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Year : 2017  |  Volume : 15  |  Issue : 2  |  Page : 116-121

The hand hygiene objective graphical assessment index: An index to assess macroscopic hand hygiene efficiency

Department of Public Health Dentistry, Divya Jyoti College of Dental Sciences and Research, Ghaziabad, Uttar Pradesh, India

Date of Web Publication13-Jun-2017

Correspondence Address:
Jishnu Krishna Kumar
Department of Public Health Dentistry, Divya Jyoti College of Dental Sciences and Research, Niwari Road, Modinagar - 201 204, Ghaziabad, Uttar Pradesh
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jiaphd.jiaphd_161_16

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Introduction: Infectious diseases are a global health problem, and are a major cause of infant mortality. Most middle- and low-income countries have a heavy burden of communicable diseases. There has been no relevant picture pertaining to individual/public hand hygiene because there is no measure to quantify, categorize or compare macroscopic hand scrub levels. Aim: This study aims to present a new index to assess the macroscopic hand hygiene scrub levels. Methodology: The Hand Hygiene Objective Graphical Assessment Index (HOGAI) records the hand hygiene levels based on the net area “not covered” during a hand scrub procedure and labels it into inadequate, basic, intermediate, adequate, advanced, and establishes it on examination of 171 participants. The data were subjected to quantitative analysis, and nonparametric tests were used. Chi-square test was used to test the difference between the males and females. Results: The total percentage of area not covered during the hand scrub ranged from 3.87% to 15.78%. The mean age of the participants were 20.99 (±2.33) years, where 41.52% had “Basic” level of hand hygiene followed by 35.67% having “Intermediate” level and a total of 19.88% had “Adequate” level of hand hygiene with 2.34% at “Advanced” level whereas 0.59% of the participants had “Inadequate” hand hygiene level. On comparison, a nonsignificant statistical difference (P ≥ 0.05) was noted pertaining to hand hygiene assessment between the two gender groups under study. Conclusion: The use of HOGAI paves a landmark into the neglected problem of lack of proper hand scrub and can be utilized in future to train and monitor better hand scrub practices. It complements with relevant information for epidemiologist and policy makers to improve hand scrub guidelines and macroscopic assessment.

Keywords: Guidelines, infection, scrub, stages, technique

How to cite this article:
Kumar JK, Patthi B, Singla A, Gupta R, Prasad M, Ali I. The hand hygiene objective graphical assessment index: An index to assess macroscopic hand hygiene efficiency. J Indian Assoc Public Health Dent 2017;15:116-21

How to cite this URL:
Kumar JK, Patthi B, Singla A, Gupta R, Prasad M, Ali I. The hand hygiene objective graphical assessment index: An index to assess macroscopic hand hygiene efficiency. J Indian Assoc Public Health Dent [serial online] 2017 [cited 2022 May 29];15:116-21. Available from: https://www.jiaphd.org/text.asp?2017/15/2/116/207912

  Introduction Top

Despite improvements in global health scenario during the last decade, infectious diseases are still a major global public health problem.[1] United Nations Children's Fund and multi-national reviews have suggested that hygiene plays a key role in reducing the pan-nation burden of communicable diseases and it can be noted in most low- and middle-income countries, as they have a limited system to educate, motivate and intervene about infection control.[2],[3],[4],[5] A notable finding is the substantially high infant mortality rates in the low-income countries due to infections of gastrointestinal and respiratory origin backed up by inadequate hand hygiene.[6],[7] Studies conducted by Magiorakos et al. and Ray et al. have shown that children growing in the household where the mothers do not maintain hand sanitization were more likely to suffer from a specific infectious disease and proposed that specific hand hygiene measures could substantially bring about a decline in mortality rates.[8],[9]

For about a century, since the advent of toiletries and sanitizing agents, global efforts have been made to assess the efficiency of each agent to reduce microbial load, ease of application, and dermal response.[10],[11],[12],[13],[14] These classical techniques are efficient in their own system of evaluating clinical consequences of a hand sanitizing agent but fail to provide information on a macroscopic scale of an improperly sanitized/washed hands, which might be more serious than the previous. Along with the fact that international trends have focused on individual and organizational hygiene quantification, but there has been no mention of how to assess an individual's personal hand scrub method.[15]

Some information might be obtained from the World Health Organization's (WHO) hand hygiene self-assessment framework but does not provide a precise picture about the personal state of hand hygiene.[15],[16] Moreover, guidelines have stressed on hand hygiene measures for health workers, but there has been a lack of similar emphasis for the general population. In 2010, World health Assembly in Geneva, Switzerland recognized the growing burden of infections world over and emphasized the need for comprehensive hygiene maintenance to avert further rise in communicable infections.[16],[17] In view of global epidemic, there is an urgent need to establish a platform to score various stages of hand hygiene.

