American Journal of Infection Control 45 (2017) 89-91

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American Journal of Infection Control American Journal of

Infection Control

j o u r n a l h o m e p a g e : w w w. a j i c j o u r n a l . o r g

Brief Report

Health care workers’ compliance to the My 5 Moments for Hand

Hygiene: Comparison of 2 interventional methods
Rima Moghnieh MD a,b,c,*, Rami Soboh MD a, Dania Abdallah PharmD d,
Mona El-Helou MD e, Salam Al Hassan MSc f, Lina Ajjour BSN f, Hani Tamim PhD g,
Samaa Al Tabbah PharmD h, Walid Nasreddine MD a,b, Anas Mugharbil MD a,b
a
Department of Internal Medicine, Makassed General Hospital, Beirut, Lebanon
b
Faculty of Medicine, Beirut Arab University, Beirut, Lebanon
c
Faculty of Medical Sciences, Lebanese University, Beirut, Lebanon
d Pharmacy Department, Makassed General Hospital, Beirut, Lebanon
e Department of Obstetrics and Gynecology, Makassed General Hospital, Beirut, Lebanon
f
Department of Nursing, Makassed General Hospital, Beirut, Lebanon
g Department of Internal Medicine, American University of Beirut, Beirut, Lebanon
h Faculty of Health Sciences, American university of Beirut, Beirut, Lebanon

Key Words: This a prospective study comparing 2 interventions, incentive-based and audit-feedback, for measuring
Hand hygiene compliance to the World Health Organization’s My 5 Moments for Hand Hygiene among nursing staff in
WHO’s My 5 Moments for Hand Hygiene a Lebanese tertiary care center over 21 weeks. Compliance was not achieved by default. The incentive-
Compliance
driven intervention helped boost compliance, and the audit-feedback intervention helped achieve high
Interventions
sustainability. Analysis of health care workers’ behavior toward hand hygiene based on the My 5 Moments
Audit
Feedback for Hand Hygiene concept is necessary to pinpoint difficulties in compliance.
© 2017 Association for Professionals in Infection Control and Epidemiology, Inc. Published by Elsevier
Inc. All rights reserved.

Hand hygiene (HH) is the most effective measure to prevent
hospital-acquired infection.1,2 To standardize HH practices global-
ly, the World Health Organization (WHO) introduced the My 5
Moments for Hand Hygiene concept to define indications for HH.1
Compliance to these 5 moments differs between institutions and
countries2 and does not occur by default. Studies have shown that
improving compliance to HH principles depends on active inter-
ventions that might be population or subpopulation specific.3-6 The
aim of our study was to compare the dynamics of 2 interventions
for implementing compliance to the WHO’s My 5 Moments for Hand
Hygiene with time: one intervention was based on audit-feedback,
and the other was based on giving incentives.
MATERIALS AND METHODS
The hospital’s HH program included 2 awareness lectures per year.
Alcohol handrub dispensers were usually placed at the door of every
patient room. The infection control officer performed an audit once
per year on health care workers’ (HCWs’) compliance to HH on entry
and exit of patients’ rooms. During the whole study period, dis-
pensers were placed at each patient’s bedside in all participating
wards. All nurses who work on day shifts of the participating wards
were included in the study. Student nurses were excluded, and
written consent was obtained from the participating registered
nurses and licensed practical nurses. The hospital’s institutional
review board granted this study approval.
An introductory lecture about the My 5 Moments for Hand
Hygiene was given to the participants by the principal investiga-
tor. The participants were divided into the 3 following groups:

We conducted a prospective interventional study at a 200-bed
university hospital in Lebanon from November 2015 to March 2016.
* Address correspondence to Rima Moghnieh, MD, Department of Internal
Medicine, Makassed General Hospital, Beirut, Lebanon.
E-mail address: moghniehrima@gmail.com (R. Moghnieh).
Conflicts of interest: None to report.
1. Control group, which included 27 nurses from the surgical ward
and a general medicine ward. The hospital HH implementa-
tion strategy was adapted without further modification.
2. Incentive-driven group, which included 33 nurses from the
obstetrics-gynecology ward and a general medicine ward. The
participants were evaluated according to a performance score
during the audit phase. A ward staff meeting was held every

