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Hand hygiene: product preference and compliance

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A study revealed how specific hand hygiene products can boost patients’ handwashing

In this article…

  • Problems with hand hygiene compliance
  • Patients’ preferred hand hygiene products
  • How handwashing products could be improved



Judith Tanner is chair of clinical nursing research; Neetesh Mistry is a research assistant, both at De Montfort University and University Hospitals of Leicester Trust.


Tanner J, Mistry N (2011) Hand hygiene: product preference and compliance. Nursing Times; 107: 6, early online publication.

Background Patient hand hygiene is poor so hospitals are attempting to improve this by providing them with handwashing products at the bedside. Patients’ compliance with handwashing depends on their satisfaction with hygiene products. However, no one has looked at which products patients prefer. This is necessary to help hospitals target hand hygiene more appropriately and effectively.

Aim To explore patient satisfaction with hand hygiene products and identify the most popular.

MethodTwo hundred patients were given five hand hygiene products to evaluate. The products represent the interventions most widely used by patients in hospitals; alcohol foams, alcohol wipes, wet cloths with antiseptic solutions, bowls of soapy water and mobile sinks.

Results Alcohol foam achieved the highest mean satisfaction score and was significantly more popular than each of the other products.

Conclusion Alcohol foam was the most popular choice regardless of age, sex, dexterity, mobility and religion.

Keywords:Infection control, Hand hygiene, Patient preference

  • This article has been double-blind peer reviewed


5 key points

  1. Most healthcare associated infections (HCAIs) are spread via direct contact, often on the hands of healthcare workers
  2. Patient hand hygiene in hospital is poor and up to 60% do not use any hand washing facilities during their stay
  3. A lack of hand hygiene facilities has been identified as contributing to poor compliance
  4. To improve patient hand hygiene hospitals are providing handwashing products at the bedside
  5. Studies of healthcare workers’ hand hygiene show user preference is crucial to compliance


The majority of healthcare associated infections (HCAIs) are spread via direct contact, most commonly on the hands of healthcare workers (Boyce and Pittet, 2003), but patients’ hands can also transmit infections (Banfield and Kerr, 2005). We know that patient hand hygiene in hospital is poor (Burnett et al, 2008) and that up to 60% of patients do not use any handwashing facilities during their stay (Lawrence, 1983).

A lack of hand hygiene facilities has previously been identified as contributing to poor compliance (Meyers and King, 2000). To address this, numerous hand hygiene products have been introduced within hospitals, and some provide patients with alcohol foams or alcohol wipes at the bedside. Other interventions are more labour intensive, for example, some ward staff provide patients with disposable bowls of soapy water or wet cloths before meals. One of the most advanced products on the market is the mobile sink, which uses an electrically powered pump to a produce a stream of warm running water.

There has been no rigorous research determining which of these products patients prefer. However, studies of healthcare workers’ hand hygiene show that user preference is crucial to compliance (Pittet et al, 2000).


The aim of this study was to explore patient satisfaction with hand hygiene products and identify the most popular one. We also looked at whether patients’ preferences were influenced by mobility, dexterity, vision, religion, gender or age. This information could then be used to increase patient compliance with hand hygiene.


Two hundred patients from eight wards at the Leicester Royal Infirmary were interviewed following approval from the local NHS Research Ethics Committee. The wards included surgical, medical and orthopaedic patients to provide a range of patient demographics and abilities. All patients were eligible to take part in the study, except those who had cognitive impairment or were in isolation rooms.

The hand hygiene products included in the study represent the range of products widely available in acute healthcare settings for inpatient use. These include:

  • Alcohol foam (Cutan Foam Hand Sanitizer);
  • Individually wrapped alcohol wipes (Purell Sanitizing Hand Wipe);
  • A disposable bowl of warm water with liquid soap (Cutan Gentle Wash);
  • A mobile sink on wheels (Teal Hygienius);
  • A wet cloth (Conti Standard Plus) with antiseptic solution (Stellisept Med).

