kind in Ethiopia. It has clearly depicted the gaps in HH implementation in each facility and is general able to other facilities in Ethiopia and resources limited settings. The use of a validated tool and external senior IPC professionals to ensure data quality was commendable. However, the selected facilities were the better performing facilities in terms of IPC and this can potentially inflate the overall IPC score. It is also worth mentioning, across-sectional study may not reliably assess a whole year performance of facilities. 5. Conclusion Despite, the role and impact of HH MMIS implementation in preventing HAIs and fighting AMR is crystal clear, Ethiopia fails to provide a due attention with urgency it deserves. The country healthcare facilities were facing devastating infections due lack in HH infrastructure and resources including capacity building for HH implementation. Facilities must be changing dimension of strategic intervention from fragmented efforts to multimodal strategies and at national level facilitate and coordinate implementation of HH activities using MMIS. This could decrease HAIs and AMR, If implemented accordingly: would decrease facility length of stay and economic burden, providing opportunities for quality care and patient safety. Facilities and policy makers should provide equivalent attention for HH implementation and shifting to containing interventions up on detection of infections occurred due multidrug resistance organisms. Abbreviations AMR Antimicrobial Resistance HHSAF Hand Hygiene Self-Assessment Framework HAIs Healthcare-Associated Infections HH Hand Hygiene IPC Infection Prevention and Control LMICs Low- and Middle-Income Countries HCWs Healthcare Workers WHO World Health Organization MMIS Multimodal Improvement Strategy IQR Interquartile Range RW Workplace Reminders ISC Institutional Safety Climate SC System Change ABHR Alcohol Based Hand-rub WHO World Health Organization FMOH Federal Ministry of Health MDROs Multidrug Resistance Organisms CDC Center of Disease Prevention and Control Declarations Data availability All data generated or analyzed during this study are comprehensively presented within this published article and its supplementary materials. The original datasets supporting the findings are available from the corresponding author upon reasonable request. Acknowledgements We would like to thank our study participants for their willingness to be part of the study and for providing the required data. Authors Contributions Conceptualization: Feyissa Regassa Senbato. Data curation: Feyissa Regassa Senbato, Zelalem Tazu Bonger, Absera Bekalu, Tewodros Asmare Gebru, Heaven Lemma Tisasu, Tesfaye Gudissa Bikila, Samrawit Alemayehu Reta. Formal analysis: Feyissa Regassa Senbato, Zelalem Tazu Bonger, Kehabtimer Shiferaw Kotiso Investigation: Feyissa Regassa Senbato, Zelalem Tazu Bonger. Methodology: Feyissa Regassa Senbato, Zelalem Tazu Bonger, Hailegabriel Abomsa, Teferi Tesfaye Bahru, Zerihun Shimeles Kasa, Garoma Kitessa, Teshome Tekle, Kasu Tola Bifa, Markos Paulos, Robel Wondemagegnehu Tefera, Tiruneh Ararsa Wayessa, Yonas Gashaye Bizuneh. Writing original draft: Feyissa Regassa Senbato, Girmay Medhin, Kibrewosen Aklilu Kiflu, Deneke Wolde Writing review & editing: Feyissa Regassa Senbato, Girmay Medhin, Kibrewossen Aklilu Kiflu, Deneke Wolde, Genet Asfaw Tilahun, Abas Hassen, Wondwossen Amogne, Deneke Ayele, Tadesse Egaule Funding The present study was not funded institutionally or by anyone else. Author information Authors and affiliations 1Infection Prevention and Control Department, Tikur Anbessa Specialized Hospital, College of Health Sciences, Addis Ababa University, P.O. Box 1176, Addis Ababa, Ethiopia Feyissa Regassa Senbato*, Tewodros Asmare, Heaven Lemma Tisasu 2The Ohio State University Global One Health, Addis Ababa, Ethiopia Feyissa Regassa Senbato, Zelalem Bonger Tizazu, and Kibrewossen Aklilu Kifle, Tadesse Eguale, Zerihun Shimeles Kasa 3Aklillu Lemma Institute of Pathobiology, Addis Ababa University, P.O. Box 1176, Addis Ababa, Ethiopia Feyissa Regassa Senbato, Girmay Medhin, Deneke Wolde, & Tadesse Eguale 4Department of Medical Laboratory Science, College of Medicine and Health Sciences, Wachemo University, P.O. Box 667, Hosanna, Ethiopia Deneke Wolde 5Department of Statistics, College of Natural and Computational Sciences, Addis Ababa University, P.O. Box 1176, Addis Ababa, Ethiopia Merga Belina 6Department of Midwifery, College of Medicine and Health Science, Wolkite University, Wolkite, Ethiopia Genet Asfaw Tilahun 7Quality Enhancement and Safety Unit, Tikur Anbessa Specialized Hospital, Addis Ababa University, P.O. Box 1176, Addis Ababa, Ethiopia Absera Bekalu, Tiruneh Ararsa Wayessa, Samrawit Alemayehu Reta, Tesfaye Gudissa Bikila 8Yekatit 12 Medical College Hospital, Addis Ababa, Ethiopia Garoma Kitessa 9Health System Innovation and Quality, Ethiopia Ministry of Health, Addis Ababa, Ethiopia Abas Hassen, Deneke Ayele, 10Infection Prevention and Control Department, Health System Innovation and Quality, Ministry of Health, Addis Ababa, Ethiopia Hailegebriel Abomsa Bedane, Kasu Tola Bifa, Markos Paulos, Robel Wondemagegnehu Tefera 11Infection Prevention and Control Department, Eka Kotebe General Hospital, Addis Ababa, Ethiopia Teferi Tesfaye Bahru 12Department of Public Health, College of Medicine and Health Sciences, Worabe University, Worabe, Ethiopia Kehabtimer Shiferaw Kotiso 13Sante Medical College, Addis Ababa, Ethiopia Yonas Gashaye Bizunesh 14Infection Prevention and Control Department, Addis Ababa City Administration Health Bureau, Addis Ababa, Ethiopia Tashome Tekle 15Department of Internal Medicine, College of Health Sciences, Addis Ababa University, P.O. Box 1176, Addis Ababa, Ethiopia Wondwossen Amogne 16Healthcare Quality, Safety, Infection Prevention and Control, and Innovation, World Health Organization, Addis Ababa, Ethiopia Corresponding author* Feyissa Regassa Senbato Ethical declarations Ethical approval and consent to participate Ethical clearance was obtained from review board of Aklilu Lemma Institute of Pathobiology Research Institutional; Addis Ababa University examined and approved the study protocol and other study materials and confidential maintained at each stage of the study. Participants were obligated to verbally give informed consent, while the information gathered from them was regarded as confidential and personal, with facility identifiers were excluded. Competing interests The authors declare no competing interests References Adal, O., Tsehay, Y. T., Ayenew, B., Abate, T. W., Mekonnen, G. B., Mulatu, S., Mamo, S. T., Ayenew, T., Messelu, M. A., & Belayneh, A. G. (2025). 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L., Apisarnthanarak, A., & Madriaga, G. (2015). The burden of healthcare-associated infections in southeast Asia: A systematic literature review and meta-analysis. In Clinical Infectious Diseases (Vol. 60, Issue 11, pp. 1690–1699). Oxford University Press. https://doi.org/10.1093/cid/civ095 Loftus, M. J., Guitart, C., Tartari, E., Stewardson, A. J., Amer, F., Bellissimo-Rodrigues, F., Lee, Y. F., Mehtar, S., Sithole, B. L., & Pittet, D. (2019). Hand hygiene in low- and middle-income countries. In International Journal of Infectious Diseases (Vol. 86, pp. 25–30). Elsevier B.V. https://doi.org/10.1016/j.ijid.2019.06.002 Sax, H., Allegranzi, B., Uçkay, I., Larson, E., Boyce, J., & Pittet, D. (2007). “My five moments for hand hygiene”: a user-centred design approach to understand, train, monitor and report hand hygiene. In Journal of Hospital Infection (Vol. 67, Issue 1, pp. 9–21). https://doi.org/10.1016/j.jhin.2007.06.004 Ssekamatte, T., Mugambe, R. K., Isunju, J. B., Wanyenze, R. K., Nalugya, A., Adyedo, C., Wafula, S. T., Buregyeya, E., Nuwematsiko, R., Bateman, J., Balen, J., Lusenaka, L., Yakubu, H., & Moe, C. L. (2024). Application of the behaviour-centred design to understand facilitators and deterrents of hand hygiene among healthcare providers: findings from a formative phase of a cluster randomised trial in the Kampala Metropolitan area. BMC Health Services Research , 24 (1). https://doi.org/10.1186/s12913-024-11512-z Steere, A. C., & Mallison, G. F. (2016). Handwashing Practices for the Prevention of Nosocomial Infections . 