The Effectiveness of a Multicomponent Education Program of Hand Hygiene in Nursing Students: a Randomized Controlled Trial
Phase: NA
Conditions: Hand Hygiene
Sponsor: The Hong Kong Polytechnic University

Protocol 
Date 1  May 2023 
 
 
 
 
 
 
 
 
 
 
The effectiveness of a multicomponent education program of hand hygiene 
 in nursing students: a randomized controlled trial 
 
NCT05872581 
Date: 1 May 2023 
 
 

Protocol 
Date 1  May 2023 
Background 
The ongoing COVID-19 pandemic has posed serious threats to public health worldwide. Although children 
have mild symptoms, they have been found to more likely transmit the virus within the household than the 
other age groups. The importance of hand hygiene cannot be underestimated in both healthcare and 
community settings (Allegranzi et al., 2011; Mathur, 2011). The promotion of hand hygiene is the best 
practices in preventing health care-associated infection (WHO, 2009). It has been estimated that hand 
hygiene could reduce over 500 000 attributable deaths per year. It was found that the annual economic 
impact of health care-associated infection in the US was approximately US$6.5 billion in 2004 (WHO, 
2009) and every US$1 spent on hand hygiene promotion could result in a US$23.7 benefit (Chen et al., 
2011). Education plays a key role in setting a good practice base in hand hygiene.  
The traditional training methods for nursing students include in-class lecture and practical, but students 
seldom receive individualized instructions and feedbacks due to limited manpower and facilities. Hence, 
there is an urgent need of designing an automated and individualized education program. This study aims 
to design and test a multicomponent education program of hand hygiene in nursing students. Specifically, 
this program has two components: 1) training videos according to the WHO guidelines on hand hygiene in 
health 
care 
(https://polyu.ap.panopto.com/Panopto/Pages/Viewer.aspx?id=f3973cee-bcfb-48fd-a306-
b6893dacaabd); 2) a hand scanner used for students to immediately visualize the missing spots of hand 
hygiene.  
This study has the following specific objectives:  
1) conduct a randomized controlled trial (RCT) to test the effectiveness of this program on knowledge and 
practice of hand hygiene in nursing students; 
2) evaluate the effects of each component and collect feedbacks from participants. 
If demonstrated effective, this program can be integrated into the curriculum of nursing students as an e-
learning approach. In future, this system can also be used at point-of-care for real-time monitoring and audit 
of healthcare workers in other healthcare settings.  
 
Methods 
Study design 
This is a four-arm RCT.  
 
Subject recruitment 
We will recruit all year one nursing students from the Bachelor of Nursing and Bachelor of Mental Health 
Nursing program in School of Nursing (total number is approximately 280) during June to July 2023. The 
participants will subscribe a timeslot of training sessions (each session has 3 participants). All participants 
who attend the same session will be assigned to the same group by cluster randomization. A statistician will 
assign the groups in advance by a random number generator. The participants will not be informed about 
their group before arriving the study site (the Squina International Centre for Infection Control in PolyU). 
 

Protocol 
Date 1  May 2023 
Pre-intervention assessment 
During the site visit, the participants will sign a consent form first and be asked to fill in a questionnaire on 
knowledge and practice of hand hygiene (attached in Appendix).  
Participants will need to put fluorescent powder on both of their hands, and hold hands under ultraviolet 
(UV) light (wavelength: 365nm) to take digital image of hands. Participants will then perform hand washing 
using liquid soap without any instructions (1st HW attempt). The camera installed above the hand-wash 
basins will take videos of both hands (no face nor other parts of the body) during this procedure. After 
washing hands, participants will hold hands under UV light again to take digital image of hands, and will 
need to scan fluorescent powder remained on their hands in a hand scanner (The Semmelweis Scanner™). 
The digital images of hands and the recorded hand washing videos will be used to train the AI algorithms 
for automatic image processing and assessments. Two IPC experts will judge the quality of hand hygiene 
in these images/videos, which will be adopted as ground truth in image processing. The percentage of 
fluorescent gel residual on hands shown in the hand scanner will be used as an objective assessment for 
efficacy of hand washing in individual participants. 
Intervention and control groups 
Group A (Hand scanner instant feedback)  
Participants will be informed about their hand scanner results of the first HW attempt to get individualized 
feedback about their hand wash performance. But no training video is provided. 
 
