1. Objectives To assess the effectiveness of strategies designed to improve hand hygiene behaviour among healthcare workers To assess the barriers to hand hygiene compliance among health care professionals

2. Inclusion Criteria Interventional, observational & qualitative studies Review articles Editorials/letters from expert authorities Guidelines/policy statements from expert committees Special lectures/discussion papers from expert scientists Reports from ongoing campaigns or research conference proceedings via the conference paper index.

3. Search Strategy Electronic databases Medline, Cinahl, Embase and Cochrane Hand search –Grey literature –Conference proceedings (past 3 years) SHEA, ICAAC, APIC, HIS, IDSA, ECCMID

4. Screening Scanning of titles –Healthcare settings –HH related or IC precaution observations or interventions –Knowledge, attitudes, practices related to HH 658 articles were reviewed by title Of those, 419 were kept

5. Abstract review Abstraction tool –Based upon Meade & Richardson’s recommendations –Piloted first to ensure completeness Two team members independently read the publications and evaluated the abstracts –target population –study design –intervention –outcomes Of the 419 abstracts reviewed, 162 were kept

6. Full article review Abstraction tool –Developed by the team –Piloted first to ensure completeness Two team members independently read the publications and evaluated the articles –More detailed info about outcome, intervention, study pop –analysis –results Of the 216 articles reviewed, 84 were kept

7. Barriers-Institutional Lack of sinks, alcohol rub, soap or towels Poor accessibility to washing facilities Skin irritation and dryness Lack of time Heavy workload Lack of role models in colleagues, superiors Lack of administrative support

8. Barriers- Individual Lack of knowledge Belief that glove use is enough Belief that the risk is low for patients and self Belief that HH interferes with providing care Patient needs come first before HH Forgot Sceptical of the importance of HH

9. Factors associated with Hand Hygiene non-compliance that cannot be modified Being a physician or nursing assistant Male Working in critical care Duties with a high risk for cross-contamination Wearing gowns or gloves Working during the week Number of indications for HH per hour of patient care

10. Interventions Education Monitoring compliance Performance Feedback Reminders (i.e. buttons, posters) Policy Change Engage staff in HH decisions Adding HH facilities (i.e. sinks, dispensers) Training Demonstrations Incentives Patient involvement Focus groups Promote safety climate Multimodal

11. Next steps Assess articles for methodological quality Developing interview tools and surveys targeting health professionals and experts in the field Develop a theoretical framework specific to hand hygiene that combinations models of behaviour change at the individual, inter-personal level, community and social levels.