65 (5), 683–688. https://doi.org/10.7326/0003-4819-83-5-683 Tantum, L. K., Gilstad, J. R., Bolay, F. K., Horng, L. M., Simpson, A. D., Letizia, A. G., Styczynski, A. R., Luby, S. P., & Arthur, R. F. (2021). Barriers and opportunities for sustainable hand hygiene interventions in rural liberian hospitals. International Journal of Environmental Research and Public Health , 18 (16). https://doi.org/10.3390/ijerph18168588 van der Kooi, T., Sax, H., Grundmann, H., Pittet, D., de Greeff, S., van Dissel, J., Clack, L., Wu, A. W., Davitt, J., Kostourou, S., Maguinness, A., Michalik, A., Nedelcu, V., Patyi, M., Perme Hajdinjak, J., Prosen, M., Tellez, D., Varga, É., Veini, F., … Zingg, W. (2022). Hand hygiene improvement of individual healthcare workers: results of the multicentre PROHIBIT study. Antimicrobial Resistance and Infection Control , 11 (1). https://doi.org/10.1186/s13756-022-01148-1 WHO. (2009). WHO guidelines on hand hygiene in health care : first global patient safety challenge : clean care is safer care . WHO. WHO. (2010a). What is its purpose? Who should use the Hand Hygiene Self-Assessment Framework? How is it structured? How does it work? Is the Hand Hygiene Self-Assessment Framework suitable for inter-facility comparison? www.who.int/gpsc/5may/tools WHO. (2010b). What is its purpose? Who should use the Hand Hygiene Self-Assessment Framework? How is it structured? How does it work? Is the Hand Hygiene Self-Assessment Framework suitable for inter-facility comparison? www.who.int/gpsc/5may/tools WHO. (2025). The case for investment and action in infection prevention and control . World Health Organization. https://doi.org/10.2471/B09330 Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-7923983","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":546338927,"identity":"97e6d473-8bf1-4610-927e-9f8c8add763f","order_by":0,"name":"Feyissa Regassa 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10:01:12","extension":"html","order_by":6,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":117115,"visible":true,"origin":"","legend":"","description":"","filename":"earlyproof.html","url":"https://assets-eu.researchsquare.com/files/rs-7923983/v1/a9c9e5ab8841804ed54cd3d8.html"},{"id":96453909,"identity":"e328fb12-41a6-4411-8a6c-4205306ce07b","added_by":"auto","created_at":"2025-11-21 10:02:02","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":25069,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eCharacteristics of Twenty Public Hospitals in Ethiopia\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-7923983/v1/98abc7d96df24faebd51d5b4.png"},{"id":96399681,"identity":"77b2c8e1-ec82-4c4b-bc3b-6020ea362f06","added_by":"auto","created_at":"2025-11-20 16:01:38","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":25152,"visible":true,"origin":"","legend":"\u003cp\u003eOverall hand Hygiene Self-Assessment Framework and Institutional Safety Climate Scores\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-7923983/v1/de03df4620460b669f28e201.png"},{"id":97898359,"identity":"2bf6b1fe-fdf0-4765-81d6-1cbccd0214b7","added_by":"auto","created_at":"2025-12-10 15:39:04","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1052258,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7923983/v1/0753e1da-b93a-4f95-8557-ac83e66588df.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Status of Hand Hygiene Implementation in Public Hospitals of Ethiopia: A Multi-Center Study","fulltext":[{"header":"1.\tIntroduction ","content":"\u003cp\u003eThe consistent emerging of multidrug resistance organisms (MDROs) accompanied by healthcare-associated infections (HAIs) pose a significant threat to patient safety, contributing to increased morbidity, mortality, and healthcare costs (World Health Organization, 2024). Although data on HAIs in low-and middle-income countries (LMICs) remains limited, available evidence indicates a higher prevalence, resulting in a substantial health and economic burdens (Adal et al., \u003cspan class=\"CitationRef\"\u003e2025\u003c/span\u003e; Allegranzi et al., \u003cspan class=\"CitationRef\"\u003e2011\u003c/span\u003e; Ling et al., \u003cspan class=\"CitationRef\"\u003e2015\u003c/span\u003e; Loftus et al., \u003cspan class=\"CitationRef\"\u003e2019\u003c/span\u003e).\u003c/p\u003e\n\u003cp\u003eHand hygiene a cornerstone of IPC, plays a crucial role in reducing HAIs by preventing the transmission of infectious pathogens through the hands of healthcare workers (HCWs), which\u0026mdash;harboring resident and transient flora frequently come into contact with patients, medical equipment, and the healthcare environment during routine clinical activities (Borodova et al., \u003cspan class=\"CitationRef\"\u003e2025\u003c/span\u003e; Sax et al., \u003cspan class=\"CitationRef\"\u003e2007\u003c/span\u003e; Steere \u0026amp; Mallison, \u003cspan class=\"CitationRef\"\u003e2016\u003c/span\u003e).\u003c/p\u003e\n\u003cp\u003eEvidence indicates that MMIS significantly reduces HAIs and mitigates AMR, with a well-structured HH improvement program capable of preventing up to 50% of avoidable infections and yielding economic benefits estimated to be 16 times greater than its implementation cost (WHO, \u003cspan class=\"CitationRef\"\u003e2025\u003c/span\u003e). A 2019 global survey using the HHSAF revealed that most healthcare facilities achieved an intermediate level of HH implementation with a median score of 350/500 points, while in a study from Sierra Leone the mean score was 273 and inadequate budgets for HH resources and lack of stronger institutional safety climate were identified as major gaps (De Kraker et al., \u003cspan class=\"CitationRef\"\u003e2022\u003c/span\u003e; Lakoh et al., \u003cspan class=\"CitationRef\"\u003e2022\u003c/span\u003e).\u003c/p\u003e\n\u003cp\u003eDespite global development, HH compliance remains suboptimal, (Lambe et al., \u003cspan class=\"CitationRef\"\u003e2019\u003c/span\u003e), especially in low resource settings where barriers such as inadequate infrastructure, resource limitations, and lack training persist (Didier Pittet, \u003cspan class=\"CitationRef\"\u003e2001\u003c/span\u003e).\u003c/p\u003e\n\u003cp\u003eIn developing countries, including Ethiopia, where the burden of HAIs is disproportionately high, improving HH in healthcare facilities is critical for patient safety (Allegranzi et al., \u003cspan class=\"CitationRef\"\u003e2017\u003c/span\u003e).\u003c/p\u003e\n\u003cp\u003eIn this study, a baseline assessment was conducted in twenty public hospitals across Ethiopia, to identify existing gaps, assess facility readiness, and generate evidence to guide targeted interventions for improvements of HH promotion and practices across the country. Furthermore, conducting this study is timely and strategically aligned with the Ethiopian Federal Ministry of Health (FMOH) efforts to initiate HAIs surveillance in twenty selected public hospitals.