Minimum material requirements for hand hygiene in community settings: A systematic review

ABSTRACT This systematic review assessed the minimum requirements necessary to create an enabling environment for sustained hand hygiene practices: quantity of water and soap, and number, spacing, location, and design of hand hygiene facilities. This review provides evidence for the development of the WHO Guidelines for Hand Hygiene in Community Settings. We searched PubMed, Web of Science, EMBASE, CINAHL, Global Health, Cochrane Library, Global Index Medicus, Scopus, PAIS Index, WHO IRIS, UN Digital Library and World Bank eLibrary, and consulted experts. Eligible studies were observational, in non- healthcare community settings, and reported on at least one of the five categories: (1) quantity of water, (2) quantity of soap, (3) location of hand hygiene materials, (4) number of users or spacing of facilities, (5) considerations for equitable access. Two reviewers independently extracted data from each study and assessed risk of bias using the Mixed Method Appraisal Tool (MMAT). This review identified 37 studies that met inclusion criteria from 28 countries, representing 4 of the 6 WHO regions— (Africa, South-East Asia, the Americas, and Europe). Household settings were the most represented (59% of studies), followed by institutional or school settings (41%) and public establishments (27%). Of the 37 studies, 13 (35%) assessed the relationship between a material requirement and hand hygiene practices. Despite extensive global research on hand hygiene, we found a lack of evidence linking material requirements with handwashing practices in community settings. This review was limited to observational studies, and more data could be derived from experimental studies. Important evidence gaps include the quantity of water and soap needed, the influence of facility location and design on hand hygiene practice, and material needs providing equitable access. Further research is needed to strengthen the evidence base for hand hygiene recommendations and supplement the expert opinion on which many recommendations are currently based. What is already known on this topic Hand hygiene is an important tool to prevent infectious disease transmission; however, there is little information about what the minimum material requirements are to enable handwashing in community settings to achieve this goal. What this study adds This systematic review examines the evidence of material needs to enable handwashing in community settings, and the relationship with handwashing-associated outcomes when reported in included studies. It highlights key gaps in the current evidence base, particularly surrounding specifics of quantities and locations of materials. The study proposes that future work collect this data and examine the association between these material needs and hand hygiene practice. This is a necessity for increasing our understanding and providing recommendations on the minimum requirements for effective and sustained hand hygiene in community settings. How this study might affect research practice or policy This review demonstrates that there is very little evidence providing critical, practical information on what materials are needed to meet handwashing needs in community settings. More detailed and specific reporting of the materials and conditions associated with handwashing, alongside evidence about practice and health and other outcomes, is needed to improve recommendations. Beyond reporting more quantitative details, there was a lack of studies focused on equitable access to handwashing, and further research is needed to specifically address material needs for handwashing for people with disabilities.