Group B (Video training)  
Participants will watch a training video about the 7 steps of hand washing after the first HW attempt, but 
they will not be informed about their hand scanner results. 
 
Group C (Hand scanner + Video training)  
Participants will be informed about their hand scanner results during the first HW attempt. They will aslo 
watch a training video about the 7 steps of hand washing. 
 
Group D (Control group without intervention) 
Participants will not be informed about the hand scanner results in the first HW attempt and no training 
videos will be provided.  
 
Post-intervention assessment 
The participants will take the second HW attempt by putting fluorescent powder on both of their hands 
again and then perform hand wash with videos recorded. Digital images of hands will again be taken under 
UV light before and after hand wash. After washing hands, participants will scan fluorescent residual 
remained on their hands again in a hand scanner.  
 
Participants will also be asked to fill in a questionnaire on knowledge and practice of hand hygiene as part 
of post-intervention assessment. 
 
For the training purpose, after the completion of post-intervention measurements, the participants of the 
control group (Group D) will watch the training video and repeated hand washing and scanning for the third 
time if they agree. But the results of their third HW attempt will not be included into data analysis in this 

Protocol 
Date 1  May 2023 
study. 
 
Randomization, allocation concealment, and blinding 
Participants will be randomly assigned to the intervention groups or control group through a process of 
randomization performed by a statistician who will not be involved in subject recruitment. The participants 
will be blinded. The RAs involved in subject recruitment and the IPC experts who judge the quality of hand 
hygiene will be blinded to the groupings. The RAs and student assistants involved in hand hygiene video 
recording at the study site will not be blinded because they will be giving instructions to the participants. 
 
Ethical consideration 
The effect of exposure to UV-A light is similar to outdoor exposure to sunlight. It is anticipated that the 
study will not pose any physical or psychological harm to the participants. The contact details of either the 
ethical or the research in-charge personnel are clearly written in the information sheet.   
Explanation of the study will be given to participants who are interested in participating in the study. 
Participants will also be given the opportunity to ask our project personnel questions. Furthermore, the 
information sheet including the purpose of the study, confidentiality of the data, and rights of the 
participants, will also be provided to the participants. The contact details of either the ethical or the research 
in-charge personnel are clearly written in the information sheet. If they agree to participate in the study, 
they are required to sign the consent form. Their participation is on a voluntary basis, they have the right to 
withdraw from the study at any time if they want to without consequence.  
All the collected data will be kept confidentially, and only the research personnel can access and handle the 
data. No personal information of the participants will be collected except the student ID number. 
 
Confidentiality and Security 
Data collection will be anonymous, only analysed for specified purposes and on the basis of the consent or 
other legitimate basis laid down by law. No personal information will be linked to image/video data. All 
the image/video data will be deleted one year after the project is completed. The Project will not involve 
any activities or results raising security issues. 
 
References 
Al-Shatri, H., Müller, S., & Klein, A. (2016, 22-27 May 2016). Distributed algorithm for energy efficient 
multi-hop computation offloading. 2016 IEEE International Conference on Communications 
(ICC),  
Allegranzi, B., Bagheri Nejad, S., Combescure, C., Graafmans, W., Attar, H., Donaldson, L., & Pittet, D. 
(2011). Burden of endemic health-care-associated infection in developing countries: systematic 
review and meta-analysis. Lancet, 377(9761), 228-241. https://doi.org/10.1016/S0140-
6736(10)61458-4  