\u003c/p\u003e"},{"header":"2.\tMethods","content":"\u003cp\u003e\u003cstrong\u003eContext of study settings\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eEthiopia has a population of over 105 million (2021), and administratively divided into 11 regions and two city administrations. The country has a three-tier healthcare delivery system with more than 353 public hospitals, 3,706 public health centers, and 17,561 health posts. (Alemu et al., \u003cspan class=\"CitationRef\"\u003e2025\u003c/span\u003e).\u003c/p\u003e\n\u003cp\u003eThe country is currently advancing efforts to strengthen the capacity of healthcare facilities and the quality of care, with a particular focus on HAIs caused by MDROs. To this effect, the FMOH is planning to piloting an HAI surveillance program across the country. As part of this initiative, the Ministry conducted a series of capacity assessments covering overall IPC and microbiology service using a tool adapted from CDC. The purpose was to identify healthcare facilities with acceptable adherence to IPC standards were considered essential for rolling out an HAI surveillance program. Based on the results, twenty public hospitals were selected to serve as national HAIs surveillance sentinel sites. The current study was conducted in these 20 HAIs surveillance sites to evaluate the HH MMIS implementation status of each facility before commencement of HAIs surveillance. Hence, FMOH to make informed decision to initiate the surveillance.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eStudy design\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eA multicenter, cross-sectional study design was conducted over the twenty public hospitals from eight of the 14 regions in Ethiopia. Thus, the study covered approximately 72% of the regions in the country. Data collection was conducted from January 1 to March 30, 2025.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData collection tool, procedure, and quality assurance.\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAs a part HH development approaches, the WHO prepared the MMIS, consisting of five key components: system change, training and education, monitoring and feedback, workplace reminders/communications, and institutional safety climate/culture change (WHO, \u003cspan class=\"CitationRef\"\u003e2009\u003c/span\u003e). The framework consists of 27 indicators, each having values ranging from 5 to 50 points, distributed across five MMIS components, each worth 100 points.\u003c/p\u003e\n\u003cp\u003eAccording to the WHO HHSAF user guide, the assessment should be completed by IPC professionals directly responsible for implementing HH improvement strategies at the facility level. Thus, one IPC focal person fully dedicated to IPC was recruited from each of the twenty selected hospitals and completed the standardized questionnaires. Furthermore, three senior external IPC officers were employed to ensure data quality and consistency during the data collection process. The officers carried out a comprehensive assessment of filled HHSAF tools and verified the information through planned interviews with each facility focal persons.\u003c/p\u003e\n\u003cp\u003eThe study assigned levels for each of the five MMIS elements according to the WHO assessment, categorizing facilities into four groups: inadequate (\u0026le;\u0026thinsp;25), basic (26\u0026ndash;50), intermediate (51\u0026ndash;75), and advanced (\u0026gt;\u0026thinsp;75). Moreover, based on the overall score of a facility, an HH implementation level was assigned as inadequate (0-125 points), basic (126\u0026ndash;250 points), intermediate (251\u0026ndash;375 points), or advanced (376\u0026ndash;500 points) (WHO, \u003cspan class=\"CitationRef\"\u003e2010a\u003c/span\u003e).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData analysis\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eData was entered, cleaned, and analyzed using SPSS version 25. The key indicators in each domain were summarized using basic descriptive analysis, and aggregated data were examined independently for each facility. Descriptive statistics were initially used to summarize HHSAF scores and categorize hospitals into implementation levels. Subgroup analysis was also carried out using component-specific scores, calculating the median and interquartile ranges for each core components. The median and interquartile range were used to summarize the HHSAF results and scores for each of the MMIS elements. The correlation between HHSAF component scores and overall HH was assessed using the Pearson correlation coefficient (r).\u003c/p\u003e"},{"header":"3.\tResults ","content":"\u003cdiv class=\"Heading\"\u003e3.1. \u003cstrong\u003eWorkforce and bed capacity of facilities involved in the study\u003c/strong\u003e\u003c/div\u003e\n\u003cdiv id=\"Sec4\" class=\"Section2\"\u003e\n \u003cp\u003eThe finding shows that tertiary hospitals have many beds (median\u0026thinsp;=\u0026thinsp;326.5) and staff (median\u0026thinsp;=\u0026thinsp;711.5) compared to secondary hospitals (median\u0026thinsp;=\u0026thinsp;578.5 for beds and 908 for staff). (Fig. \u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e). All studied facilities have an IPC program and dedicated full-time IPC officers.\u003c/p\u003e\n \u003cp\u003e3.2. \u003cstrong\u003eHHSAF Scores Assessment of Twenty Public Hospitals in Ethiopia\u003c/strong\u003e\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec5\" class=\"Section2\"\u003e\n \u003cp\u003eThe overall median HHSAF score was 203.75(IQR: 153.75-233.75), categorizing it within the basic HH implementation level. A marginally elevated score was noted in tertiary hospitals (210; IQR: 152\u0026ndash;225) in comparison to secondary hospitals (178; IQR: 155-197.5).\u003c/p\u003e\n \u003cp\u003eFour out of the twenty public hospitals achieved intermediate-level performance. Three of these intermediate performing facilities are among the secondary hospitals, and one of them is among the tertiary hospitals. The MMIS of the majority of hospitals is at a basic level, while two hospitals attained an inadequate hand hygiene level (Fig. \u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e). In secondary hospitals, reminders in the workplace (RW) had the highest median score of 63.75.\u003c/p\u003e\n \u003cp\u003eInstitutional Safety Climate (ISC) lagged behind with a median of 45, highlighting a weaker organizational culture and commitment to safety practices. In tertiary hospitals, reminders in the Workplace (RW) remained the strongest domain, with a median of 52.5, indicating that visible reminders continue to be more consistently implemented than systemic changes. System Change (SC) scored the lowest with a median of 20 (Table\u0026nbsp;1).\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eTable 2: HHSAF Assessment Scores of Twenty Public Hospitals in Ethiopia, 2025\u003c/strong\u003e\u003c/p\u003e\n \u003cdiv class=\"gridtable\"\u003e\n \u003cdiv align=\"left\" class=\"colspec\"\u003e\u003cimg 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\"\u003e\u003c/div\u003e\n \u003cdiv align=\"left\" class=\"colspec\"\u003e\u003cbr\u003e\u003c/div\u003e\n \u003c/div\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec6\" class=\"Section2\"\u003e\n \u003ch2\u003e3.3. The scores of public hospitals across each domain of the HHSAF\u003c/h2\u003e\n \u003cp\u003eThere are notable variations in domain-specific scores across the five thematic areas. System change has the lowest weighted score both at secondary hospitals (20:00 (IQR: 13.75)) and at tertiary hospitals 20:00 (IQR: 12.50). None of the hospitals had alcohol-based hand rub (ABHR) continuously available at each point of care, with only 2 (10%) ensuring facility-wide and point-of-care access in majority of wards. Half of the hospitals had a constant supply of clean water, although soap was consistently accessible at sinks in only 6 (30%) and single use towel were universally absent. Furthermore, 95% of hospitals reported the absence of a dedicated budget for hand hygiene products, however, 50% of the hospitals had realistic plan to improve the HH in their respective facilities.