Challenges to sustainability of hand hygiene at a rural hospital in Rwanda

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Many hand hygiene (HH) programs have been implemented across Sub-Saharan Africa (SSA); however, most of these have been in large, referral hospitals. Our objective was to assess the impact of HH programs aimed at improving compliance at a rural hospital, and to identify unique challenges to HH sustainability.


Interventions to improve HH through providing handwashing stations, health care worker (HCW) training, and alcohol handrub were completed in 2014 and 2015. HH infrastructure, compliance, and glove use were assessed among HCWs after the intervention in 2015 and 2016. HCWs were interviewed about challenges to sustainability of HH compliance.


Total HH compliance decreased 32.1% between 2015 and 2016 (P < .001). HH for patient protection was completed significantly less than HH for HCW protection in 2016, and HCWs appeared to substitute HH for patient protection with glove use. A high rate of physician turnover was associated with a larger decrease in HH compliance compared with nurses, and interviews suggested recruiting and retention of key personnel might play a role in HH sustainability. Availability of alcohol-based handrub in patient rooms decreased from 100% in 2015 to 79.5% in 2016 (P < .01).


Many challenges exist to sustaining HH compliance in SSA. In rural settings, difficulty recruiting and retaining trained personnel, inconsistent availability in HH infrastructure, and variability in HCW HH training may be contributing factors.

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