The Graphical Assessment Technique (GAT) is a simple arbitrary hand scrub quantification and comparative technique used to provide an objective layout of an individual/population hand scrub techniques or guideline follow-up based on stipulated guidelines as published by the WHO.[18],[19],[20] An effort had been made to develop an index which would reduce the time required to inspect and feasibly estimate the intra- or inter-hand scrub variability. After considerable trial and error, this index was developed based on GAT and WHO Hand Hygiene Assessment Framework along with Hand hygiene guidelines.[18],[19],[20] In this study, the efficiency in macroscopically and objectively assessing hand scrub status has been described. The Hand Hygiene Objective Graphical Assessment Index (HOGAI) utilizes GAT wherein the data are recorded using ultraviolet (UV) fluorescence technique over the hand, and the replication of the uncovered regions during hand scrub onto the graph sheets. Although GAT provides the overall estimate of hand hygiene, it requires a systematic approach to segregate and delineate between statuses of hygiene: Inadequate, basic, intermediate, adequate, and advanced.

The aim of the present study was to present with a new index that assesses the macroscopic hand hygiene scrub levels. Further, the rationale that urged the development of the HOGAI was requisite for a readily observable individual quantification and comparative index that could be used universally.

  Methodology Top

A cross-sectional study was conducted on 197 students aged 18–26 years from a Government Aided College in Modinagar, India and constituted local group of students from all sections of the society. The study was carried out for 3 months from May 2016 to July 2016. Informed consent was individually obtained from every participant after explaining the study. Ethical approval was obtained from Institutional Review Committee at Modinagar, India.

HOGAI is an index used to assess the efficiency of an individual's hand scrub motion, by objectively analyzing the amount of area covered during hand scrub. The ventral surface examined for HOGAI are selected by drawing the outline using a 0.5 mm felt tip or by smudge proof marker or as assessed during GAT.[19] The HOGAI was developed with an aim to present a new index for macroscopic hand hygiene assessment and labels different hand hygiene levels into (1) inadequate, (2) basic, (3) intermediate, (4) adequate, and (5) advanced [Table 1].
Table 1: Hand hygiene assessment framework

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A pilot study was conducted on 25 participants to check for the feasibility of the study as per GAT, and these participants were not included in the main study.[19]

The study participants were selected from the college record office. Out of the total sample of 197 students, 171 were included in the study as they agreed to participate in the study and were present at the day of the examination and satisfied the inclusion and exclusion criteria (as stated below).

Inclusion criteria

  1. Participants aged 18–26 years
  2. Individual with normal anatomic and physiologically functioning upper extremities.

Exclusion criteria

  1. Previous history of dermatologic complications
  2. Neuropsychological disorders that would hamper the communication and the perception of information
  3. History of drug allergy
  4. Individuals with formal training on hand hygiene guidelines and follow-up.

Examining methods and scoring system

To obtain scores, the total area of the hand covered on the graph sheet is tabulated by summing each of the smallest squares on the graph sheet which equals 1 mm 2 in area. The marked areas are noted, replicating the areas that are not covered during hand scrub. It has to be made sure that the total area and the marked area have been separately tabulated for further analysis. The difference between the total area and the marked surface is calculated, inferring the amount of area that tends to be covered during hand wash motion. To ensure consistent judgment, a team of three examiners involved in the field trial underwent 2 days of theoretical and clinical training in hand hygiene and GAT [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6].[19] Sample laminated pictures and audio-visual aids were utilized as a reference to HOGAI scoring [Table 1].
Figure 1: Illustration of the Hand Hygiene Objective Graphical Assessment

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Figure 2: Analysis of hand wash practiced by the subject

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Figure 3: Application of ultraviolet fluorescent Gel

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Figure 4: Ultraviolet assessment in a dark room

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Figure 5: Assessment on graph sheet

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Figure 6: Graphical assessment “yellow” markings depict “area not covered (A)

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Calculation of HOGAI

A = (B/C) × 100,

Where [illustration: [Figure 1],

“A” is the percentage area not covered during hand hygiene procedure (Area interposed between the blue outline and the yellow mark-up)

“B” is the area not covered during hand hygiene procedure (Area depicted with “yellow”) and

“C” is the total area covered by the individual's hand on a graph sheet (Total area within the blue outline).

