環境感染誌

Vol. 39 no. 1, 2024

〈原 著〉

Effectiveness of Implementing WHO Multimodal Hand Hygiene Improvement Strategy for
Geriatric Health Services Facility Staff
Sachiko TAKAHASHI1,2）, Ryota OCHIAI1） and Setsuko WATABE1,3）
Department of Nursing, Graduate School of Medicine, Yokohama City University, 2）Social Welfare Organization

1）

Saiseikai Imperial Gift Foundation Kanagawaken Saiseikai Wakakusa Hospital, 3）Health Science Curriculum, Graduate
School of Health Sciences, Shonan University of Medical Sciences(Received: January 23, 2023; Accepted: September 9, 2023)
Abstract
To evaluate the effects of a hand hygiene-focused educational program on hand hygiene compliance and infection morbidity in older adults care facilities in Japan, hand hygiene compliance
was observed at three time points and residentsʼ infection morbidity was calculated at two time
points. Results showed that participantsʼ hand hygiene compliance was 75 (19.7%), 213 (57.0%),
and 210 (55.1%) before, 1 month, and 8 months after the intervention, respectively (p ＜.001). Infection rates were 1.84 and 0.81 before and after the intervention, respectively. Findings indicatethat a nurse-led multimodal hand hygiene education program for staff working in geriatric facilities improves hand hygiene compliance and reduces infection morbidity.
Key words: hand hygiene, geriatric health services facility, hand hygiene compliance, infection
morbidity, WHO multimodal hand hygiene improvement strategy

giene compliance rates in older adult care facilities

Introduction
Japan is becoming a hyper-aged society, which will
create unique issues for the country; in 2017, there

have reported largely inadequate compliance, with
rates of 17.5% in Italy and 14.7% in Canada６，７）.

were 35.15 million people in Japan aged 65 years or

To improve hand hygiene compliance, a multimodal

older, which represented 27.7% of the total population,

approach is needed. This is because previous studies

the highest proportion ever recorded in the country.

involving single-method interventions have only re-This number is projected to grow to 36.77 million byported temporary improvements in hand hygiene com-

2025１）. Further, this increase in the older population,

pliance, lasting a maximum of several weeks８〜１３）. On

along with the nuclearization of families, has also

the contrary, interventions based on the multimodal

caused an increase in the number of older persons re-hand hygiene improvement strategy proposed by the２）siding in care facilities .

WHO have reported improved hand hygiene compli-

An infection morbidity survey conducted in 2018 byance rates lasting 6-9 months１４〜１６）. Further, the imple-

Japanʼs Ministry of Health, Labour and Welfare３） atmentation of a multimodal approach in three older

older adult care facilities reported occasional outbreaks

adult care facilities in Hong Kong resulted in an im-of infectious gastroenteritis, influenza, and other respi-

provement in the compliance rate from 25.8% toratory infections; such outbreaks among older and vul-

33.3%１７）, while a similar study conducted at three older

nerable residents can become very serious. At medical

adult care facilities in Taiwan reported an improve-

care facilities, hand hygiene is considered one of thement from 9.3% to 30.4%１８）. Meanwhile, the implemen-most important practices for preventing the spread oftation of a multimodal approach in a long-term care fa-

contagious microorganisms and healthcare-associatedcility (LTCF) in the US resulted in a significant reduc-infections４，５）. This may also be the case for older adulttion in infection rates for lower respiratory tract infec-

care facilities. In other countries, studies of hand hy-

tions１９）.