\u003c/p\u003e\n \u003cp\u003eThe median score for \u003cem\u003eTraining and Education (TE)\u003c/em\u003e was 35.0 (IQR: 17.50) for secondary and 32.5 (IQR: 18.13) for tertiary hospitals. Gaps in training and education in the study hospitals were evident. Half of hospitals (50%) provided regular HH training for all professional categories at least annually, while the remaining half offered no consistent or structured training. Only 8 hospitals had a process in place to confirm that all healthcare workers completed the training, indicating limited follow-up and accountability mechanisms. Access to WHO hand hygiene resources was inconsistent: ten hospitals had the WHO Guidelines summary, none had the Technical Reference Manual, 11 provided the \u0026ldquo;Why, How, and When\u0026rdquo; brochure, and three had the Glove Use Information Leaflet. A majority of hospitals 65% had no professionals with adequate skills designated to train HCWs on HH practice and 40% had structured system for training and evaluating HH compliance observers.\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eEvaluation and Feedback (EF)\u003c/strong\u003e scored median of 37.5 (IQR: 52.50) in secondary hospitals and median of 38.75 (IQR: 16.88) in tertiary hospitals. Fewer than one fourth conducted regular audits of HH resources and less than half routinely assessed healthcare workers knowledge of correct HH techniques. Direct observation of hand hygiene compliance using WHO\u0026rsquo;s \u0026ldquo;My 5 Moments\u0026rdquo; methodology was limited: six hospitals observed quarterly or more often, three annually, eight irregularly, and three never.\u003c/p\u003e\n \u003cp\u003eCompliance rates were generally below 50% in most hospitals. Although half of the hospitals provided immediate feedback following audits and minority demonstrated regular trend analysis and data sharing.\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eReminders in the Workplace (RW)\u003c/strong\u003e achieved the highest scores across both hospital levels \u0026mdash; 56.25 (IQR: 38.13) in secondary and 57.50 (IQR: 25.00) in tertiary hospitals. Among the 20 hospitals evaluated, posters explaining indications for HH were available in most wards in 15(75%) of the facilities, while posters on correct hand rub and handwashing techniques were displayed in all wards in only 30% and 25% of hospitals, respectively. Routine audits of poster condition were uncommon, conducted only in 40% of facilities. Furthermore, fewer than half (40%) undertook additional HH promotional activities, and 45% provided information leaflets for patients or visitors. Other workplace reminders, such as screensavers or stickers, were reported in 45% of hospitals.\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eInstitutional Safety Climate (ISC)\u003c/strong\u003e had median scores of 45.0 (IQR: 17.50) for secondary and 47.5 (IQR: 30.00) for tertiary hospitals, suggesting moderate but uneven leadership engagement and safety culture.\u003c/p\u003e\n \u003cp\u003eOnly seven hospitals had a dedicated hand hygiene team, all of which met monthly, but only five allocated time for active promotion activities, including teaching, monitoring, and organizing events. Leadership support was strong, with commitment from Chief Executive Officers, Medical Directors, and Directors of Nursing reported in 17 hospitals each. Facility-wide plans for the 5 May \u0026ldquo;Save Lives: Clean Your Hands\u0026rdquo; initiative existed in 10 hospitals.\u003c/p\u003e\n \u003cp\u003eSystems to designate hand hygiene champions were in place in nine hospitals, and recognition of role models in seven hospitals. Patient engagement was reported in thirteen hospitals, though only seven had formalized programs. Continuous improvement initiatives were inconsistently applied: three hospitals used e-learning tools, eight set annual institutional targets, four shared tested local innovations, seven included hand hygiene in regular communications, three had personal accountability systems, and nine implemented a buddy system for new employees.\u003c/p\u003e\n\u003c/div\u003e\n\u003cdiv id=\"Sec7\" class=\"Section2\"\u003e\n \u003ch2\u003e3.4. \u003cstrong\u003eOverall HHSAF and Institutional safety climate\u003c/strong\u003e\u003c/h2\u003e\n \u003cp\u003eThere is a very strong positive correlation (r\u0026thinsp;=\u0026thinsp;0.98) between the institutional safety climate score and the overall HHSAF score across the twenty hospitals. Facilities with higher safety climate scores consistently attained higher overall HHSAF scores. Conversely, hospitals with weaker safety climates performed poorly overall (Fig. \u003cspan class=\"InternalRef\"\u003e2\u003c/span\u003e)\u003c/p\u003e\n\u003c/div\u003e"},{"header":"4.\tDiscussion ","content":"\u003cp\u003eAccording to this study, the HHSAF score of the public hospitals that were evaluated indicates that most of them operate at a fundamental level of HH implementation. The findings reveal substantial gaps across nearly all components, highlighting persistent challenges to achieving effective and sustainable HH programs in the study hospitals.\u003c/p\u003e\n\u003cp\u003eThe lowest median scores in \u003cstrong\u003esystem change\u003c/strong\u003e at both secondary and tertiary hospitals indicates substantial deficiencies in the supplies and infrastructure required for effective hand hygiene. None of the hospitals had continuous availability of ABHR at point of care, only 2(10%) ensured widespread access in most wards. Although half of the hospitals maintained a regular water supply, 30% access to soap, and none of the facilities access the single use towels. Furthermore, 95% lacked a dedicated for hand hygiene products.\u003c/p\u003e\n\u003cp\u003eThese findings are consistent with studies from Low-and Middle-income countries such as Nigeria, Kenya, and India which reported similar infrastructure and resource limitations affecting HH implementation. The low scores observed here suggests persistent barriers to basic resource provision, which is a critical prerequisite for any hand hygiene improvement(De Kraker et al., \u003cspan class=\"CitationRef\"\u003e2022\u003c/span\u003e). The absence of soap at every point-of-care sink in most facilities, the universal lack of single-use towels, and the absence of dedicated procurement budgets further undermine the ability to maintain effective hand hygiene practices. These infrastructural gaps are consistent with observations in both high and low resource settings, where suboptimal ABHR and soap availability are associated with lower hand hygiene compliance and increased risk of healthcare-associated infections (Tantum et al., \u003cspan class=\"CitationRef\"\u003e2021\u003c/span\u003e).\u003c/p\u003e\n\u003cp\u003eIn contrast, system change typically scores much higher especially in high-income settings, due to well-established infrastructure and continuous ABHR availability and reduced HAIs(De Kraker et al., \u003cspan class=\"CitationRef\"\u003e2022\u003c/span\u003e; van der Kooi et al., \u003cspan class=\"CitationRef\"\u003e2022\u003c/span\u003e).