Accordingly, the HOGAI grading has been done considering the percentage area not covered during hand hygiene procedure or scrub (A). The HOGAI levels [Table 1] were further coined considering 0.6 cm 2 as “big mistakes” and taking into account “5 cm × 0.6 cm” as a level in HOGAI.[21]

Data analysis

The collected data were analyzed using SPSS software (version 19.0), Chicago, IL, USA. The data were subjected to quantitative analysis, and nonparametric tests were used. Chi-square test was used to test the statistically significant difference (P < 0.05) between the males and females.

  Results Top

The hand hygiene assessment interpretation guideline was made based on the observation made after the examination of the 171 participants aged between 18 and 26 years where 51.46% participants were females and 48.54% were males. The notable finding was that the total score/percentage of the area not covered during the hand scrub ranged 3.87%–15.78% and it was according to which the assessment levels were equally categorized.

[Table 2] describes the demographic characteristics of the study participants, where mean age of the participants were 20.99 (±2.33) years, and 51.46% of the participants were females and 48.54% were males. [Table 3] describes overall hand hygiene level among all the participants and its gender-based variations. It was noted that 41.52% had “Basic” level of hand hygiene followed by 35.67% having “Intermediate” level. About 19.88% had “Adequate” level of hand hygiene with 2.34% were at “Advanced” level whereas 0.59% of the participants had “Inadequate” level of hand hygiene. Further, it was noted that the highest proportion of males, i.e., 21.64% where at the “Intermediate” level while 23.39% of females were at the “Basic” level of hand hygiene. Subsequently, a nonsignificant difference (P ≥ 0.05) between the males and females was noticed regarding the hand hygiene assessment.
Table 2: Demographic characteristics of the study participants

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Table 3: Hand hygiene based descriptives

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Reproducibility of the Hand Hygiene Objective Graphical Assessment Index

It was noted that 250 g of UV fluorescent paste and powder (ALKEM Laboratories India Pvt. Ltd., Mumbai, India) could be used for 152 individuals and its price tag was INR 3000 that means per individual cost inferred to be INR 19.74 along with a reusable UV lamp worth INR 3000 that runs on rechargeable battery source.

The appraisal of HOGAI is based on data describing the relationship between the GAT and status of hand hygiene of respective individuals determined using GAT. The ventral surfaces of all participants were examined after careful examination with stepwise GAT, in field for the development of the index.[19]

The scores of HOGAI is determined on the basis of direct assessment of the hand surfaces not covered during hand scrub motion that is being replicated onto a graph sheet. These hygiene levels may be used to categorize and compare hand hygiene assessment in various population groups. It was noted that the hand hygiene maintenance pattern varied between the age groups and a notable factor was the hand scrub motion was noted to be better in individuals who perceived hand hygiene to be important.

Scores are assigned according to the following criteria on the basis of the examined participants, the mean variation and the individual's hand hygiene levels are calculated on the basis of [Table 2].

  Discussion Top

For the past few decades, public health researchers worldwide have focused on multidimensional approach to track down infections. “Clean care is safer care” as proposed by the WHO, has distinguished the need for cost efficient hand hygiene promotion along with sustained, comprehensive evaluation to avert the risk of cross transmission seen in schools, day care centers, medical institutes and country settings.[21],[22] After the promotion of “clean your hands” campaign by the WHO and the Royal Society of Public Health, the hand sanitization programs spearheaded globally through application-based researches on antiseptic agents including quaternary ammonium compounds, iodine, iodophors, chlorhexidine, triclosan, chlorxylenol, and alcohol but the disparity lies in macroscopic assessment of hand scrub.[15],[23]

Although there has been a decline in the rates of infectious diseases in the high-income countries, there is a requisite for an index that assesses preventive interventions and distinguishes between different stages of individual hand scrub and maintenance. Furthermore, in low- and middle-income countries, along with deprived communities within high-income countries, people are ignorant about infections, its prevention as well as the relevant countermeasures.[24] Hence, a diagnostic, evaluative, and comparative index that would enable a policy-based hand scrub assessment system was required. HOGAI was designed to facilitate the assessment of participants into various groups according to their hand scrub technique. The earlier observations and studies pertaining to hand hygiene assessment and evaluation were inherently based on categorizations on microbial load, comparative evaluation of agents used, and comparison after health education interventions.[18],[24] HOGAI is a method for classifying and comparing variations in hand hygiene status of population group along with a great degree of objective evaluation, comparability and offers a rapid method for assessing the hand hygiene between population groups. For HOGAI, the ventral surface of hand is studied that plays a key role in hand hygiene with the help of GAT, as explained below.[19]

The HOGAI is the first ever index that would develop a platform for the development of macroscopic hand scrub observational and prospective evaluation along with quantification and of the same after imparting intervention with the WHO hand scrub and hygiene maintenance guidelines.[18],[19]

The present indexing technique has a cost advantage over studies conducted by Boyce and elaborative review conducted by Marra and Edmond.[25],[26] Although further studies may be conducted to elaborate on its cost-benefit and cost-effectiveness. The range of time taken per individual after careful explanation of the procedure was noted to be 5.20–6.30 min.