―1―環境感染誌

Vol. 39 no. 1, 2024
Study period

Previous findings suggest that introducing the WHO
multimodal hand hygiene improvement strategy as

Pre-intervention infection morbidity was studied for

education programs for staff at older adult care facili-nine months, from August 1, 2016, to April 30, 2017. Inties would positively influence hand hygiene compli-

addition, the pre-intervention hand hygiene complianceance and infection rates. However, few studies haverate was evaluated over one week (seven days), begin-evaluated both hand hygiene compliance and the mor-ning June 5, 2017. The education intervention was im-

bidity of infectious diseases. Considering this, the pre-plemented in July 2017. Post-intervention infection

sent study evaluated the effectiveness of an education

morbidity was studied from August 1, 2017, to April

program based on the WHO multimodal hand hygiene

30, 2018 (nine months; same seasonal period as the pre-improvement strategy in terms of hand hygiene com-

intervention study to align conditions by season). Post-

pliance and infection morbidity in older adult care fa-intervention hand hygiene compliance was evaluatedcilities in Japan. The implementation of the WHO mul-at two time points: during one week (seven days) fromtimodal hand hygiene improvement strategy in older

August 28, 2017 (one month post-intervention), and for

adults care facilities where infection control specialists

one week from March 26, 2018 (eight months post-

are not available may reduce the incidence of infec-

intervention).
Intervention

tious diseases among older adults.

Within the five components of the WHO multimodal
hand hygiene improvement strategy, four subpro-

Materials and methods

grams of hand hygiene education were implemented:

Design(1) Training/Education, (2) Reminders in the Work-

This study adopted a semi-experimental approach,place, (3) Institutional Safety Climate, and (4) Evalu-

applying a single-group pretest-posttest design.
Participants

ation and Feedback (changes in hand hygiene compli-

The study participants were 52 healthcare workersance). Education was provided by a certified infection(36 caregivers, 11 nurses, 5 physical and occupational

control nurse with specialized training in infection con-therapists) at a geriatric health services facility

trol.

[GHSFs] in Kanagawa Prefecture, Japan. Kanagawaʼs(1) Training/Educationsociety is rapidly aging１）, meaning infection control is a

The hand hygiene education program was based onpriority. In this study, we selected a GHSF, a type ofa PowerPoint presentation created by the WHO for

older adult care facility in Japan, as the target facility.

medical facilities, which we modified slightly. During

GHSFs are care homes for persons aged 65 years andthe training, using a colored gel, appropriate hand hy-older who require medical care and/or rehabilitation.

giene practice was taught, and a visual representation

They represent intermediate facilities that possess theof the effectiveness of handwashing was provided.

characteristics of both medical facilities and home envi-

Each floor leader of the target facility was assigned as

ronments. GHSFs employ physicians, nurses, physicala hand washing facilitator to visually confirm thatand occupational therapists, and caregivers (including

hand hygiene was being performed correctly and to

uncertified caregivers), and provide medical care, nurs-

develop leadership in hand hygiene practices in theing services, and rehabilitation. GHSFs have private

workplace.

rooms, multi-bed rooms, a jointly-used function and(2) Reminders in the workplace

training room, a dining room, bathroom(s), and a

A poster with illustrations depicting specific exam-

lounge. Since older and vulnerable residents cohabit inples of the WHOʼs “five moments for hand hygiene”４，５）

GHSFs, and residents and health workers engage inin the context of older adult care facilities was created,

contact through medical care, nursing services, and re-and copies were posted on facility walls in locations

habilitation, the risk of infectious diseases among resi-

where they would be easily visible by staff members.

dents may be particularly high. The studied facility

Another poster was created to show the correct

was registered to accommodate 100 residents and did

method of implementing hand hygiene, and copies of

not employ infection-control specialists, both of whichthese were posted at handwash stands and alcohol-

are typical for GHSFs in Japan.

based hand rub stands.

―2―

環境感染誌

Vol. 39 no. 1, 2024

(3) Institutional safety climate

were introduced and greeted, and it was explained toGroup work was conducted with facility staff mem-them that they would be observing their caregiving

bers to develop measures for improving hand hygiene

duties. Staff members who could not give their consent

compliance; floor leaders were appointed as group fa-with the research participation consent form at thiscilitators. Each hand hygiene “moment” was presented,

point were excluded from the subjects.

and each group discussed specific methods of reliable②The subjects were observed for hand hygiene inhand hygiene and made a presentation regarding thenecessary situations during the day shift (Participation

discussion results.

observation).
③Observation was focused on the following situ-(4) Evaluation and feedback
The pre-intervention hand hygiene compliance rate(overall compliance rate and compliance rate at eachations: before and after meals, cleanliness, and toilet
care.
④Each subject was observed in about six moments.

