Best Handwashing Technique: WHO’s 6-Step Process Is Effective, but Data Inconclusive

The World Health Organization’s (WHO) 6-step handwashing technique effectively reduces the microbial load on health care workers’ hands compared with other techniques, but there is not enough data to conclusively say it is the most effective way of washing hands.

Hand hygiene compliance is the most effective way to prevent infection; yet, compliance is low among health care workers. To increase compliance, the most effective and feasible way of performing hand washing needs to be found and followed.

In a systematic review of 9 studies, carried out by WHO and published in the American Journal of Infection Control, investigators examined the effectiveness of the WHO 6-step hand hygiene technique and compared it with others, including the Centers for Disease Control and Prevention’s (CDC) 3-step technique, and modified or adapted 3- and 6-step techniques. The CDC’s method involves applying an alcohol-based handrub (ABHR) on one’s hands, covering all hand surfaces, and rubbing them together until dry.

The review, which constitutes an update to a previous 2018 review, included any studies that referred to the WHO 6-step technique or the technique described was consistent with the WHO technique. Investigators considered including hand hygiene (HH) studies from any country that focused on health care professionals or health care students performing either a hand rubbing or handwashing within any health care context. Those settings included hospitals, hospital laboratories, and university hospital training facilities. The health care workers observed included, but were not limited to, physicians, nurses, nursing assistants, allied health professionals, and health care students. Ultimately, 9 studies were included in the review.

The data in the 9 studies varied; some of the studies included in the review found that the WHO 6-step technique was more effective; however, others found no difference between that and the CDC 3-step.

“The evidence is supportive of use of the WHO 6-step technique but is insufficient to advise any changes to the current recommendations regarding how long the technique should be applied," Lucyna Gozdzielewska, PhD, corresponding author and investigator with the Research Centre for Health at Glasgow Caledonian University, told Infection Control Today®. “WHO guidelines should be followed and reinforced, and health care workers should continue using the WHO 6-step technique during routine patient care.”

Further, the WHO technique was determined to be more effective than an adapted 3-step technique in laboratory settings, but not in clinical practice. An adapted 6-step technique in 1 study determined to be more effective than the WHO technique.

Finally, this review identified the need to include a thorough description of the HH techniques, sampling strategy, and population/sample in each study when reporting the findings of HH research. A checklist for reporting HH studies is warranted to help improve the evidence base.

The review “showed that studies differed in terms of study designs, data collection methods, hand hygiene techniques being compared, hand hygiene products used, their volume and application times, and these differences could have contributed to inconsistencies in the findings,” Gozdzielewska told ICT®. “Therefore, we need further research using robust study designs and standardized protocols to determine which hand hygiene technique is the most effective and in what context.”

A key limitation of the studies included in the review was that most participants were observed performing hand hygiene, meaning their performance in everyday clinical practice may be different due to workload pressures, as ICT® Editorial Advisory Board member Sharon Ward-Fore, MS, MT(ASCP), CIC, says.

“The WHO 6-step method for HH is the gold standard; however, most health care personnel do not take, or have the time to do it correctly,” she told ÎCT®. “Most clean hand surfaces but neglect the fingertips. A method that reduces bioburden and is quick is needed.”