\u003c/p\u003e\n\u003cp\u003eMedian scores of \u003cstrong\u003eeducation and training\u003c/strong\u003e were 35.0 (IQR 17.50) in secondary and 32.5 (IQR 18.13) in tertiary hospitals reflecting inadequate and inconsistent capacity building for HCWs. Only half of the hospitals provided regular training to all professionals categories at least once per year, and eight hospitals-maintained mechanisms to verify that all staff completed the training. These findings align with evidence from other LMICs, where training on HH often lacks structure, follow-up, and sustainability (Allegranzi et al., \u003cspan class=\"CitationRef\"\u003e2013\u003c/span\u003e; Irek et al., \u003cspan class=\"CitationRef\"\u003e2019\u003c/span\u003e). Limited access to WHO resources such as the technical reference manual and glove use guidelines further constraints the effectiveness of educational interventions. WHO emphasizes that regular, structured education tailored to professional roles is cornerstone sustainable improvement (WHO, \u003cspan class=\"CitationRef\"\u003e2009\u003c/span\u003e, \u003cspan class=\"CitationRef\"\u003e2010b\u003c/span\u003e).\u003c/p\u003e\n\u003cp\u003eThe limited availability of skilled trainers and compliance observers, as well as the absence of dedicated training budgets in most hospitals, are barriers that have been identified in the literature as contributing to poor hand hygiene performance and sustainability of interventions (Tantum et al., \u003cspan class=\"CitationRef\"\u003e2021\u003c/span\u003e). The literature underscores that regular, comprehensive training is essential for sustained compliance and is a key driver of higher overall hand hygiene performance (De Kraker et al., \u003cspan class=\"CitationRef\"\u003e2022\u003c/span\u003e). Moreover, continuous professional development, practical demonstrations, and simulation-based training have significantly improved compliance and reduced HAIs Click or tap here to enter text.\u003c/p\u003e\n\u003cp\u003eThe \u003cstrong\u003eEvaluation and Feedback\u003c/strong\u003e Scores determined to be 37.5 (IQR 52.50) in secondary and 38.75 (IQR 16.88) in tertiary hospitals, with a particularly wide IQR in secondary facilities, point to inconsistent monitoring and feedback mechanisms. Fewer than one-fourth hospitals conducted regular audits of HH resources, and less than half evaluated HCWs knowledge. The infrequent ward-based audits, with only four hospitals conducting annual assessments, and the lack of regular monitoring of ABHR and soap consumption, indicate that most facilities lack robust systems for tracking and improving hand hygiene resource availability and use.\u003c/p\u003e\n\u003cp\u003eDirect observation of hand hygiene compliance using the WHO \u0026ldquo;My 5 Moments\u0026rdquo; methodology was irregular or absent in the majority of hospitals, and compliance rates were generally below 50%. Immediate feedback to staff was inconsistently provided, and systematic feedback to staff and leadership was not universal. These findings are in line with multicenter surveys demonstrating that inconsistent monitoring and feedback are associated with lower compliance and ineffective hand hygiene programs (Loftus et al., \u003cspan class=\"CitationRef\"\u003e2019\u003c/span\u003e; Tantum et al., \u003cspan class=\"CitationRef\"\u003e2021\u003c/span\u003e).\u003c/p\u003e\n\u003cp\u003eThe \u003cstrong\u003ereminders in the workplace\u003c/strong\u003e domain achieved the highest scores 56.25 (IQR 38.13) in secondary and 57.50 (IQR 25.00) in tertiary hospitals indicating widespread use of visual cues such as posters and signage. The available literatures consistently demonstrate that visual cues especially those explaining indications, demonstrating correct handrub use, and illustrating handwashing technique can modestly improve hand hygiene compliance, particularly when combined with other interventions (Gould et al., \u003cspan class=\"CitationRef\"\u003e2017a\u003c/span\u003e). However, the sustainability and effectiveness of these reminders are highly variable. Audits for poster maintenance are infrequent, and materials are often not regularly updated or replaced, leading to diminished impact over time. Studies have shown that the presence of both visual and verbal reminders is associated with higher compliance rates, but the effect is attenuated when reminders are not actively maintained or when staff become habituated to static cues (Gould et al., \u003cspan class=\"CitationRef\"\u003e2017b\u003c/span\u003e). Additional promotional materials, such as leaflets and digital reminders, can reinforce key messages, but their reach and influence depend on integration into broader educational and feedback systems (Drey et al., \u003cspan class=\"CitationRef\"\u003e2020\u003c/span\u003e).\u003c/p\u003e\n\u003cp\u003eMedian scores of 45.0 (IQR 17.50) for secondary and 47.5 (IQR 30.00) for tertiary hospitals in \u003cstrong\u003einstitutional safety climate\u003c/strong\u003e suggest a moderate but uneven commitment to safety culture and leadership engagement. The global survey found that Institutional Safety Climate often lags behind other domains, and the current findings are consistent with this trend. Leadership support and a strong safety culture are recognized as essential for sustaining hand hygiene improvements, but these elements remain underdeveloped in many settings Facility-wide plans for initiatives such as the 5 May \u0026ldquo;Save Lives: Clean Your Hands\u0026rdquo; campaign can galvanize attention and foster a culture of safety, but their impact is contingent on ongoing leadership involvement and integration with continuous improvement activities (De Kraker et al., \u003cspan class=\"CitationRef\"\u003e2022\u003c/span\u003e; Glowicz et al., \u003cspan class=\"CitationRef\"\u003e2023\u003c/span\u003e).\u003c/p\u003e\n\u003cp\u003eSystems for designating hand hygiene champions and recognizing role models are variably implemented. Recognition and reward mechanisms, including formal acknowledgment of high-performing wards or individuals, have been shown to motivate staff and reinforce positive behaviors (Ssekamatte et al., \u003cspan class=\"CitationRef\"\u003e2024\u003c/span\u003e).\u003c/p\u003e\n\u003cp\u003ePatient engagement, through formalized programs that encourage patients to remind healthcare workers about hand hygiene, is recommended and can further enhance accountability, though uptake remains inconsistent (De Kraker et al., \u003cspan class=\"CitationRef\"\u003e2022\u003c/span\u003e). Continuous improvement initiatives such as e-learning tools, annual institutional targets, sharing local innovations, regular communications, personal accountability systems, and buddy systems for new employees are variably adopted and often limited by resource constraints and competing priorities (De Kraker et al., \u003cspan class=\"CitationRef\"\u003e2022\u003c/span\u003e; Glowicz et al., \u003cspan class=\"CitationRef\"\u003e2023\u003c/span\u003e). In addition, embedding hand hygiene into broader patient safety and quality improvement frameworks, with regular feedback and adaptation to local context, is essential for long-term success (Allegranzi et al., \u003cspan class=\"CitationRef\"\u003e2013\u003c/span\u003e).