Abstract
BACKGROUND: This systematic review assessed the minimum requirements necessary to create an enabling environment for sustained hand hygiene practices: quantity of water and soap, and number, spacing, location, and design of hand hygiene facilities. METHODS: We searched PubMed, Web of Science, EMBASE, CINAHL, Global Health, Cochrane Library, Global Index Medicus, Scopus, PAIS Index, WHO IRIS, UN Digital Library and World Bank eLibrary, and consulted experts. Eligible studies were published through 29 March 2023, observational, in non-healthcare community settings, and reported on at least one of the five categories: (1) quantity of water, (2) quantity of soap, (3) location of hand hygiene materials, (4) number of users or spacing of facilities and (5) considerations for equitable access. Two reviewers independently extracted data from each study and assessed risk of bias using the Mixed Method Appraisal Tool. RESULTS: This review identified 37 studies that met inclusion criteria from 27 countries, representing 4 of the 6 WHO regions (Africa, South-East Asia, the Americas and Europe). Household settings were the most represented (59% of studies), followed by institutional or school settings (41%) and public establishments (27%). Of the 37 studies, 12 (32%) assessed the relationship between a material requirement and hand hygiene practices. Despite extensive global research on hand hygiene, we found a lack of evidence linking material requirements with handwashing practices in community settings. CONCLUSIONS: This review was limited to observational studies, and more data could be derived from experimental studies. Important evidence gaps include the quantity of water and soap needed, the influence of facility location and design on hand hygiene practice, and material needs providing equitable access. Further research is needed to strengthen the evidence base for hand hygiene recommendations and supplement the expert opinion on which many recommendations are currently based. PROSPERO REGISTRATION NUMBER: CRD42023429145.