0196-6553/© 2017 Association for Professionals in Infection Control and Epidemiology, Inc. Published by Elsevier Inc. All rights reserved.
http://dx.doi.org/10.1016/j.ajic.2016.08.012
90 R. Moghnieh et al. / American Journal of Infection Control 45 (2017) 89-91
Fig 1. Average hand hygiene compliance rates (%) in the groups during each week of the study.
week in which 2 winners were announced. The participant who
achieved the highest score was awarded a sum of money equiv-
alent to 1 overtime shift payment. The second best score achiever
was granted 75% of the same amount. No detailed feedback was
given to the rest of the team.
3. Audit/feedback group, which included 29 nurses from the
hematology-oncology ward and a general medicine ward. The
primary investigator gave feedback to the participants as a whole
group and also to each nurse alone during a weekly ward staff
meeting. The feedback consisted of giving participants their cor-
responding scores, the moments of HH they have missed, in
addition to reminding them each time about the importance of
HH in preventing hospital-acquired infection in the era of in-
creasing antimicrobial resistance.
For the incentive-driven and audit-feedback groups, the inter-
vention was from week 1 to week 14; however, the audit was carried
out in the 3 groups from week 1 to week 21.
Auditors were medical house staff who were blinded to the study
protocol. They performed their task subtly during daily ward ac-
tivities. They have been previously lectured by the principal
investigator, and the audit of the My 5 Moments for Hand Hygiene
was thoroughly discussed and practiced. They reported weekly
written data to the primary or coinvestigators, to whom they dis-
cussed the results of their audits.
The audited HH opportunities were exactly the same as those
described in the WHO’s My 5 Moments for Hand Hygiene guidelines.1
SPSS version 21 (SPSS, Chicago, IL) was used for data entry, man-
agement, and analyses. P < .05 was considered statistically significant.
RESULTS
A total of 89 nurses were audited citing 9,345 HH opportuni-
ties. Comparing baseline characteristics of our participants pertaining
to age, job description, and educational background, there was no
statistical significance among the groups. The baseline HH compli-
ance rates were similar in the 3 groups (P = .42) (Fig 1). In the
control group, the HH compliance rate did not show any statisti-
cally significance change throughout the 21 weeks, ranging from
16%-20%. During the intervention, the incentive-driven group
showed a significant increase in the compliance rate compared
with baseline (21%): a 3-fold increase at week 8, reaching 60%,
and a 4-fold increase peaking at 77% by week 14 (P < .0001).
However, in the audit-feedback group, we observed a 2-fold
increase by week 8, reaching 43%, which peaked at week 14,
reaching 51% compared with baseline (23%) (P < .0001). Compar-
ing both interventions, the difference in compliance was found to
be statistically significant at week 14 (77% in the incentive-driven
group vs 51% in the audit-feedback group, P < .0001). After stop-
ping the interventions, the compliance rate in the incentive-based
group dropped to 34% by week 21 (in comparison with 43% at
week 8, P < .0001). This was unlike the audit-feedback group,
which achieved a steady state in the compliance rate (48%),
therefore prevailing a significantly higher sustainability than the
incentive-driven method at week 21 (48% vs 34%, respectively;
P < .0001). Analyzing compliance to each of the My 5 Moments for
Hand Hygiene separately, we realized that participants were mostly
compliant to moment 3 (immediately after contact with body
fluids, mucous membranes, or wound dressings) and moment 4
(after contact with patients) and were least compliant to moment
2 (before aseptic technique) (Fig 2).
DISCUSSION
This study is original in that it is from the Eastern Mediterra-
nean region, an unstudied area regarding compliance to the WHO’s
My 5 Moments for Hand Hygiene concept. In a recent European
study,5 HH compliance in the emergency department only was
 R. Moghnieh et al. / American Journal of Infection Control 45 (2017) 89-91
Fig 2. Average hand hygiene compliance rates (%) to each of the My 5 Moments for Hand Hygiene during the study period. average of wk 1-wk 2, beginning of the inter-
vention; average of wk 11-wk 14, peak of compliance; average of wk 17-wk 21, cessation of the intervention; Moment 1, before patient contact; Moment 2, before carrying
out an aseptic procedure; Moment 3, after exposure to body fluids; Moment 4, after contact with patients; Moment 5, after touching patient surroundings on leaving the
patient zone.
assessed before and after implementation of the WHO multimodal
intervention method. They reported 12% baseline compliance
with the My 5 Moments for Hand Hygiene, which was actually
comparable with our rate of compliance (16%-20%). The audit-
feedback strategy was a backbone in their intervention that yielded
a rise in the compliance rate, reaching 50%, which was also
comparable with our compliance rate (48%). However, our results
showed a quicker and an earlier response with the incentive-
driven method, but higher sustainability in HH compliance using
the audit-feedback method. This sustainability was also seen in
the multicenter Feedback Intervention Trial, which aimed at im-
proving HH compliance in U.K. HCWs.6 This result does not give
any preference to one method over the other. On the contrary, it
reinforces the importance of multifaceted interventions to improve
HH, as described by the WHO.7 On dissecting each of the My 5
Moments for Hand Hygiene separately, we found against all odds
that moment 2 involving HH before an aseptic procedure was the
least considered by HCWs and the most difficult step to imple-
ment. These procedures are considered high risk, and a maximum
reduction in microbial counts on the hands is necessary.8,9 Our
results were in exact concordance with those of the European
study,5 where moments 3 and 4 were the most applied, whereas
moment 2 was the least applied. On questioning our nurses about
their opinion about HH before the aseptic technique, most of
them responded that it was unnecessary to clean hands because
they would be wearing gloves that would prevent microorganism
transmission during the aseptic procedure. HCWs should be edu-
cated that gloves do not prevent cross-infections in the absence of
HH before wearing them.10 Despite our small sample size and the
91
relatively short time that elapsed before the measurement of
sustainability, this focused type of study can help tailor interven-
tions in resource-limited systems.
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