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eStrength and limitations\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis is a multicentered study and the first of its kind in Ethiopia. It has clearly depicted the gaps in HH implementation in each facility and is general able to other facilities in Ethiopia and resources limited settings. The use of a validated tool and external senior IPC professionals to ensure data quality was commendable. However, the selected facilities were the better performing facilities in terms of IPC and this can potentially inflate the overall IPC score. It is also worth mentioning, across-sectional study may not reliably assess a whole year performance of facilities.\u003c/p\u003e\n\u003cp\u003e\u003cbr\u003e\u003c/p\u003e"},{"header":"5.\tConclusion","content":"\u003cp\u003eDespite, the role and impact of HH MMIS implementation in preventing HAIs and fighting AMR is crystal clear, Ethiopia fails to provide a due attention with urgency it deserves. The country healthcare facilities were facing devastating infections due lack in HH infrastructure and resources including capacity building for HH implementation. Facilities must be changing dimension of strategic intervention from fragmented efforts to multimodal strategies and at national level facilitate and coordinate implementation of HH activities using MMIS. This could decrease HAIs and AMR, If implemented accordingly: would decrease facility length of stay and economic burden, providing opportunities for quality care and patient safety. Facilities and policy makers should provide equivalent attention for HH implementation and shifting to containing interventions up on detection of infections occurred due multidrug resistance organisms.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eAMR\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eAntimicrobial Resistance\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eHHSAF\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eHand Hygiene Self-Assessment Framework\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eHAIs\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eHealthcare-Associated Infections\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eHH\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eHand Hygiene\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eIPC\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eInfection Prevention and Control\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eLMICs\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eLow- and Middle-Income Countries\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eHCWs\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eHealthcare Workers\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eWHO\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eWorld Health Organization\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eMMIS\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eMultimodal Improvement Strategy\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eIQR\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eInterquartile Range\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eRW\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eWorkplace Reminders\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eISC\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eInstitutional Safety Climate\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eSC\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eSystem Change\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eABHR\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eAlcohol Based Hand-rub\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eWHO\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eWorld Health Organization\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eFMOH\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eFederal Ministry of Health\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eMDROs\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eMultidrug Resistance Organisms\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eCDC\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eCenter of Disease Prevention and Control\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eData availability\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll data generated or analyzed during this study are comprehensively presented within this published article and its supplementary materials. The original datasets supporting the findings are available from the corresponding author upon reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe would like to thank our study participants for their willingness to be part of the study and for providing the required data.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors Contributions\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eConceptualization: Feyissa Regassa Senbato.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eData curation: Feyissa Regassa Senbato, Zelalem Tazu Bonger, Absera Bekalu, Tewodros Asmare Gebru, Heaven Lemma Tisasu, Tesfaye Gudissa Bikila, Samrawit Alemayehu Reta.\u003c/p\u003e\n\u003cp\u003eFormal analysis: Feyissa Regassa Senbato, Zelalem Tazu Bonger, Kehabtimer Shiferaw Kotiso\u003c/p\u003e\n\u003cp\u003eInvestigation: Feyissa Regassa Senbato, Zelalem Tazu Bonger.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eMethodology: Feyissa Regassa Senbato, Zelalem Tazu Bonger, Hailegabriel Abomsa, Teferi Tesfaye Bahru, Zerihun Shimeles Kasa, Garoma Kitessa, Teshome Tekle, Kasu Tola Bifa, Markos Paulos, Robel Wondemagegnehu Tefera, Tiruneh Ararsa Wayessa, Yonas Gashaye Bizuneh.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eWriting original draft: Feyissa Regassa Senbato, Girmay Medhin, Kibrewosen Aklilu Kiflu, Deneke Wolde\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eWriting review \u0026amp; editing: Feyissa Regassa Senbato, Girmay Medhin, Kibrewossen Aklilu Kiflu, Deneke Wolde, Genet Asfaw Tilahun, Abas Hassen, Wondwossen Amogne, Deneke Ayele, Tadesse Egaule\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eFunding\u0026nbsp;\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe present study was not funded institutionally or by anyone else.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor information\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors and affiliations\u003c/strong\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e1Infection Prevention and Control Department, Tikur Anbessa Specialized Hospital, College of Health Sciences, Addis Ababa University, P.O. Box 1176, Addis Ababa, Ethiopia\u003c/p\u003e\n\u003cp\u003eFeyissa Regassa Senbato*, Tewodros Asmare, Heaven Lemma Tisasu\u003c/p\u003e\n\u003cp\u003e2The Ohio State University Global One Health, Addis Ababa, Ethiopia\u003c/p\u003e\n\u003cp\u003eFeyissa Regassa Senbato, Zelalem Bonger Tizazu, and Kibrewossen Aklilu Kifle, Tadesse Eguale, Zerihun Shimeles Kasa\u003c/p\u003e\n\u003cp\u003e3Aklillu Lemma Institute of Pathobiology, Addis Ababa University, P.O. Box 1176, Addis Ababa, Ethiopia\u003c/p\u003e\n\u003cp\u003eFeyissa Regassa Senbato, Girmay Medhin, Deneke Wolde, \u0026amp; Tadesse Eguale\u003c/p\u003e\n\u003cp\u003e4Department of Medical Laboratory Science, College of Medicine and Health Sciences, Wachemo University, P.O. Box 667, Hosanna, Ethiopia\u003c/p\u003e\n\u003cp\u003eDeneke Wolde\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e5Department of Statistics, College of Natural and Computational Sciences, Addis Ababa University, P.O. Box 1176, Addis Ababa, Ethiopia\u003c/p\u003e\n\u003cp\u003eMerga Belina \u0026nbsp;\u003c/p\u003e\n\u003cp\u003e6Department