Hand hygiene among cleaning staff in acute care hospitals: a scoping review

Abstract

Objectives:

The aim of this study was to examine attitudes and behaviors related to hand hygiene among hospital cleaning staff and to identify promoting and inhibiting factors influencing hand hygiene behavior. In addition, existing worldwide target group-specific interventions for this occupational group were mapped.

Methods:

A comprehensive literature search was conducted for publications from 2009 to 2025 in MEDLINE (via PubMed^®), the Cochrane Library, CINAHL (via EBSCO), Embase, and Scopus. Additional research was carried out in WHO IRIS, BASE, and Science.gov, and internationally applicable guidelines were identified using the TRIP Database. Included were studies from worldwide somatic acute care hospitals examining hand hygiene compliance, knowledge, attitudes, practices, influencing factors, or interventions among cleaning staff. Texts limited to other hygiene domains, airborne infections, non-acute-care settings, or study populations consisting of mixed occupational groups and not limited to cleaning staff exclusively were excluded. Literature screening was performed in two stages (title/abstract and full-text screening), and data extraction was conducted by one reviewer using a standardized extraction table.

Results:

In total, 33 sources met the inclusion criteria, comprising five guidelines, 25 full-text studies, and three conference abstracts, which formed the primary basis of this review. The conference abstracts identified during the research for which corresponding full texts were not provided were documented for the sake of completeness, but not included in the main analysis and qualitative synthesis, as relevant information may not be available due to the lack of full texts. The base of evidence was heterogeneous and predominantly descriptive, addressing knowledge, attitudes, practices, as well as promoting and inhibiting factors. Identified interventions related to infection prevention and control and hand hygiene among cleaning staff were based on the provision of target group-oriented training materials, simulation-based training, and multimodal approaches and training programs.

Conclusion:

The findings indicate overall limited and predominantly descriptive evidence regarding hand hygiene among hospital cleaning staff. This underscores the need for methodologically diverse research as well as the development of target group–specific interventions and guidelines to strengthen infection prevention, particularly hand hygiene, in acute care hospital settings.

1 Introduction

The World Health Organization (WHO) defines the term “patient safety” in its 2009 “WHO Patient Safety Curriculum Guide for Medical Schools” as “[...] a concern that affects everyone – healthcare professionals, cleaning and catering staff, managers, bureaucrats, consumers, and politicians” (1). This conception of patient safety also applies to the prevention of healthcare-associated infections (HAIs). Basic hygiene is a fundamental component of HAIs prevention and represents a multifactorial concept in which several interrelated measures complement one another. These include hand hygiene, surface hygiene, barrier measures, medical device reprocessing, waste disposal, linen handling, bed hygiene, tableware handling, education of patients, and visitors regarding personal hygiene measures as well as isolation of patients at increased risk of transmission (1, 2). When considering basic hygiene from the perspective of individual occupational groups, it becomes apparent that cleaning staff, the third largest group of employees in hospitals, carry out a substantial proportion of these measures as part of their daily work. Hand hygiene is considered the most important measure for reducing nosocomial infections and reducing the transmission of antibiotic-resistant pathogens. The umbrella term hand hygiene encompasses both handwashing with soap and water as well as hand disinfection, frequently in the form of alcohol-based hand sanitizers. The distinction between handwashing and hand disinfection is particularly relevant with regard to hand hygiene compliance (HHC), as these two measures differ in terms of their indications within a clinical context (1). Regarding hand hygiene, the “Five Moments of Hand Hygiene” concept (WHO) must be implemented by all professional groups with direct or indirect contact with patients (2). The interventions studied by Pittet et al. (3) show a decrease in the incidence of nosocomial infections from 16.9% to 9.9% by increasing staffs' adherence to HHC from 47.6% to 66.2%. Nevertheless, non-compliance with adequate hand hygiene continues to be a significant issue in healthcare facilities among all professional groups, for instance, physicians, nurses, cleaning staff, etc. (1–4). According to the study by He et al. (5), the “Five Moments of Hand Hygiene” approach (WHO) is assumed to be less consistently adhered to by cleaning staff. This is especially true because this approach is difficult to implement into the daily work of cleaning staff. Studies in recent years have contributed to a more comprehensive understanding of HHC (4–6). In 2009, the WHO Guidelines for Hand Hygiene in Healthcare were published as part of the first WHO global patient safety initiative (2). They provide a comprehensive and evidence-based overview and therefore represent a relevant basis for improving hand hygiene behavior in healthcare facilities. Departing from the base of these guidelines, the development of target group-oriented interventions considering the work processes of all healthcare stakeholders is an important and promising approach for optimizing HHC (4–6). Previous approaches to improving HHC have mostly focused on healthcare professionals. Studies and interventions for professional groups without direct patient contact, especially cleaning staff, are rare (7), and further research in this area has been called for (5). A preliminary search of MEDLINE (via PubMed^®), the Cochrane Library, International Prospective Register of Systematic Reviews (PROSPERO), and Open Science Framework (OSF) did not reveal any current or ongoing systematic or scoping reviews nor research syntheses on this topic. Consequently, this review attempts to offer insight into this untreated intersection. In addition, it will provide a comprehensive overview on prevailing research regarding the current state of research on hand hygiene among cleaning staff in acute care hospitals worldwide. The foci consist of identifying knowledge, attitudes, and practices (KAP) as well as factors that promote and inhibit hand hygiene behavior, and identifying already established target group-specific interventions for cleaning staff in hospitals. The focus on KAP as well as on factors that facilitate or hinder hand hygiene arises from the observation that relevant insights regarding this target group already exist but remain scattered across individual studies and have not yet been systematically synthesized. Consolidating this evidence will support a clearer and more comprehensive understanding of the needs, challenges, and existing capacities of cleaning staff in healthcare settings.

