Based on a recent World Health Organization (WHO) global infection prevention and control (IPC) report, out of 100 patients in acute care hospitals, 15 patients in low- and middle-income countries (LMICs) and seven patients in high-income countries developed at least one healthcare-associated infection during their hospital stay. Of the cases with healthcare-associated infections (HAIs), 10% died (WHO, 2022). In a systematic review of device-related HAIs, the median value for catheter-related bloodstream infections, the most dangerous and deadly HAIs, was 8.92 in developing countries versus 2.38 in developed countries per 1000 catheter days (Pettemerides et al., 2018). In Ethiopia, the second most populous nation in Africa and a low-income country, the overall prevalence of HAIs in tertiary health care facilities was determined to be 19.4%, higher than the average (7.1%) in high-income countries (Ali et al., 2018; Allegranzi et al., 2011; Bagheri Nejad et al., 2011; European Centre for Disease Prevention and Control, 2008). The hands of healthcare workers (HCWs) play an essential role in the transmission of pathogens from one patient to another and within the healthcare environment during healthcare activities (Bellissimo-Rodrigues et al., 2017; Goel et al., 2017; Hugonnet and Pittet, 2000; Pittet et al., 2006; WHO, 2009a). Proper performance of hand hygiene (HH) among HCWs is therefore recognized as the primary and most effective factor to decrease preventable HAIs and their associated morbidity, mortality to patients and socio-economic burden to healthcare systems (Allegranzi and Pittet, 2009; Gould et al., 2008; Mathur, 2011).

A recent systematic review from sub-Saharan Africa showed HH compliance to be low, with an average compliance rate of 21.1% (range 9.2%–54%) (Ataiyero et al., 2019). In a review, Loftus et al. (2019) reported a broad range in HH compliance in LMICs, ranging from 8 to 68.9% depending on the country and type of healthcare institution. A cross-sectional study from Ghana also showed compliance with care-related HH practices to be as low as 9.2%, with variations among service areas (Yawson and Hesse, 2013). A study from Addis Ababa also reported a very low HH adherence of 2.1% before an intervention has been implemented (Schmitz et al., 2014).

In their review of 27 studies of reasons for low HH compliance, Ataiyero et al. (2019) concluded that heavy workload, infrastructural deficits (e.g., the lack of water, soap, hand sanitizer and blocked/leaking sinks) and poorly positioned facilities were the main barriers to HH practices among HCWs in Sub-Saharan Africa. Similarly, many other researchers from LMICs also pointed at the absence of basic HH facilities as the main barrier to achieve HH compliance (Schmitz et al., 2014; Tenna et al., 2013; Yallew et al., 2019; Yawson and Hesse, 2013). Other obstacles mentioned are insufficient maintenance of hygiene facilities (Yallew et al., 2019), poor knowledge among HCWs about HH practice (Yawson and Hesse, 2013) as well as a lack of role models and training (Tenna et al., 2013). In a pan-African review on water, sanitation, and hygiene facilities (WASH) amongst healthcare facilities, Ethiopia showed the lowest number of sufficient HH infrastructure (Guo et al., 2017).

Introducing effective methods to tackle different obstacles and behavioural barriers to enhance HH adherence is a core component of the WHO initiative “SAVE LIVES: Clean Your Hands”, launched in 2009 in order to improve patient safety (WHO, 2009a). Therefore, WHO developed a multimodal implementation strategy and practices for HH (Pittet et al., 2008), which are validated in various healthcare settings around the world. Among these, the needs of healthcare facilities in LMICs received particular attention, to ensure a possible implementation regardless of the available resources (Allegranzi et al., 2013; Pfäfflin et al., 2017; Santosaningsih et al., 2017). Implementation of the WHO's multimodal promotion strategy in a referral hospital in Mali resulted in overall HH compliance from a baseline of 8.0% to 21.8% at follow-up after intervention (Allegranzi et al., 2010). Similar to this, in a university hospital in Rwanda, HH compliance increased from 25.2 and 24.8%, to 58 and 43.5% before and after patient contact following intervention (Manzi and Ogbuagu, 2014). In a university hospital from Addis Ababa, Ethiopia, the implementation of a HH intervention which includes availability of soap and hand sanitizer, training on importance of HH in improving quality of care for patients, posting visual reminders for hand HH and selecting HH champions was also associated with an increase in HCWs‘ HH adherence from 2.1 to 12% (Schmitz et al., 2014).

In recognition to the relevance of increasing HH compliance in Sub-Saharan Africa, non-governmental organizations such as the Infection Control African Network have supported many countries in the region to develop IPC policies, specifically HH policies (Loftus et al., 2019). The Ethiopian Federal Ministry of Health has also included the HH in the IPC policies (National Infection Prevention and Control, 2019). However, the implementation in many health institutions still needs to be improved due to a shortage of material, a lack of training and hospital-based policies. There is also limited data on HH compliance and particularly on the impact of WHO multimodal HH strategy in Tigray region and in the country at large. To reduce this gap, the present work aims at providing insights into a strategy to implement the multimodal concept of the WHO adapted to local conditions and obstacles encountered at a tertiary university hospital in Mekelle, Tigray, Ethiopia.