Status of Hand Hygiene Implementation in Public Hospitals of Ethiopia: A Multi-Center Study

Background: Healthcare-associated infections (HAIs) are a major threat to patient safety, especially in low-resource settings. Hand hygiene (HH) is the most crucial pillar of infection prevention and control (IPC), yet its multimodal improvement strategy (MMIS) implementation in Ethiopian hospitals remains uninvestigated. This study assessed HH MMIS implementation using the World Health Organization (WHO) Hand Hygiene Self-Assessment Framework (HHSAF) across public hospitals in Ethiopia. Methods: A cross-sectional study was conducted from January 1 to March 30, 2025, in twenty public hospitals designated as national sites for HAIs surveillance. The study adopted the WHO HHSAF, covering five components and twenty-seven indicators; MMIS elements (system change, training and education, evaluation and feedback, reminders in the workplace, and institutional safety climate). The assessment was completed by the IPC focal of each participating hospital and validated by external senior IPC officers. Facilities’ implementation level was then categorized as inadequate, basic, intermediate, or advanced. Descriptive statistical and subgroup analyses were performed using SPSS v.25. Findings were summarized using medians and interquartile ranges (IQRs). Results: Overall, the median HHSAF score was 203.75 (IQR: 153.75–233.75), indicating a basic level of implementation. Four hospitals (20%) achieved an intermediate level, while two were inadequate. Tertiary hospitals scored slightly higher, with a median of 210 (IQR: 152.5–225), compared to secondary hospitals at178.75 (IQR: 155–197.5). Across all hospitals, the highest average scores were observed for reminders in the workplace (median: 63.75 in secondary hospitals; 52.5 in tertiary hospitals), while system change registered the lowest score (median: 20). A strong positive correlation (r=0.98) was observed between institutional safety climate (ISC) and overall HHSAF score. HH compliance was found to be poor, with 75% of the facilities demonstrating below 50% of compliance rate. Conclusion: The study revealed significant variability and unsatisfactory level implementation of MMIS public across hospitals. Hence, poor hand hygiene compliance was observed in studied facilities. Policymakers and healthcare leaders should prioritize embedding HH with routine clinical activities, supported by dedicated budgets and accountability structures. Such comprehensive and sustained efforts are crucial to enhance the compliance, reducing HAIs, and promoting patient safety.