Hand hygiene compliance and glove use in Greece: a multicenter, observational study in eight public hospitals
Our latest research study was published in the Journal of Hospital Infection (UK Healthcare Infection Society) on June 10, 2026.
Hand hygiene compliance and glove use in Greece: a multicenter, observational study in eight public hospitals
by
Astrinaki E, Bolikas E, Vitsaxaki E, Saplamidou S, Koutsouraki A, Marinaki E, Christofaki D, Salvaraki A, Papathanasaki S, Markopoulou C, Magouli E, Messaritaki A, Kritsotakis EI, Ioannou P, Kofteridis D.
Abstract
Background: Hand hygiene is the single most effective action to prevent pathogen transmission and healthcare-associated infections. Systematically measuring hand hygiene compliance (HHC) is a fundamental requirement of any infection prevention and control program.
Aim: To establish baseline HHC prevalence rates and evaluate associated glove use across all eight public hospitals in Crete, Greece, where such data are currently lacking.
Methods: Accredited auditors conducted overt, direct observation in 2025 to collect data using the World Health Organization's "5 Moments" framework and the "Australian National Hand Hygiene Initiative Manual". Fully anonymized data were entered into the Hand Hygiene Compliance Application with permission from Hand Hygiene Australia. A mixed-effects logistic regression model with a nested cluster random effect at the hospital-ward-session level was used to estimate HHC proportions and their 95% confidence interval (CI).
Results: Data were collected from forty wards through 718 sessions, totaling 289 audit hours. A total of 13,359 Moments were recorded, with 4,020 being compliant (mean HHC 30%, CI 28-32%). Among healthcare workers, registered nurses demonstrated HHC of 39% (CI 36-42%), whereas specialized physicians recorded 26% (CI 21-31%). The highest compliance percentage was observed after body fluid exposure risk (53%, CI 48-57%), while the lowest was recorded before touching a patient (11%, CI 9-13%). Alcohol-based hand rub was the preferred technique (66%), yet hand hygiene was omitted in 68% of all Moments where glove use was recorded.
Conclusion: Findings revealed suboptimal HHC, suggesting a potential association with glove use, thus allowing significant room for improvement in both practices.
Keywords: Greece; glove use; hand hygiene; hand hygiene compliance; public hospitals.
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Statistical methods
HHC was recorded and analyzed at the "hand hygiene Moment" level (unit of analysis). The primary outcome endpoint was the HHC percentage (compliant over total Moments x 100) at the time of the survey. Mean HHC percentages and their respective 95% confidence intervals (CIs) in participating hospitals were estimated using a generalized linear mixed-effects model to account for correlated data within different wards and survey days (entered as random-effect clusters). The model used a logit link function and assumed a Binomial distribution for the number of compliant Moments (rubbing or washing) and a Normal distribution for the random effect (log odds ratio) across clusters defined by different combinations of wards and survey days. The model parameters were estimated using the maximum likelihood method. The same approach was used to estimate other secondary endpoints, such as the proportions of missed moments before glove donning and after glove removal. Of note, HHC data would likely be clustered within healthcare workers due to repeated observations of the same worker on some occasions. However, individual-level clustering could not be analyzed because of anonymization during data collection.The Binomial-Normal mixed-effects model was further employed for a multivariable regression analysis to examine factors independently associated with the odds of compliant hand hygiene Moments. Factors examined were hospital care level (primary, secondary, or tertiary), department/ward specialty (critical, medical, surgical, or mixed care), healthcare worker group (doctor, nurse/midwife, physiotherapist, student doctor/nurse, patient transporter, or cleaning staff), and type of hand hygiene Moment. Adjusted odds ratios and their 95% CІs were calculated to summarize the strength and direction of association. Statistical modeling was performed using the melogit command in Stata 19.