One researcher conducted face-to-face interviews with each patient at the bedside over a two-month period. During the interviews, patients were asked to try each product once and then rate them on a numerical scale from 1 to 5, with 5 being the best. The researcher also asked patients to identify their favourite product overall, and gave them the opportunity to comment on any of the products. Demographic data for age, gender, religion, vision, dexterity and mobility was collected. Interview questions and information sheets were also available in Gujarati, Hindi and Punjabi.

One researcher recorded patients’ responses on an interview sheet. A second researcher entered the data on to an Access database, then the first researcher checked data inputting for accuracy.

Statistical tests were carried out to determine which hand hygiene product achieved the highest mean satisfaction rating, was preferred overall and if there was any correlation between demographic category and preferred product.

The survey was piloted with 10 patients before the study began. No changes were made after the pilot study, and the results from the pilot are included with the main findings.


Thirty patients (15%) did not have a spare plug socket beside their bed and were therefore unable to evaluate the mobile sink, which needs to be plugged in to an electrical source to pump and heat the water. Alhough these patients rated the remaining products, their results have not been presented as they did not compare all five products. Patient demographics for the remaining 170 patients are shown in Table 1.

Satisfaction scores

Patients were asked to rate each hand hygiene product on a scale of 1-5, with 5 being the best. Alcohol foam had the highest mean satisfaction score, while the bowl of water and mobile sink had the lowest (Table 2).

Preferred product

Patients were asked to choose which of the five hand hygiene products they preferred. The results (Table 3) showed alcohol foam was significantly more popular than each of the other products (p<0.0001 for each comparison). Patients considered the alcohol foam to be soft, quick drying, easy to use, cooling and pleasantly scented, though some found it a little sticky. They found the wet cloth with antiseptic solution on it refreshing.  Several patients talked about being frightened or worried by the bowl of water, concerned it would splash or that the bowl would be knocked over.

Most of the comments about the alcohol wipes related to the difficulties in opening the packet and unfolding the wipe, although the patients quite liked the product itself, finding it very refreshing. The mobile sink appeared to polarise patients - they either loved or hated it - however, overall the mobile sink was considered to be a “bit of a fuss” with patients finding it bulky or cumbersome.

Relationship between patient demographics and preferred product

Alcohol foam was the preferred product for each demographic category - age, sex, mobility, and dexterity - but religion and visual ability were two marginal exceptions (Table 4). Mobile sinks shared first place with alcohol foam for Muslim and Hindu patients. However, with just seven patients the sample size was small. One visually impaired patient preferred the alcohol foam but again, the sample size was too small to draw any conclusions.

Product design limitations

Two products - individually wrapped alcohol wipes and the mobile sink - had design flaws, which limited their usability. Thirty-four patients (20%) struggled with the individually wrapped alcohol wipe. Seven did not know what to do with the packet, 20 could not open it, four tried to pour alcohol out of the opened packet, one could not get the wipe out of the packet and eight could not unfold the wipe. Of the 34 patients who struggled with the alcohol wipes, four were in their sixties, 13 were in their seventies and 16 were in their eighties. One patient was in their twenties but had restricted dexterity.

The upright design of the sink was problematic. Patients who were bed-bound found it difficult to lean over to reach the it and those who were chair-bound struggled to reach up and get close enough to the sink.

Products that required an electrical supply created a problem as plug sockets were not always available. Each bed headspace in the wards surveyed had two sockets. Thirty of the 200 patients surveyed (15%) did not have a spare socket as both were already being used for other devices such as mattresses, fans and pumps. Patients who did not have free plug sockets beside their beds were increasingly likely to be bed-bound or chair-bound. Table 5 shows 74% of patients with a spare socket as ambulatory, compared with 50% of patients without a spare socket.


Alcohol foam for patient hand hygiene

Numerous studies exploring hand hygiene compliance among healthcare staff have shown that it is crucial to provide products they like using (von Baum, 2008). This is the first study to contribute to successful patient hand hygiene compliance by identifying which products patients prefer.

Patients in this study found alcohol foam simple, practical and convenient, and declared it significantly preferable to other hand hygiene products. This preference was not affected by age, gender, mobility or dexterity.

Hospitals hoping to increase hand hygiene compliance among patients should provide them with alcohol foam. Though alcohol-free hand sanitisers are available, they are less commonly used and there is limited evidence of their effectiveness.