Protocol 
Date 1  May 2023 
Chen, Y. C., Sheng, W. H., Wang, J. T., Chang, S. C., Lin, H. C., Tien, K. L., Hsu, L. Y., & Tsai, K. S. 
(2011). Effectiveness and limitations of hand hygiene promotion on decreasing healthcare-
associated infections. PLoS One, 6(11), e27163. https://doi.org/10.1371/journal.pone.0027163  
Gasteiger, N., Dowding, D., Ali, S. M., Scott, A. J. S., Wilson, P., & van der Veer, S. N. (2021). Sticky 
apps, not sticky hands: A systematic review and content synthesis of hand hygiene mobile apps. J 
Am Med Inform Assoc, 28(9), 2027-2038. https://doi.org/10.1093/jamia/ocab094  
Mathur, P. (2011). Hand hygiene: back to the basics of infection control. Indian J Med Res, 134(5), 611-
620. https://doi.org/10.4103/0971-5916.90985  
Mueller, F., Bernard, F., Sotnychenko, O., Mehta, D., Sridhar, S., Casas, D., & Theobalt, C. (2018). 
GANerated Hands for Real-time 3D Hand Tracking from Monocular RGB. In Proceedings of the 
IEEE Conference on Computer Vision and Pattern Recognition, 49-59.  
WHO. (2009). In WHO Guidelines on Hand Hygiene in Health Care: First Global Patient Safety 
Challenge Clean Care Is Safer Care. https://www.ncbi.nlm.nih.gov/pubmed/23805438  
Yang, L., Lu, Y., Cao, J., Huang, J., & Zhang, M. (2020). E-Tree Learning: A Novel Decentralized Model 
Learning Framework for Edge AI. IEEE Internet of Things Journal.  
 
 
 
 

Protocol 
Date 1  May 2023 
Appendix 
Survey on knowledge and practice of Hand Hygiene in Nursing Students  
 
Part I: Demographic 
1. 
Student ID: 
                                             . 
2. 
Age:  
 
                                             yrs 
3. 
Gender:  
 Female  
  Male 
4. 
Programme:   
 BSN    
  Mental Health Nursing 
 
Part II: Hand hygiene  
5. 
Have you ever received formal training in hand hygiene? 
 
 Yes  
  No 
If your answer is yes; when did you receive the training (give the latest year)?            
Answer:                                        (yyyy). 
 
 
6. 
How many steps are required for healthcare workers to perform hand hygiene (please give a 
number) ? 
 
Answer:                                               . 
 
7. 
How many types of hand hygiene are there (please give a number)? 
 
Answer:                                               . 
 
8. 
How long is the minimal duration of hand washing?  
Answer:                                               . seconds 
 
9:  
Which of the following sequence is correct for hand hygiene? (MC Question) 
A 
Ans: B 
C 
Finger webs 
Finger webs 
Thumbs 
Finger tips 
Back of fingers 
Finger tips  
Back of fingers 
Thumbs 
Finger webs 

Protocol 
Date 1  May 2023 
Thumbs 
Finger tips 
Back of fingers 
 
10. 
Which of the following is one of hand hygiene steps EXCEPT? 
 Rub palms 
 Rub fingernails 
 Rub wrists 
 Fingers interlocked 
 
11.  
Do you agree or disagree with the following statement:  
Hand hygiene is part of infection prevention and control in healthcare settings. 
 Strongly agree 
 Agree 
 Neither agree nor disagree 
 Disagree 
 Strongly disagree 
 
Additional questions for post evaluation 
12. 
What are the 7-steps of hand washing? (MC Questions) 
 
 
A 
B 
C 
Answers 
Step 1 
Finger tips 
Palms 
Between fingers 
Palms 
Step 2 
Back of hands 
Back of fingers 
Palms 
Back of hands 
Step 3 
Thumbs 
Finger tips 
Between fingers 
Between fingers 
Step 4 
Palms 
Between fingers 
Back of hands 
Back of fingers 
Step 5 
Finger tips 
Thumbs 
Back of fingers 
Thumbs 
Step 6 
Back of fingers 
Finger tips 
Wrists 
Finger tips 
Step 7 
Wrists 
Thumbs 
Back of hands 
Wrists 
 
13. 
What is the sequence for hand hygiene? 
Steps 
 
 
Drag Answer Here: 
Finger tips 
 
Step 1 
 
Back of hands 
 
Step 2 
 
Thumbs 
 
Step 3 
 
Palms 
 
Step 4 
 

Protocol 
Date 1  May 2023 
Finger tips 
 
Step 5 
 
Back of fingers 
 
Step 6 
 
Wrists 
 
Step 7