{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,7,27]],"date-time":"2026-07-27T16:00:46Z","timestamp":1785168046344,"version":"3.55.0"},"reference-count":54,"publisher":"American Medical Association (AMA)","issue":"7","content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["JAMA Netw Open"],"abstract":"\n Importance<\/jats:title>\n Evidence on hand hygiene promotion in resource-limited settings remains sparse, and its generalizability and long-term sustainability are poorly understood. Previous studies have predominantly relied on single-center, short-duration, before-and-after interventional designs.<\/jats:p>\n <\/jats:sec>\n \n Objective<\/jats:title>\n To assess the long-term impact of the World Health Organization (WHO) multimodal improvement strategy (MMIS) supported by locally manufactured alcohol-based handrub (ABHR) on hand hygiene performance across multiple health care facilities in Uganda.<\/jats:p>\n <\/jats:sec>\n \n Design, Setting, and Participants<\/jats:title>\n This stepped-wedge cluster randomized trial was conducted at 8 health care facilities across 4 districts in eastern Uganda from November 1, 2020, to July 31, 2024 (45 months). Participants included all health care workers at the participating sites.<\/jats:p>\n <\/jats:sec>\n \n Intervention<\/jats:title>\n Following a baseline phase of 12 to 21 months, the WHO MMIS combined with locally manufactured ABHR was sequentially introduced in each district at 3-month intervals and implemented for 12 to 21 months (ie, the intervention phase), followed by a 12-month follow-up period without additional intervention.<\/jats:p>\n <\/jats:sec>\n \n Main Outcomes and Measures<\/jats:title>\n The primary outcome was hand hygiene adherence among health care workers. Secondary outcomes included scores on the WHO Hand Hygiene Self-Assessment Framework (HHSAF) and the Infection Prevention and Control Assessment Framework (IPCAF).<\/jats:p>\n <\/jats:sec>\n \n Results<\/jats:title>\n \n A total of 27\u202f895 hand hygiene opportunities were observed. Hand hygiene adherence increased from 22.1% (95% CI, 11.4%-32.8%) at baseline to 79.2% (95% CI, 67.2%-91.2%;\n P<\/jats:italic>\n \u2009&amp;lt;\u2009.001) during the intervention phase and remained high at 72.7% (95% CI, 57.8%-87.6%;\n P<\/jats:italic>\n \u2009&amp;lt;\u2009.001) during follow-up. Median HHSAF scores improved significantly from 145.00 (IQR, 52.50-202.50) at baseline to 383.75 (IQR, 367.50-417.50 [\n P<\/jats:italic>\n \u2009=\u2009.008]) during the intervention phase and 366.25 (IQR, 316.25-380.00 [\n P<\/jats:italic>\n \u2009=\u2009.008]) during follow-up. Median IPCAF scores followed a similar pattern, from 335.00 (IQR, 235.00-520.25) at baseline to 657.50 (IQR, 648.75-705.00) (\n P<\/jats:italic>\n \u2009=\u2009.008) during the intervention phase and 676.25 (IQR, 656.25-705.00) (\n P<\/jats:italic>\n \u2009=\u2009.008) during follow-up. ABHR accounted for more than 99% of observed hand hygiene actions during the intervention and follow-up phases.\n <\/jats:p>\n <\/jats:sec>\n \n Conclusions and Relevance<\/jats:title>\n In this study of hand hygiene promotion in eastern Uganda, the WHO MMIS supported by locally produced ABHR led to substantial and sustained improvements in hand hygiene adherence. This stepped-wedge cluster randomized trial provides robust evidence supporting the scalability of this approach at regional and national levels in resource-limited settings.<\/jats:p>\n <\/jats:sec>\n \n Trial Registration<\/jats:title>\n \n University Hospital Medical Information Network Clinical Trials Identifier:\n UMIN000039483<\/jats:ext-link>\n <\/jats:p>\n <\/jats:sec>","DOI":"10.1001\/jamanetworkopen.2026.25250","type":"journal-article","created":{"date-parts":[[2026,7,27]],"date-time":"2026-07-27T15:30:30Z","timestamp":1785166230000},"page":"e2625250","source":"Crossref","is-referenced-by-count":0,"title":["World Health Organization Multimodal Improvement Strategy for Hand Hygiene"],"prefix":"10.1001","volume":"9","author":[{"given":"Emma","family":"Nyawere","sequence":"first","affiliation":[{"name":"Saraya Manufacturing Uganda Ltd, Kampala, 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