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Gyi, Aye Aye, PhD, MPhil, MBBS, MMedSc

doi: 10.1097/SGA.0000000000000432
Departments: Cochrane Nursing Care Corner

Aye Aye Gyi, PhD, MPhil, MBBS, MMedSc, is Research Assistant, The Joanna Briggs Institute, The University of Adelaide, North Adelaide, Australia.

Correspondence to: Aye Aye Gyi, PhD, MPhil, MBBS, MMedSc, The Joanna Briggs Institute, The University of Adelaide, North Adelaide, 5005, Australia (



The Mission of the Cochrane Nursing Care Field (CNCF) is to improve health outcomes through increasing the use of the Cochrane Library and supporting Cochrane's role by providing an evidence base for nurses and related healthcare professionals involved in delivering, leading, or researching nursing care. The CNCF produces “Cochrane Corner” columns (summaries of recent nursing care–relevant Cochrane Reviews) that are regularly published in collaborating nursing care–related journals. Information on the processes this Field has developed can be accessed at:

The author declares no conflicts of interest.

Received September 26, 2018

Accepted October 07, 2018

This article is the summary/review of the following article:

Ejemot-Nwadiaro, R. I., Ehiri, J. E., Arikpo, D., Meremikwu, M. M., & Critchley, J. A. (2015). Hand washing promotion for preventing diarrhoea. Cochrane Database of Systematic Reviews, (9), 1–95. doi:10.1002/14651858.CD004265.pub3

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Diarrhea is one of the world's most common public health problems. It can range from a mild, temporary condition to a potentially life-threatening one. Globally, an estimated two billion cases of diarrheal disease occur each year, and 1.8 million children younger than 5 years—mostly in developing countries—die from the disease. Most cases of diarrhea are caused by infection in the gastrointestinal tract.

Poor hand hygiene is a major risk factor for transmission of diarrhea. The following interventions can help prevent diarrhea: clean and safe drinking water; good sanitation systems, for example, wastewater and sewage; good hygiene practices, including handwashing with soap and water after defecation; clean disposal of a child's stool after defecation and getting the child to wash his or her hands as part of normal practice before preparing food and before eating; and education on the spread of diarrhea infection.

In developing countries, prevention of diarrhea may be more challenging due to general conditions of dirty water and poor sanitation. There is evidence that interventions from public health bodies to promote hand hygiene can cut diarrhea rates by approximately one-third. However, sustained increase in hand hygiene compliance continues to remain low. Interventions to promote handwashing may require infrastructural cultural and behavioral changes.

Nurses are among the healthcare providers who spend the most time in patient care in a variety of clinical settings, including communities and hospitals. For this reason, it is necessary to systematically review literature to identify the short- and long-term effects of interventions aimed at promoting handwashing in this field of practice in many geographical locations and regions.

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This is an updated (second) version of a previous systematic review of randomized controlled trials (RCTs) investigating an effect size of interventions to promote handwashing on diarrheal episodes in children and adults. Observational, case-control, and controlled before-and-after studies were excluded. Participants were adults and children in institutional settings, communities or households, and hospitals. A large spectrum of activities to promote handwashing was considered (e.g., small group discussions, meetings, posters, radio and television shows, etc.); consequently, high levels of heterogeneity among trials were expected. In addition, these interventions (using educational programs, leaflets, and discussions) were compared with other hygiene promotion interventions that included handwashing but no specific activities to promote handwashing. In other words, controls did not include the promotion of handwashing.

Primary outcomes were acute primary diarrhea defined as three or more loose or watery stools in a 24-hr period, persistent diarrhea lasting 14 or more days, and dysentery defined as bloody diarrhea. Secondary outcomes were diarrhea-related death, behavioral changes, and changes in knowledge and attitudes toward handwashing.

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Utilizing a comprehensive search strategy for relevant trials published up to May 2015, eight additional trials were identified. Combining with the 14 from the original review achieved a total of 22 included trials involving 69,309 children and 148 adults. All eight additional trials had primary interventions except for one trial, which was a follow-up study assessing the sustainability of the hand hygiene interventions in preventing diarrhea.

Twelve trials were institution-based (day care centers or primary schools), and all took place in high-income countries, except for three trials conducted in China, Egypt, and Kenya in settings with limited resources and materials for handwashing. The participants were mainly day care providers or educators and children varying in age from less than 3 to 10 years. They were exposed to multiple hygiene interventions with the aim of providing education about personal hygiene, diarrhea transmission, treatment, and prevention, and the importance of and techniques for handwashing with soap.

Nine of the included trials evaluated community-based interventions conducted in low- and middle-income countries in Africa, Asia, and South America. Five of these evaluated had only handwashing with soap interventions, one assessed the sustainability of the interventions, and three included handwashing with soap and proper disposal of feces interventions. The participants were mainly mothers or caregivers as well as children with ages ranging up to 15 years, who were provided with handwashing materials and involved in large-group hygiene education training. All trials assessed episodes of diarrhea in the children and three assessed changes in handwashing behavior. Follow-up periods in all trials ranged from 4 to 12 months.

This review also examined a trial in a high-risk group (patients with acquired immunodeficiency syndrome in the United States), in which patients received intensive handwashing promotion delivered by specialist nurses during 1 year. The outcomes were measured as mean episodes of diarrhea in each group and number of handwashing episodes per day.

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Findings of the review reported that institution-based (child day care centers or schools) handwashing promotion interventions implemented in high-income countries (nine trials) and low- and middle-income countries (only two trials) resulted in a 30% reduction of diarrhea episodes. There was also a 28% reduction in such episodes associated with community-based interventions conducted in low- and middle-income countries (five trials). However, handwashing interventions cannot be double blinded and consequently may have been biased toward an inflated effect.

The handwashing intervention in the high-risk group in hospital-based setting achieved a reduction of 1.68 diarrhea episodes (only one trial). A positive behavioral change was also found in the target communities receiving the interventions compared with the control group in all settings. However, difficulties in maintaining improved handwashing behavior were reported in a follow-up trial conducted in low- and middle-income countries.

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The review found that handwashing promotion programs in high-income countries and low- and middle-income countries can reduce diarrhea episodes by about 30%. However, outcomes were measured only in the short term, and the long-term sustainability of these interventions is uncertain. Adequately powered RCTs with longer follow-up are needed to confirm these outcomes. Evidence regarding the benefits of handwashing on reducing diarrhea incidence in hospital-based setting is limited. This is also the case in the child day care centers or schools in low- and middle-income countries. Further research in these settings is required to determine the efficacy of handwashing intervention in preventing diarrhea.

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Implications for Practice

Public health programs should promote handwashing. Well-designed studies addressing the key uncertainties in handwashing promotion should be conducted in child day care centers or schools in low- and middle-income countries.

© 2019 by the Society of Gastroenterology Nurses and Associates, Inc.