moment) surveyed in June was fed back along with

⑤Observers were allowed to observe up to two sub-the educational intervention in July. The hand hygiene
compliance rate one month after the implementation ofjects at the same time.
⑥In consideration of the burden on the subject,

the educational program was also fed back with a lecture in October.

each observation was limited to 20 minutes or less per

Outcomes

subject, and the observer moved on to the next sub-

The primary outcome of this study was “partici-

ject.
⑦If a subject could not be observed for six scenes

pantsʼ hand hygiene compliance rate”; the secondary

in 20 minutes, he or she was given another opportu-

outcome was “residentsʼ infection morbidity.”

nity up to twice a day.

Participantsʼ hand hygiene compliance rate
Many residents in older adults care homes have dif-

⑧Five to six day shift workers in one department

ficulty in performing hand hygiene by themselves due

and about 15 subjects per day in three departments

to the decline in their physical and cognitive functions,were observed for about five hours per day for six

even though their hands become contaminated whendays at a time during one observation period.

they touch environmental surfaces, and they need as-⑨Data was collected on a total of 380 opportunities

sistance from staff. Therefore, the hand hygiene situ-

before the intervention, 374 opportunities one monthations to be observed were defined as WHOʼs “five mo-

after the intervention, and 381 opportunities eightments”, with the addition of situations in which staff

months after the intervention.

assisted residents with hand hygiene after toileting⑩If observation interfered with the work of the staff

and before eating, which were defined as “six mo-

or interfered with the privacy of the residents, consid-

ments”.

eration was given to how to maintain a distance from

The participantsʼ hand hygiene compliance rate atthem.
⑪Observation was conducted only when there wasmoments when hand hygiene practice was necessary
was determined through direct observation. After dis-risk of compromising the safety of the residents.

cussions between researchers specialized in infection⑫Samples were collected to determine whether orcare and one of the present authors (a nurse certified

not hand hygiene was performed in situations requir-

in infection control), six hand hygiene moments were

ing hand hygiene, not whether or not hand hygiene

identified (the five proposed by the WHO and an addi-

was performed by individual residents.

tional one: when a health worker at the GHSF helps a⑬To avoid bias in the job categories and depart-

resident to implement hand hygiene). For the observa-

ments observed, the daily observation occasions weretion, sheets based on the “Observation and Calculation

divided into three major categories according to theForm” of the WHOʼs hand hygiene technical reference

nature of care (cleanliness care, meals, and elimination

１９）

manual were used . Based on a timetable of when,care), and observation times were set for each day ofwhere, and which moments to observe, the researcher

the week and each department.
⑭To minimize the psychological pressure and Haw-

(first author) made the following observations as thethorne effect on the subject during observation, we

participants went about their normal operations.
①At the beginning of each day shift, the subjects

kept a certain distance from the subject during obser-―3―環境感染誌

Vol. 39 no. 1, 2024

vation so that the subject was not strongly aware thatmaterials. Two participants withdrew after the inter-he/she was being observed. The researcher followed

vention: one caregiver (retired) and one occupational

the method described above and pretested to improvetherapist (maternity leave); thus, the hand hygiene

the accuracy of the observation data.

compliance rate was evaluated among the remaining

The hand hygiene compliance rate was calculatedusing the WHOʼs equation２５）:50 participants (at one month and eight months postintervention; Figure 1). The person-days among the fa-compliance ＝ Performed actions ÷ opportunities ×

cility residents were 2,963, 2,783, and 2,753 before, onemonth after, and eight months after the intervention,

100.

respectively.