There are three main methods for measuring hand hygiene performance namely by, directly observing, measuring product use, and conducting surveys.[27] Thus, the present study falls under the spectrum of “directly observed” measurement system. Microbiological techniques provide a varied assessment but are complex, time taking, and expensive to carry out.[28],[29]

Earlier studies that utilized “directly observed” system were utilized by Srigley et al. and Cheng et al. where they examined hand scrub motion through electronic monitoring systems and video monitoring systems on Healthcare Associated Infections, but they were primarily linked to monitor hand hygiene performance related to Health Care Workers (HCW's).[30],[31] Thus, they could not give a clear evidence for indexing with regard to general population. Similarly, Szilágyi et al. assessed hand rub coverage of HCW's using Stery-Hand monitoring device and checked for “small” and “big” missed spots on hand scrubs, but this study did not aim at cost efficient, readily observable quantification system.[32] Pointing out these lacunae, the current study and index derivation was based on GAT.

In the present study, macroscopic hand hygiene level was correlated and measured based on the potential uncovered areas left over during an individual's hand scrub motion. The way hand hygiene framework is assessed and presented may have a considerable impact on health decision makers in devising new guidelines. The study population consisted of college students with mean age of 20.99 (±2.33) years. The presented data describe the hand hygiene levels of the participants where it was noted that the majority of the participants possessed “Basic” level of hand hygiene accounting to 41.52%, followed by 35.67% of individuals at “Intermediate” level. This finding suggests that the net area not covered during hand scrub practice of individual accounts to 15.00–9.01 of the graph area covered. This might be due to the lack of knowledge about hand hygiene, infection control, spread of infection, and proper hand scrub technique. Gender-based categorization showed no statistically significant difference (P ≥ 0.05) in hand hygiene performance levels of males and females.

The public health workers should fulfill its ethical mandate and present health decision makers with pertinent comparative information related to macroscopic hand hygiene evaluation and disease outcomes in varied population groups. The index provides five different stages of clinical hand scrub evaluative scheme on a comparative real-time scale. Presenting data based on HOGAI will provide health planners with relevant information which is complementary to data on disease status of a community per se. The demonstrated high level of examiner agreement in the present assessment for HOGAI suggests good reproducibility and indicates the reliability of HOGAI. The index proved to be applicable in quantifying various stages of macroscopic hand hygiene levels and is applicable in all settings with minimum armamentarium and under simple field condition. The index is easy and safe to use, even for nonhealthcare professionals and does not require any cumbersome procedure.

It was noted that the participants whose “objective hygiene level” was “Inadequate” gave a history of from frequent gastrointestinal discomforts and related infections. The said condition has not been correlated with the macroscopic assessment system considering the urgent requisite for the development of an index and the future prospect of further comparative longitudinal multicentric population-based studies. Due to paucity of similar published literature, it is difficult to compare the present findings. The use of HOGAI paves a landmark into the neglected problem of lack of proper hand scrub, training, monitoring, and implementation. It also creates a new era of macroscopic hand hygiene assessment protocol that can be elaborated in the near future.

  Conclusion Top

The present study included a group of healthy individuals. Hence, the index must be reproduced on larger samples to ascertain any necessity for modification. Expanded multi-centric studies on varied population such as children, geriatric, special group must be carried out to ascertain any modification and to avoid bias. Prospective evaluation of hand scrub at fixed intervals to interpret the outcome of HOGAI and inclusion of HOGAI as part of primary health check-up and screening, considering the importance of proper hand scrub is suggested.

Public health significance

HOGAI is a milestone in the new spectrum of macroscopic hand hygiene assessment system. It can aid in better understanding of individual hand hygiene levels and may provide psychological reinforcement to improve them. The ease of applicability can further inculcate community participation and thus improve acceptability. HOGAI can be used to maintain a global database for comparison of hand hygiene levels. It may be further used to improvise or modify hand scrub technique according to special needs of varied population.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

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  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]

  [Table 1], [Table 2], [Table 3]

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