of Midwifery, College of Medicine and Health Science, Wolkite University, Wolkite, Ethiopia\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eGenet Asfaw Tilahun\u003c/p\u003e\n\u003cp\u003e7Quality Enhancement and Safety Unit, Tikur Anbessa Specialized Hospital, Addis Ababa University, P.O. Box 1176, Addis Ababa, Ethiopia\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAbsera Bekalu, Tiruneh Ararsa Wayessa, Samrawit Alemayehu Reta, Tesfaye Gudissa Bikila\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e8Yekatit 12 Medical College Hospital, Addis Ababa, Ethiopia\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eGaroma Kitessa\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e9Health System Innovation and Quality, Ethiopia Ministry of Health, Addis Ababa, Ethiopia\u003c/p\u003e\n\u003cp\u003eAbas Hassen, Deneke Ayele,\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e10Infection Prevention and Control Department, Health System Innovation and Quality, Ministry of Health, Addis Ababa, Ethiopia\u003c/p\u003e\n\u003cp\u003eHailegebriel Abomsa Bedane, Kasu Tola Bifa, Markos Paulos, Robel Wondemagegnehu Tefera\u003c/p\u003e\n\u003cp\u003e11Infection Prevention and Control Department, Eka Kotebe General Hospital, Addis Ababa, Ethiopia\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eTeferi Tesfaye Bahru\u003c/p\u003e\n\u003cp\u003e12Department of Public Health, College of Medicine and Health Sciences, Worabe University, Worabe, Ethiopia\u003c/p\u003e\n\u003cp\u003eKehabtimer Shiferaw Kotiso\u003c/p\u003e\n\u003cp\u003e13Sante Medical College, Addis Ababa, Ethiopia\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eYonas Gashaye Bizunesh\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e14Infection Prevention and Control Department, Addis Ababa City Administration Health Bureau, Addis Ababa, Ethiopia\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eTashome Tekle\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e15Department of Internal Medicine, College of Health Sciences, Addis Ababa University, P.O. Box 1176, Addis Ababa, Ethiopia\u003c/p\u003e\n\u003cp\u003eWondwossen Amogne\u003c/p\u003e\n\u003cp\u003e16Healthcare Quality, Safety, Infection Prevention and Control, and Innovation, World Health Organization, Addis Ababa, Ethiopia\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCorresponding author*\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eFeyissa Regassa Senbato\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eEthical declarations\u003c/p\u003e\n\u003cp\u003eEthical approval and consent to participate\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eEthical clearance was obtained from review board of Aklilu Lemma Institute of Pathobiology Research Institutional; Addis Ababa University examined and approved the study protocol and other study materials and confidential maintained at each stage of the study.\u0026nbsp;Participants were obligated to verbally give informed consent, while the information gathered from them was regarded as confidential and personal, with facility identifiers were excluded.\u003c/p\u003e\n\u003cp\u003eCompeting interests\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe authors declare no competing interests\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n \u003cli\u003eAdal, O., Tsehay, Y. 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Implementation of hand hygiene in health-care facilities: results from the WHO Hand Hygiene Self-Assessment Framework global survey 2019. \u003cem\u003eThe Lancet Infectious Diseases\u003c/em\u003e, \u003cem\u003e22\u003c/em\u003e(6), 835\u0026ndash;844. https://doi.org/10.1016/S1473-3099(21)00618-6\u003c/li\u003e\n \u003cli\u003eDidier Pittet. (2001). \u003cem\u003eSpecial Issue\u003c/em\u003e. https://pmc.ncbi.nlm.nih.gov/articles/PMC2631736/pdf/11294714.pdf\u003c/li\u003e\n \u003cli\u003eDrey, N., Gould, D., Purssell, E., Chudleigh, J., Moralejo, D., Gallagher, R., Jeanes, A., Wigglesworth, N., \u0026amp; Pittet, D. (2020). Applying thematic synthesis to interpretation and commentary in epidemiological studies: Identifying what contributes to successful interventions to promote hand hygiene in patient care. \u003cem\u003eBMJ Quality and Safety\u003c/em\u003e, \u003cem\u003e29\u003c/em\u003e(9), 756\u0026ndash;763. https://doi.org/10.1136/bmjqs-2019-009833\u003c/li\u003e\n \u003cli\u003eGlowicz, J. B., Landon, E., Sickbert-Bennett, E. E., Aiello, A. E., Dekay, K., Hoffmann, K. K., Maragakis, L., Olmsted, R. N., Polgreen, P. M., Trexler, P. A., Vanamringe, M. A., Wood, A. R., Yokoe, D., \u0026amp; Ellingson, K. D. (2023). SHEA/IDSA/APIC Practice Recommendation: Strategies to prevent healthcare-associated infections through hand hygiene: 2022 Update. \u003cem\u003eInfection Control and Hospital Epidemiology\u003c/em\u003e, \u003cem\u003e44\u003c/em\u003e(3), 355\u0026ndash;376. https://doi.org/10.1017/ice.2022.304\u003c/li\u003e\n \u003cli\u003eGould, D. J., Moralejo, D., Drey, N., Chudleigh, J. H., \u0026amp; Taljaard, M. (2017a). Interventions to improve hand hygiene compliance in patient care. In \u003cem\u003eCochrane Database of Systematic Reviews\u003c/em\u003e (Vol. 2017, Issue 9). John Wiley and Sons Ltd. https://doi.org/10.1002/14651858.CD005186.pub4\u003c/li\u003e\n \u003cli\u003eGould, D. J., Moralejo, D., Drey, N., Chudleigh, J. H., \u0026amp; Taljaard, M. (2017b). Interventions to improve hand hygiene compliance in patient care. In \u003cem\u003eCochrane Database of Systematic Reviews\u003c/em\u003e (Vol. 2017, Issue 9). John Wiley and Sons Ltd. https://doi.org/10.1002/14651858.CD005186.pub4\u003c/li\u003e\n \u003cli\u003eIrek, E. O., Aliyu, A. A., Dahiru, T., Obadare, T. O., \u0026amp; Aboderin, A. O. (2019). Healthcare-associated infections and compliance of hand hygiene among healthcare workers in a tertiary health facility, southwest Nigeria. \u003cem\u003eJournal of Infection Prevention\u003c/em\u003e, \u003cem\u003e20\u003c/em\u003e(6), 289\u0026ndash;296. https://doi.org/10.1177/1757177419848141\u003c/li\u003e\n \u003cli\u003eLakoh, S., Maruta, A., Kallon, C., Deen, G. F., Russell, J. B. W., Fofanah, B. D., Kamara, I. F., Kanu, J. S., Kamara, D., Molleh, B., Adekanmbi, O., Tavernor, S., Guth, J., Sagili, K. D., \u0026amp; Wilkinson, E. (2022). How Well Are Hand Hygiene Practices and Promotion Implemented in Sierra Leone? A Cross-Sectional Study in 13 Public Hospitals. \u003cem\u003eInternational Journal of Environmental Research and Public Health\u003c/em\u003e, \u003cem\u003e19\u003c/em\u003e(7). https://doi.org/10.3390/ijerph19073787\u003c/li\u003e\n \u003cli\u003eLambe, K. A., Lydon, S., Madden, C., Vellinga, A., Hehir, A., Walsh, M., \u0026amp; O\u0026rsquo;Connor, P. (2019). Hand hygiene compliance in the ICU: A systematic review. In \u003cem\u003eCritical Care Medicine\u003c/em\u003e (Vol. 47, Issue 9, pp. 1251\u0026ndash;1257). Lippincott Williams and Wilkins. https://doi.org/10.1097/CCM.0000000000003868\u003c/li\u003e\n \u003cli\u003eLing, M. L., Apisarnthanarak, A., \u0026amp; Madriaga, G. (2015). The burden of healthcare-associated infections in southeast Asia: A systematic literature review and meta-analysis. In \u003cem\u003eClinical Infectious Diseases\u003c/em\u003e (Vol. 60, Issue 11, pp. 1690\u0026ndash;1699). Oxford University Press. https://doi.org/10.1093/cid/civ095\u003c/li\u003e\n \u003cli\u003eLoftus, M. J., Guitart, C., Tartari, E., Stewardson, A. J., Amer, F., Bellissimo-Rodrigues, F., Lee, Y. F., Mehtar, S., Sithole, B. L., \u0026amp; Pittet, D. (2019). Hand hygiene in low- and