Facility residentsʼ infection morbidity

Hand hygiene compliance rate

In the pre-intervention survey, newly emerging
cases of upper respiratory tract infection, pneumonia,

In older adults care facilities, many residents haveinfluenza, and gastroenteritis among the facility resi-

difficulty performing hand hygiene by themselves due

dents (diagnosed retrospectively by physicians) wereto physical and cognitive decline, even when theirrecorded. In order to avoid seasonal effects, the post-

hands get dirty from touching environmental surfaces,intervention survey was conducted in the same way

and require assistance from staff. Therefore, this study

during the same period the following year. The infec-

considered it effective to observe the WHOʼs “five mo-tion incidence rate was calculated according to the fol-ments” of hand hygiene situations that should be ob-lowing equation developed by the Centers for Disease

served, and then add the “six moments” of staff assist-

Control and Preventionʼs National Healthcare Safety

ing residents with hand hygiene.The overall rate of

２０）

hand hygiene compliance was 19.7% (75/380 opportuni-

Network :Number of patients， newly diagnosed with infec-ties) pre-intervention but increased to 57.0% (213/374

tious disease during the period ÷ person-days among

opportunities) and 55.1% (210/381 opportunities) at one

the facility residents during the period × 1,000 (mor-month and eight months post-intervention, respec-

bidity among 1,000 residents).

tively, p ＜.001 (Table 1). Among individual profes-

Analysis

sions, the largest improvement was observed among

The overall hand hygiene compliance rate was calcu-

caregivers(Table2).

Forcaregivers,

the

pre-

lated, and the rates at three time points (pre-intervention hand hygiene compliance rate was 13.1%

intervention and one month and eight months post-(35/268 opportunities); this significantly improved to2intervention, respectively) were compared using a χ

55.1% (151/274 opportunities) at one month post-

test. The infection-incidence rate was calculated pre-intervention, before slightly decreasing to 52.3% (148/and post-intervention, along with the relative risk of in-

283 opportunities) at eight months post-intervention, p

fection pre- and post-intervention. For statistical analy-＜.001. For nurses, the pre-intervention hand hygieneses, SPSS ver. 24.0 for Windows (Armonk, NY, USA;compliance rate was 33.8% (26/77 opportunities); this

IBM Corp.) was used. All analyses were two-tailed, andimproved to 61.0% (50/82 opportunities) at one month

the significance level was set at p ＜.05.

post-intervention, and slightly increased to 64.2% (52/

Ethics81 opportunities) at eight months post-intervention,

This study was conducted with the approval of therepresenting a significant improvement, p ＜.001. For“Ethics Committee for Human Genome and Gene Re-

physical and occupational therapists, pre-intervention

search” of Yokohama City University [Permission No.:

hand hygiene compliance rate was 40.0% (14/36 oppor-

A170200008].

tunities); this improved to 66.7% (12/18 opportunities)
at one month post-intervention, before decreasing to

Results

58.8% (10/17 opportunities) at eight months post-

All 52 target participants provided written consent(consent rate: 100%). First, before the intervention, theintervention, showing a significant improvement, p=.144.

participantsʼ hand hygiene compliance rate was evalu-

Infectious morbidity

ated. Twenty-nine of the 52 participants attended theDuringpre-intervention

observation

for

newly

lecture, technical training, and group work (attendance

emerging infectious diseases, 47 cases of upper respira-rate: 55.8%); absent participants were given printed

tory infection, 2 cases of pneumonia, 1 case of influ-―4―

環境感染誌

Vol. 39 no. 1, 2024

Health-care workers, The target Subjects of this study (n=52)
Care workers(n=36), nurses(n-11), physical andoccupaƟonal therapists(n=5)

Health-care workers who parƟcipated in the pre-interverƟon evaluaƟon(n-52)
Care workers(n=36), nurses(n=11), physical andoccupaƟonal therapists(n=5)

Health-care workers parƟcipated in the educaƟonal lecture(n=29)
Care workers(n=17), nurses(n=10), physical andoccupaƟonal therapists(n=2)
Health-care workers who were absent from the lecture but received handouts(n=23)

Withdrew(n=2)
ReƟred(n=1)
Maternity leave(n=1)

health-care workers who parƟcipated in the post-intervenƟon evaluƟon(one and eight months later; n=50)
Care workers(n=35), nurses(n=11), physical andoccupaƟonal therapists(n=4)
Figure 1