The research question to be answered is therefore: What is the current level of knowledge regarding hand hygiene of cleaning staff in acute care hospitals for human healthcare with regard to KAP, promoting and inhibiting factors, and intervention possibilities?

2 Methods

The scoping review was conducted in accordance with the JBI methodology for scoping reviews using the JBI Manual for Evidence Synthesis (2024) for Scoping Reviews (8).

The checklist “Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews” (PRISMA-ScR) was used to verify the reporting standard of the scoping review by Tricco et al. (9). This scoping review was registered via the Open Science Framework (OSF, 10 May 2025, registration DOI: https://doi.org/10.17605/OSF.IO/ZCK34).

DeepL Translator (free version), Google Translate and Chat GPT (paid version, version 5.1) were used to translate identified sources from French, Turkish, and Chinese to German. When possible, ambiguous text passages were translated using both DeepL Translator and Google Translate, and then compared. All translations were manually checked by the authors, assuring mutual quality control and by means of back-translation and comparison with the original texts.

2.1 Search strategy

The inclusion and exclusion criteria were formulated based on the population, concept, context (PCC) approach, and supplemented by the aspect of source types. The inclusion and exclusion criteria used are listed in abbreviated form below in the text; the detailed version is provided in Appendix 1. The search for literature published between 2009 and 2025 (2009: publication of the WHO guidelines on hand hygiene in healthcare (2)) was conducted between May and June 2025. There were no language restrictions (10).

A three-stage search strategy was used to compile the scoping review: Stage 1: A limited search was conducted in at least one database relevant to the topic, in this case MEDLINE (via PubMed^®), in order to identify articles relevant to the topic. The titles and abstracts of the articles identified were analyzed for index terms and keywords. An information scientist from the Leibniz Institute for Prevention Research and Epidemiology – BIPS was involved in the development, and particularly the refinement of the search strategy (see Appendix 2.1). Stage 2: A comprehensive search strategy was developed based on these keywords and index terms. The search strategy, including all identified keywords and index terms, was customized for each database and/or information source included (using the Polyglot Search Translator, TERA Tools). Separate searches were conducted in MEDLINE (via PubMed^®), Cochrane Library, CINAHL Database (via EBSCO), Embase, and Scopus. The final search strings developed for MEDLINE (via PubMed^®), based on the PCC scheme, are listed in Appendix 2.1.

The individual search strands (1, 2, 3), supplemented by the relevant period, were connected with the Boolean operator AND. The final search strings for all databases are provided in Appendix 2.2 for reproduction.

The WHO Institutional Repository for Information Sharing (IRIS), Bielefeld Academic Search Engine (BASE) and Science.gov databases were used to research gray literature. The TRIP Medical Database was used to identify internationally applicable guidelines (see Appendix 2.3). Consensus, an AI-powered academic search engine, was used as an additional research and comparison tool (see Appendix 2.4). Stage 3: The reference lists of all included sources were checked for further relevant studies. These results were documented systematically. Literature without direct access options was obtained via interlibrary loan and author requests.