middle-income countries. In \u003cem\u003eInternational Journal of Infectious Diseases\u003c/em\u003e (Vol. 86, pp. 25\u0026ndash;30). Elsevier B.V. https://doi.org/10.1016/j.ijid.2019.06.002\u003c/li\u003e\n \u003cli\u003eSax, H., Allegranzi, B., U\u0026ccedil;kay, I., Larson, E., Boyce, J., \u0026amp; Pittet, D. (2007). \u0026ldquo;My five moments for hand hygiene\u0026rdquo;: a user-centred design approach to understand, train, monitor and report hand hygiene. In \u003cem\u003eJournal of Hospital Infection\u003c/em\u003e (Vol. 67, Issue 1, pp. 9\u0026ndash;21). https://doi.org/10.1016/j.jhin.2007.06.004\u003c/li\u003e\n \u003cli\u003eSsekamatte, T., Mugambe, R. K., Isunju, J. B., Wanyenze, R. K., Nalugya, A., Adyedo, C., Wafula, S. T., Buregyeya, E., Nuwematsiko, R., Bateman, J., Balen, J., Lusenaka, L., Yakubu, H., \u0026amp; Moe, C. L. (2024). Application of the behaviour-centred design to understand facilitators and deterrents of hand hygiene among healthcare providers: findings from a formative phase of a cluster randomised trial in the Kampala Metropolitan area. \u003cem\u003eBMC Health Services Research\u003c/em\u003e, \u003cem\u003e24\u003c/em\u003e(1). https://doi.org/10.1186/s12913-024-11512-z\u003c/li\u003e\n \u003cli\u003eSteere, A. C., \u0026amp; Mallison, G. F. (2016). \u003cem\u003eHandwashing Practices for the Prevention of Nosocomial Infections\u003c/em\u003e. \u003cem\u003e65\u003c/em\u003e(5), 683\u0026ndash;688. https://doi.org/10.7326/0003-4819-83-5-683\u003c/li\u003e\n \u003cli\u003eTantum, L. K., Gilstad, J. R., Bolay, F. K., Horng, L. M., Simpson, A. D., Letizia, A. G., Styczynski, A. R., Luby, S. P., \u0026amp; Arthur, R. F. (2021). Barriers and opportunities for sustainable hand hygiene interventions in rural liberian hospitals. \u003cem\u003eInternational Journal of Environmental Research and Public Health\u003c/em\u003e, \u003cem\u003e18\u003c/em\u003e(16). https://doi.org/10.3390/ijerph18168588\u003c/li\u003e\n \u003cli\u003evan der Kooi, T., Sax, H., Grundmann, H., Pittet, D., de Greeff, S., van Dissel, J., Clack, L., Wu, A. W., Davitt, J., Kostourou, S., Maguinness, A., Michalik, A., Nedelcu, V., Patyi, M., Perme Hajdinjak, J., Prosen, M., Tellez, D., Varga, \u0026Eacute;., Veini, F., \u0026hellip; Zingg, W. (2022). Hand hygiene improvement of individual healthcare workers: results of the multicentre PROHIBIT study. \u003cem\u003eAntimicrobial Resistance and Infection Control\u003c/em\u003e, \u003cem\u003e11\u003c/em\u003e(1). https://doi.org/10.1186/s13756-022-01148-1\u003c/li\u003e\n \u003cli\u003eWHO. (2009). \u003cem\u003eWHO guidelines on hand hygiene in health care : first global patient safety challenge : clean care is safer care\u003c/em\u003e. WHO.\u003c/li\u003e\n \u003cli\u003eWHO. (2010a). \u003cem\u003eWhat is its purpose? Who should use the Hand Hygiene Self-Assessment Framework? How is it structured? How does it work? Is the Hand Hygiene Self-Assessment Framework suitable for inter-facility comparison?\u003c/em\u003e www.who.int/gpsc/5may/tools\u003c/li\u003e\n \u003cli\u003eWHO. (2010b). \u003cem\u003eWhat is its purpose? Who should use the Hand Hygiene Self-Assessment Framework? How is it structured? How does it work? Is the Hand Hygiene Self-Assessment Framework suitable for inter-facility comparison?\u003c/em\u003e www.who.int/gpsc/5may/tools\u003c/li\u003e\n \u003cli\u003eWHO. (2025). \u003cem\u003eThe case for investment and action in infection prevention and control\u003c/em\u003e. World Health Organization. https://doi.org/10.2471/B09330\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Hand Hygiene, Multimodal Improvement Strategy","lastPublishedDoi":"10.21203/rs.3.rs-7923983/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7923983/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cem\u003e\u003cstrong\u003eBackground:\u003c/strong\u003e\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eHealthcare-associated infections (HAIs) are a major threat to patient safety, especially in low-resource settings. Hand hygiene (HH) is the most crucial pillar of infection prevention and control (IPC), yet its multimodal improvement strategy (MMIS) implementation in Ethiopian hospitals remains uninvestigated. This study assessed HH MMIS implementation using the World Health Organization (WHO) Hand Hygiene Self-Assessment Framework (HHSAF) across public hospitals in Ethiopia.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u003cstrong\u003eMethods:\u003c/strong\u003e\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eA cross-sectional study was conducted from January 1 to March 30, 2025, in twenty public hospitals designated as national sites for HAIs surveillance. The study adopted the WHO HHSAF, covering five components and twenty-seven indicators; MMIS elements (system change, training and education, evaluation and feedback, reminders in the workplace, and institutional safety climate). The assessment was completed by the IPC focal of each participating hospital and validated by external senior IPC officers. Facilities’ implementation level was then categorized as inadequate, basic, intermediate, or advanced. Descriptive statistical and subgroup analyses were performed using SPSS v.25. Findings were summarized using medians and interquartile ranges (IQRs).\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u003cstrong\u003eResults:\u003c/strong\u003e\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eOverall, the median HHSAF score was 203.75 (IQR: 153.75–233.75), indicating a basic level of implementation. Four hospitals (20%) achieved an intermediate level, while two were inadequate. Tertiary hospitals scored slightly higher, with a median of 210 (IQR: 152.5–225), compared to secondary hospitals at178.75 (IQR: 155–197.5). Across all hospitals, the highest average scores were observed for reminders in the workplace (median: 63.75 in secondary hospitals; 52.5 in tertiary hospitals), while system change registered the lowest score (median: 20).\u003c/p\u003e\n\u003cp\u003eA strong positive correlation (r=0.98) was observed between institutional safety climate (ISC) and overall HHSAF score. HH compliance was found to be poor, with 75% of the facilities demonstrating below 50% of compliance rate.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u003cstrong\u003eConclusion:\u003c/strong\u003e\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThe study revealed significant variability and unsatisfactory level implementation of MMIS public across hospitals. Hence, poor hand hygiene compliance was observed in studied facilities. Policymakers and healthcare leaders should prioritize embedding HH with routine clinical activities, supported by dedicated budgets and accountability structures. Such comprehensive and sustained efforts are crucial to enhance the compliance, reducing HAIs, and promoting patient safety.\u003c/p\u003e","manuscriptTitle":"Status of Hand Hygiene Implementation in Public Hospitals of Ethiopia: A Multi-Center Study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-11-20 16:01:33","doi":"10.21203/rs.3.rs-7923983/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"72e7fa3b-074c-4e66-9c29-6d739d437a04","owner":[],"postedDate":"November 20th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2025-12-09T11:39:04+00:00","versionOfRecord":[],"versionCreatedAt":"2025-11-20 16:01:33","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-7923983","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7923983","identity":"rs-7923983","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}