Flowchart of the study

enza, and no cases of gastrointestinal infection were

follows: in the pre-intervention 2016-2017 season, theidentified. Post-intervention, the numbers of newly

maximum number of influenza cases reported per

emerging cases were 21, 1, 0, and 0, respectively. The

fixed point was 49.49, and the period during which theoverall morbidity for all infectious diseases was 1.84

warning level (30.00) was exceeded lasted three weeks,and 0.81 before and after the intervention, respectively

whereas in the post-intervention 2017-2018 season, the(relative risk = 0.44, 95% CI [0.27, 0.73]), calculated as

maximum number of reports per fixed point was 66.31“the number of new cases multiplied by the total num-and the period of time when the alarm level was ex-

ber of residents in the facility during the period ×

ceeded was 4 weeks. This indicates that the degree of

1,000.” Morbidity of upper respiratory tract infection

influenza

was 1.73 and 0.77 pre- and post-intervention, respec-

intervention season compared to the pre-intervention

tively (relative risk = 0.45, 95% CI [0.27, 0.75]). Signifi-

season. However, the incidence of influenza and othercant decreases were observed in the morbidities of all

respiratory infections decreased significantly after thestatistical items (Table 3).

educational intervention.

prevalence

wasgreater

in

the

post-

The number of new patients is calculated as “thenumber of newly occurring patients divided by the to-

Discussion

tal number of residents in the facility during the pe-

In this study, a hand hygiene education program

riod ×1,000.” 1.84 and 0.81 pre- and post-intervention,

was provided to the health workers at a GHSF in Ja-

respectively (relative risk = 0.44, 95% CI [0.27, 0.73]).

pan, and its effects were evaluated. The key findings

The morbidity of upper respiratory tract infection was

included: 1) the education program improved the hand

1.73 and 0.77 pre- and post-intervention, respectively

hygiene compliance of the health workers at the facil-(relative risk = 0.45, 95% CI [0.27, 0.75]). Significant de-ity; and 2) the education program reduced the resi-

creases were observed in the morbidities of all statisti-

dentsʼ infection morbidity. The study results are dis-cal items (Table 3).

cussed below in terms of 1) the characteristics of the

In addition, Kanagawa Prefecture reported that the
influenza prevalence during the study period was aseducation program, and 2) the effects of the intervention.

―5―

Performed actions
Not performed
Performed actions
Not performed
Performed actions
Not performed
Performed actions
Not performed
Performed actions
Not performed
Performed actions
Not performed

Before touching a resident

Before clean/aseptic procedures

After body fluid exposure/risk

After touching a resident

After touching a residentʼssurroundings

When helping a resident toimplement hand hygiene

9
23

9
47

23
67

20
56

14
90

0
22

75
305

Opportunities

28.1%
71.9%

16.1%
83.9%

25.6%
74.4%

26.3%
73.7%

13.5%
86.5%

0.0%
100.0%

19.7%
80.3%

compliance ＊

‒

‒

‒

‒

‒

‒

−4.4

−1.6

−5.5

−6.4

−5.9

−3.6

−11.6
‒

Adjusted
residual

Pre-intervention

30
6

7
17

37
33

75
34

47
45

17
26

213
161

83.3%
16.7%

29.2%
70.8%

52.9%
47.1%

68.8%
31.2%

51.1%
48.9%

39.5%
60.5%

57.0%
43.0%

compliance ＊

―6―

25
14

11
29

56
24

56
24

45
55

17
25

210
171

Performed actions
Not performed
Performed actions
Not performed

Nurse

PT/OT

14
21

26
51

35
233

75
305

Opportunities

40.0%
60.0%

33.8%
66.2%

13.1%
86.9%

19.7%
80.3%

compliance＊

‒

‒
−1.9

−4.2

−11.1
‒

−11.6
‒

Adjusted
residual

Pre-intervention

12
6

50
32

151
123

213
161

Opportunities

66.7%
33.3%

61.0%
39.0%

55.1%
44.9%

57.0%
43.0%

compliance＊

0.7
‒

0.9
‒

4.7
‒

2.8
‒

2.4
‒

1.6
‒

5.4
‒

1.7

6.0

6.2

−1.5
‒

‒

‒

‒

10
7

52
29

148
135

210
171

58.8%
41.2%

64.2%
35.8%

52.3%
47.4%

55.1%
44.9%

compliance＊

0.7
‒

2.4
‒

5.0
‒

5.4
‒

Adjusted
residual

Eight months post-intervention
Adjusted Opporresidual tunities

One-month post-intervention

PT/OT: physical therapists/occupational therapists
hand hygiene compliance＝Performed actions ÷ Opportunities (Performed actions＋Not performed)×100.

