Health care-associated infections (HAIs) are a major threat to patient safety worldwide [1–4]. Such infections spread between patients in the health-care settings by various means, mainly via the hands of health-care workers (HCWs) [5, 6].

Hand hygiene (HH) is the single most effective strategy for preventing HAIs [7–9]. Hand hygiene is defined as either rubbing the hands with an alcohol-based handrub or handwashing with soap and water [6]. WHO has launched a multimodal hand hygiene improvement strategy to optimize hand hygiene in health care settings [10]. This strategy is now recommended as the most reliable and evidence-based method for ensuring sustainable hand hygiene improvement around the world [11–16]. HCWs compliance with hand hygiene during routine patient care is an integral part of this strategy. HH compliance is measured in a variety of ways. These include: direct observation, handrub consumption, and survey methods [17, 18]. Direct observation of HCWs using WHO’s hand hygiene observation tool is currently recognized as the gold standard for hand hygiene monitoring in the sequence of care [6, 10, 17].

World Health Organization has endorsed “My five moments for hand hygiene” approach, the moments when hand hygiene is required, to effectively interrupt the spread of HAIs [19]. This approach encourages HCWs to clean their hands, i.e., (1) before patient contact, (2) before an aseptic procedure, (3) after body fluid exposure, (4) after patient contact and (5) after contact with patient surroundings [20]. The World Health Organization (WHO) has defined these moments as hand hygiene opportunities (HHOs) to which HCWs should comply with [10, 18]. Hand hygiene opportunity exists whenever one of the indications for hand hygiene occurs. Each opportunity corresponds to hand hygiene action [18].

In developing countries with high burden of health-care-associated infections, improving HCWs compliance with hand hygiene during routine patient care is urgently needed for the patient safety [2, 21]. Despite the clear benefits of hand hygiene practices in healthcare settings, compliance remains an issue in developing countries [11]. In Ethiopia, data on hand hygiene compliance is available only for few health-care facilities [14, 22]. In Debre Berhan referral hospital, HCWs compliance to the WHO’s five moments for hand hygiene was not investigated so far. This study aimed to assess hand hygiene compliance among health-care workers in Debre Berhan referral hospital through direct observation of the WHO’s five moments. The result of this study provides insights about hand hygiene compliance level of health care providers.

This study captured hand hygiene compliance of HCWs over a 24 h period. Overall hand hygiene compliance was low (22%). HH compliance was low across all professional categories and similar by shift. In line with our study, HH compliance was found low in previous studies [14, 22, 24]. In low-income and middle-income countries, HH compliance was averaged 22·4% before multimodal intervention [11]. Hand hygiene compliance was much lower in the present study compared to post- multimodal intervention studies from India (82%) [15], Kuwait (61.4%) [25], and Colombia (77%) [26]. The possible reason for low compliance in our study might be due to the WHO’s multimodal HH improvement strategy which was not implemented. For instance, HH resources were deficient at the point of patient care. There were no visual reminders for hand hygiene at work place. Similarly, there was lack of HH monitoring and provision of performance feedback to HCWs. Studies have demonstrated that implementation of a multimodal strategy is globally accepted as best approach to achieve HH compliance in health-care settings [11, 27, 28].

Hand hygiene compliance was inconsistent by the five indications for hand hygiene which might be another reason for low compliance. Lower levels of compliance were witnessed for indications before patient contact, before an aseptic procedure and after contact with patient surroundings. By contrast, compliance with hand hygiene was relatively higher after body fluid exposure followed by after patient contact. This suggests that HCWs more likely to perform HH for the indications that protect themselves from microbial contamination and infection rather than that protect patients. Self-protection tendency of HCWs has been identified in multiple studies [11, 25, 29–31].

Hand rubbing is recommended as the gold standard for hand hygiene according to the “my five moments for hand hygiene” in clinical situations [9, 21]. Particularly in resource-constrained settings, the use of alcohol based hand rubs is a practical solution to overcome constraints because they can be distributed individually to staff for pocket carriage and placed at the point of care [20, 21]. In contrary to findings from other studies [11, 12, 32], the present study revealed that hand rubbing was not the preferred means for hand hygiene. One reason could be that alcohol based hand rub was deficient at the point of care and was obstacle to performing HH according to recommendation. Ensuring availability of alcohol-based hand rubs at the point of patient care is a key factor for hand hygiene improvement in previous studies [30, 33, 34].

The strength of this study is that observation was done over a 24 h to minimize selection bias. In addition to this, the HCWs were unaware of being observed to minimize “Hawthorne effect”. This study was not free of limitations. This study solely employed direct observation method. As a result, did not address why HH compliance was found to be low. The cross-sectional results of this study might not be representative of HH compliance throughout the year. This study conducted in a single hospital, and hence the generalizability of our results to other settings might be limited.

This study showed that HH compliance of HCWs was found to be low. Indications that are high risk to the patient have lower compliance. This suggests that the need of HH compliance improvement strategy is evident. Implementing WHO’s multimodal strategy is crucial to improve HH compliance of HCWs. Access to HH resources should be emphasised as an integral part of HH improvement strategy.