Evaluation of the Effectiveness of the World Health Organization's 6-Step Approach for Hand Hygiene for Healthcare Staff

  • Lucyna Gozdzielewska

Student thesis: Doctoral ThesisDoctor of Philosophy (PhD)


The World Health Organization recommends the 6-step technique for the application of alcohol-based handrubs for hygienic hand antisepsis in healthcare. This technique involves rubbing palm to palm (step one), rubbing right palm over left dorsum with interlaced fingers and vice versa (step two), rubbing palm to palm with fingers interlaced (step three), rubbing the backs of fingers to opposing palm with fingers interlocked (step four), rotationally rubbing left thumb clasped in right palm and vice versa (step five), and rotationally rubbing of clasped fingertips of right hand against left palm and vice versa (step six). Yet, the contribution of each step to bacterial load reduction and hand surface coverage with alcohol-based handrub is unknown and healthcare workers' compliance with the 6-step handrubbing technique is low, possibly because of low acceptability or feasibility of this approach. Therefore, this PhD aimed to evaluate the effectiveness of the 6-step handrubbing technique for healthcare staff with consideration of acceptability and feasibility.

A mixed methods study was conducted. Stage one was a Latin square design study involving 35 volunteers. It compared the 6-step handrubbing technique with its six variations, in which one of the steps was omitted, for bacterial load reduction and the coverage of all hand surfaces with alcohol-based handrub. EN 1500 test procedure was used with samples collected from hands using glove juice method. Hand surface coverage was measured using the HandlnScan®. Stage two was a cross-sectional survey of the acceptability and feasibility of using the 6-step handrubbing technique in clinical practice. An online questionnaire was completed by 78 respondents.

Omitting step four resulted in significantly lower bacterial load reduction on hands than when the full 6-step technique was used (p=0.001), while omitting step one or step two resulted in significantly lower percent coverage of hands in comparison with all other technique variations (p<0.001). Furthermore, using the 6-step handrubbing technique in clinical practice was perceived as acceptable and feasible, with step one perceived as the most acceptable and feasible step.

The results indicated that step four had the greatest contribution to the bacterial load reduction, while step one and two had the greatest contribution to covering hand surfaces with alcohol-based handrub. High acceptability and feasibility of the 6-step handrubbing technique was inconsistent with the evidence on healthcare workers' suboptimal compliance with this approach. Thus, acceptability and feasibility alone do not seem to explain healthcare workers' compliance with the 6-step technique.
Date of Award2020
Original languageEnglish
Awarding Institution
  • Glasgow Caledonian University
SupervisorJacqui Reilly (Supervisor), Susan Lang (Supervisor), Kareena McAloney-Kocaman (Supervisor) & Lesley Price (Supervisor)

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