Performed actions
Not performed

Caregiver

Hand hygiene
Performed actions
Not performed

＊

64.1%
35.9%

27.5%
72.5%

70.0%
30.0%

70.0%
30.0%

45.0%
55.0%

40.5%
59.5%

55.1%
44.9%

Adjusted
residual

χ2

1.80

‒

‒
3.86

17.66

124.37‒135.44
‒

χ2

18.89
‒

‒

12.55
‒

30.97
‒

32.24
‒

11.78
‒

107.72‒Pre-post evaluation of hand-hygiene compliance for each profession, presented in terms of each time point.

All

Health worker

Table 2

3.5
‒

0.9
‒

0.9
‒

3.3
‒

3.7
‒

1.4
‒

6.2
‒

compliance ＊Eight months post-intervention

Adjusted Opporresidual tunities

One-month post-intervention
Opportunities

hand hygiene compliance＝Performed actions ÷ Opportunities (Performed actions＋Not performed)×100.

＊

Performed actions
Not performed

Hand Hygiene

Pre-post evaluation of hand-hygiene compliance for the six moments, presented in terms of each time point.

All moments

Moments

Table 1

.18

‒

.144

＜.001
‒

＜.001
‒

＜.001
‒

p

＜.001
‒

‒

＜.001
‒

＜.001
‒

＜.001
‒

＜.001
‒

＜.001
‒

p

環境感染誌
Vol. 39 no. 1, 2024

Characteristics of the education program

The intervention applied in the current study was

based on the WHO multimodal hand hygiene improve-

ment strategy, which is the global standard in medicalcare. When implementing the program in the GHSFs,

環境感染誌
Table 3Vol. 39 no. 1, 2024

Infection morbidity rate at each time point.
95% confidence
interval

Infection

Time point

Person-days Infectious
diseaseincidence

Morbidity＊

Relative
risk

Lower
limit

Upper
limit

All infections

Pre-intervention＊＊
Post-intervention＊＊＊27,242
27,105

50
22

1.84
0.81

‒
0.44

‒
0.27

‒
0.73

Upper respiratory tract infection

Pre-intervention＊＊
Post-intervention＊＊＊27,242
27,105

47
21

1.73
0.77

‒
0.45

‒
0.27

‒
0.75

Pneumonia

Pre-intervention＊＊
Post-intervention＊＊＊27,242
27,105

2
1

0.07
0.04

‒
0.50

‒
0.05

‒
5.54

Influenza

Pre-intervention＊＊
Post-intervention＊＊＊27,242
27,105

1
0

0.04
0.00

‒
‒

‒
‒

‒
‒

Infectious gastroenteritis

Pre-intervention＊＊
Post-intervention＊＊＊27,242
27,105

0
0

0.00
0.00

‒
‒

‒
‒

‒
‒

＊
Infection morbidity per 1,000 resident-days＝Number of patientsʼ newly diagnosed with infectious disease during the period ÷ person-days among the facility residents during the period×1,000.
＊＊
Pre-intervention: from August 1, 2016, to April 30, 2017.
＊＊＊
Post-intervention: from August 1, 2017, to April 30, 2018.

we felt that there was a risk that the participants

externally sourced strategies for disseminating best

would dislike being administered an education pro-practices induced spontaneous behavioral changes,

gram by a researcher (a certified nurse in infection

leading to continued improvement in hand hygiene

control) who was not affiliated with the facility. There-practices.