Alcohol foams destroy bacteria, viruses and fungi, which cause HCAIs such as surgical site infections, meticillin-resistant Staphylococcus aureus (MRSA), and vancomycin-resistantenterococcus (VRE), and are also effective against the flu virus and common cold virus. An advantage that alcohol foams have over other hand hygiene products is they are comparatively cheap and require no nursing staff input to deliver them. However, waterless alcohol hand hygiene products do not remove or destroy all micro-organisms, most notably Clostridium difficile and norovirus which are removed with soap and water (Martin et al, 2008).

While soap and running water remains the most effective method of hand hygiene, it is better that patients clean their hands with alcohol foams rather than not at all. The foams are easy to distribute. An individually sized, 50ml alcohol foam could be given to each patient on admission. There have been reported incidents of patients with alcohol addiction attempting to consume alcohol hand hygiene products (Cooke et al, 2005). However, these incidents are extremely rare.

The cost effectiveness of providing patients with hand hygiene products is not known. However, there are some findings from hand hygiene studies aimed at healthcare workers that may give an indication of the figures involved. The global hand hygiene campaign initiated by the World Alliance for Patient Safety is estimated to have prevented 20,000 HCAIs, with projected savings of £20 million (DH, 2007). In addition, a smaller study found that £1 spent on alcohol gel was associated with a saving of £20 on teicoplanin for patients with MRSA (McDonald et al, 2004).

Improving product design

The study provided useful feedback about the alcohol wipes and mobile sink, which could be used to improve their design. This reinforces the need to test or evaluate new products on “real” patients in hospital settings. The straight upright design of the mobile sink made it difficult for bed-bound and chair-bound patients to reach. Having the sink bowl on an arm may overcome this problem.

The need for a plug also restricted the number of patients who could use the mobile sink. This was most acute among bed-bound patients where plug sockets were most likely to be in use. Unfortunately, these patients are unable to get to bathrooms and most likely to be in need of washing facilities at the bedside. Other methods of powering the sink could be considered. For example, a sink that could be charged up may be more flexible, though associated increases in size and noise would be problematic.

Individually wrapped alcohol wipes received a mediocre satisfaction score, with many patients complaining about their packaging; 17% could not open the packet or unwrap the wipe. As most of the problems related to the single-use packaging, re-sealable multi-wipe packets would overcome this problem.

Alcohol foam and Muslim or Hindu patients

It would be unwise to recommend alcohol foam for all patients without considering the views of Muslim and Hindu patients. Articles discussing whether it is acceptable for Muslims or Hindus to have skin contact with alcohol-based hand hygiene products do not reach a consensus (Ahmed et al, 2006). Some believe that Muslims or Hindus can use alcohol products for medicinal purposes if there are no other alternative alcohol-free products available. The opposing view is that alcohol cannot be used under any circumstance. This has obvious implications for Muslim and Hindu patients and visitors and the success of hand hygiene campaigns solely based on alcohol products.

The purpose of this survey was not to specifically elicit the views of Muslim and Hindu patients, however we noted that seven took part in the survey and none of them refused to test the alcohol wipes or foam. This topic would benefit from further investigation, including an evaluation of the effectiveness of alcohol-free hand hygiene products.

Patient empowerment

During the course of the study, patients were seen to be taking control of their own care when they came into hospital already armed with their own supply of handwashing products. For decades, patients have been encouraged to shrug off their passive role and to become empowered (DH, 2004). It would appear that when it comes to hand hygiene, patients are genuinely taking control. The study was not designed to identify how many patients brought their own hand hygiene products into hospital with them. However, participants showed the researcher wipes, sprays and foams they had bought before admission. This emerging phenomenon has presumably been initiated by national media coverage about MRSA, dirty hospitals, C. difficile and, most recently, swine flu.


Our study findings show that patients significantly preferred alcohol foam, and we recommend it is given to all patients on admission to improve patient hand hygiene. However, we would stress that alcohol foams are not effective against C. difficile and norovirus. Further work needs to be carried out to explore Muslim and Hindu patients’ views on alcohol products. Hospitals should also recognise that many patients are taking control of their own hand hygiene.

  • This study was funded by a grant from the Hospital Infection Society.
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