fore, a suitable strategy for encouraging the partici-

Effects of the intervention

pants to spontaneously change their behavior was re-

Improvement in hand hygiene compliancequired. For the subprogram “technical training and

The present study findings demonstrate that hand

education,” the study team appointed the facilityʼs floor

hygiene compliance at older adult care facilities can beleaders as facilitators, who were tasked with checking

greatly improved. The pre-intervention hand hygienethat hand hygiene was performed correctly (as nocompliance rate was 19.7%. Pan et al.７） reported a rate

infection-control specialists were present in the facil-of 17.5% among care workers at an LTCF in Italy,ity). Next, group work was introduced as part of thewhile Smith et al.２２） reported a corresponding rate of“Institutional Safety Climate” subprogram, during

14.7% in Canada. A systematic review of hand hygiene

which the participants considered how performing

compliance among medical staff at medical facilities re-hand hygiene could be facilitated. This led to an im-

ported a rate of approximately 40%６）; thus, it appears

provement in the work environment, as the positions

that the rate among workers at LTCFs, includingof alcohol-based hand-rub stands were modified to en-

older adult care facilities, is lower than that at medical

able easier access.

facilities.

These subprograms are considered to correspond to

The improvement in hand hygiene compliance ob-

the “frontline ownership” approach that is proposed byserved in this study (19.7%, 57.0%, and 55.1% at pre-the Association for Professionals in Infection Control

intervention and at one month and eight months post-

and Epidemiology as a strategy for implementing

intervention, respectively) was larger than that re-infection-prevention-focused behavioral changes. Fron-

ported in previous studies conducted in older adulttline ownership involves on-the-spot decision-making, incare facilities; for example, studies conducted in Hongwhich staff members are encouraged to develop ideas,

Kong and Taiwan reported improvements from 25.8%

make decisions, and create and execute plans using

to 33.3% and from 9.3% to 30.7%, respectively１４，１８）. The

their own initiative, and to be open to practices sug-large increase observed in the current study may be

２１）

due to the drastic improvement among caregivers. In

gested by external parties . In the present research,―7―

環境感染誌

Vol. 39 no. 1, 2024

the current study, the caregiversʼ hand hygiene com-

rate. Third, since the researcher (the first author)

pliance rate improved from 13.1% pre-intervention tomade observations while the participants performed

55.1% and 52.3% at one month and eight months post-

normal operations, there were significant differences inintervention, respectively. As mentioned previously, a

the respective number of observations of the six mo-

６）indicated that the median compli-

ments, and some participants were observed more fre-ance rate for medical staff in a previous study was ap-

quently than others. Since the researcher providing

proximately

systematic review

pre-the education program made non-blinded, direct obser-intervention rates among nurses (33.8%) and physicalvations, it is not possible to completely exclude ob-

and occupational therapists (40%). However, the pre-server bias. Fourth, while previous studies２３，２４） have re-intervention rate for caregivers was 13.1%; signifi-

ported that the educational effects decrease after sev-

cantly lower than the other professions, which may beeral months, this study did not examine a period

owing to their limited access to knowledge regarding

longer than one year, and consequently could notinfection control related to their lack of higher educa-

evaluate long-term educational effects. Fifth, because

tion and experience of service at hospitals. Thus, pro-this study measured the effects of a combined inter-viding educational interventions to caregivers rather

vention in a single-group pretest-posttest design withthan other professionals may improve general handno control group, it was not possible to examine which

hygiene compliance. Thus, of the four components of aof the educational program interventions were effec-

multifaceted hand hygiene education program, (1)tive and to what extent each was effective. In future

training/education may have been more effective instudies, a double-blinded survey should be performed,

this study in a geriatric facility staffed predominantly

along with multiple intervention groups and a control

by caregivers.

group, in order to exclude the Hawthorne effect and40%,

similartotheobserved

Reduction in infection morbidity

observer bias.

Overall morbidity for all infectious diseases was 1.84

Despite these limitations, this study is valuable inand 0.81 at pre- and post-intervention, respectively

that it assessed improvement in hand hygiene compli-(relative risk: 0.44). Many residents of older adult careance among healthcare workers at a GHSFs. After thefacilities have limited ability to clean themselves andcompletion of this study, the coronavirus disease 2019

have weakened immune systems. Consequently, in(COVID-19) became globally prevalent. Since COVID-

such facilities, the hand hygiene compliance of caregiv-

19 symptoms tend to be more severe among older

ers and others significantly affects morbidity. The

adults, and clusters have been reported in GHSFs, theTaiwan-based study reported, after providing a com-

results of this study are even more important, espe-

prehensive hand hygiene program to nurse assistants,

cially during the present COVID-19 era.

a reduction from 1.74 to 1.52 in nursing home residentsʼ infection morbidity１８）. The studyʼs morbidity re-Conclusions

duction was larger than that in the Taiwan-based

By implementing the multimodal hand hygiene edu-

study possibly because of in addition to an increase incation program, the overall hand hygiene compliancehand hygiene compliance by caregivers and others, werate at an older adult care facility improved frombelieve this is due to the impact of caregivers assisting

19.7% pre-intervention to 57.0% and 55.1% at one

residents with hand hygiene.

month and eight months post-intervention, respectively. Meanwhile, the infection morbidity of the residents was reduced significantly, from 1.84 to 0.81. This

Limitation
This study has five limitations. First, it was per-indicates the importance of providing a hand hygiene

formed at just one GHSF in Kanagawa Prefecture, Ja-

program to health workers, especially caregivers, atpan. Since a complete evaluation of the characteristics

older adult care facilities.

of the facility and its employees was not performed,
the results should be interpreted with caution. Second,

Declarations of interest: There is no COI to disclose.

since a direct observation survey was conducted, it ispossible that the Hawthorne effect occurred, resulting

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〔Reprint request:
Sachiko Takahashi, Social Welfare Organization Saiseikai Imperial Gift Foundation Kanagawaken Saiseikai Wakakusa Hospital faculty of infection prevention and control
E-mail: takahashi.s@wakakusa.saiseikai.or.jp〕―9―

環境感染誌

Vol. 39 no. 1, 2024

介護老人保健施設の職員に対する WHO 手指衛生多角的戦略実施の効果
高橋

幸子 1,2）・落合亮太 1）・渡部節子 1,3）1）
横浜市立大学大学院医学研究科看護学専攻，2）社会福祉法人恩賜財団済生会支部神奈川県済生会若草病院，
3）
湘南医療大学大学院保健医療学研究科

要旨
本研究は，WHO 手指衛生多角的戦略に基づく教育プログラムが，手指衛生の遵守および感染症
罹患率に及ぼす有効性を評価することを目的とし，介護老人保健施設の職員を対象に教育プログラ
ムを実施した介入研究である．対象群を設けない単一群試験において，介入前，介入後 1 ヶ月，介
入後 8 ヶ月の 3 時点で手指衛生の遵守状況を観察し，入居者の感染症罹患率は，介入前と，季節による条件を揃えるため介入前調査の翌年同時期の 2 時点で算出した．その結果，参加者の手指衛生遵守率は，介入前は 19.7％（75/380 場面），介入 1 ヶ月後は 57.0％（213/374 場面），介入 8 ヶ月後「新規発生した患者数÷期間内のは 55.1％（210/381 場面）だった（p ＜0.001）．感染症罹患率は，施設入所者数の総和×1,000」として算出し，介入前が 1.84，介入後が 0.81 であった．所見から，介護老人保健施設の職員に対する看護師主導の WHO 手指衛生多角的戦略に基づく教育プログラムの実施は，手指衛生の遵守を改善し，感染症罹患率を低下させることが示唆された．
Key words：手指衛生，介護老人保健施設，手指衛生遵守率，感染症罹患率，WHO 手指衛生多角的戦略〔連絡先：〒236-8653 神奈川県横浜市金沢区平潟町 12-1
社会福祉法人恩賜財団済生会支部神奈川県済生会若草病院感染防止対策室
E-mail: takahashi.s@wakakusa.saiseikai.or.jp〕― 10 ―

高橋幸子