2.2 Inclusion and exclusion criteria

Following the PCC framework, inclusion and exclusion criteria were formulated and considered in the systematic literature search and selection. The framework was further supplemented by the criterion “source types.”

2.2.1 Population

We included cleaning staff and other occupational groups without direct patient contact, such as cleaners, and building technicians in acute care hospitals worldwide. Mixed populations comprising cleaning staff, nursing staff, and physicians were excluded when separate results for cleaning staff were not reported. In many of these studies, cleaning staff represented only a small proportion of the overall sample, limiting the relevance and interpretability of the findings for the target group and preventing a sufficiently target-group-specific analysis. This approach was intended to ensure greater methodological consistency and target-group specificity. Studies focusing exclusively on occupational groups with direct patient contact, such as nurses and physicians, were also excluded.

2.2.2 Concept

We considered texts assessing the current situation regarding compliance and KAP, as well as factors that promote or hinder hand hygiene. The hand hygiene measures considered were hygienic hand disinfection, handwashing, and the combination of hygienic hand disinfection and handwashing. Studies examining infection prevention and control (IPC) measures more broadly also met the inclusion criteria, provided that they explicitly addressed hand hygiene. Possible interventions included reminder systems, training and continuing education programs, electronic systems, and multifactorial approaches. Studies focusing on the current situation with an emphasis on skin care and protection as well as surface and textile hygiene, without a clear link to hand hygiene, were excluded. Furthermore, data collection and interventions related to infectious diseases mainly transmitted by airborne pathogens were not considered.

2.2.3 Context

We included studies on somatic acute care hospitals worldwide. Studies focusing on veterinary facilities, psychiatric facilities, and non-medical facilities were excluded.

2.2.4 Types of sources

In terms of the relevant study designs, this review included observational studies, experimental, and quasi-experimental as well as qualitative and interventional study designs in addition to various types of systematic reviews with and without meta-analyses. Additional literature such as expert interviews, reports from professional societies, and national and international guidelines, was included in the analysis. There were no exclusion criteria regarding source types.

2.3 Source of evidence selection

The freely available literature management software Zotero (Digital Scolar, 6.0.36, 2024, Vienna, VA, USA) was used to record and manage the identified literature. The identified literature was uploaded to both Zotero and Rayyan, an AI-powered platform for managing systematic reviews. Deduplication was performed and compared using both programs.

The screening process for the identified literature was carried out in two steps using the Rayyan platform. The first step involved screening the titles and abstracts, which were reviewed by two independent reviewers based on the predefined inclusion criteria for the review (see Appendix 1). Interrater agreement in the title and abstract screening was 95.9% (725/756) with 31 discrepancies. Interrater reliability for the title and abstract screening was assessed using Cohen's kappa. The resulting kappa coefficient was κ = 0.78, indicating substantial agreement (0.61–0.80) between reviewers. If a title and abstract were deemed relevant, the second step involved a full-text review (8). Due to resource constraints, approximately 25% of the randomly selected full texts were screened jointly by two reviewers. The remaining texts were screened by one reviewer, with a second and third reviewer consulted in cases of uncertainty. The literature excluded in step 2, along with the reasons for exclusion, is listed in a separate table, which is part of the Supplementary material. In case of uncertainty regarding the inclusion and exclusion criteria of individual literature, an additional reviewer could be consulted.

During the research work, conference and poster abstracts without accompanying full text were also identified. These are also listed in the Supplementary material in the detailed extraction table, but not included in the main analysis and qualitative synthesis, as relevant information may not have been available due to the lack of full text and therefore could not be considered.

The results of the search and the process of inclusion and exclusion of literature are presented in a PRISMA flow diagram (41) (see Figure 1).

Figure 1

2.4 Data extraction

The identified texts were divided into three self-defined categories (see Appendix 3.1). A pilot screening was conducted using randomly selected texts from the included studies to test the suitability of the self-developed data collection form, consisting of an Excel spreadsheet (see Appendix 3.2).

2.5 Data analysis and presentation

The data were presented in narrative and tabular form, considering the relevant thematic priorities. Flowcharts, diagrams, and graphs were used to additionally illustrate relevant relationships. Based on the recommendations of the JBI Manual for Evidence Synthesis (2024), the quality of the evidence was not assessed during the preparation of the scoping review (8). To ensure transparency and quality of reporting, only studies with full texts available were included in the manuscript. For several identified conference and poster abstracts, corresponding full texts could not be retrieved, resulting in insufficient information for an adequate evaluation of these studies. Therefore, contents of these abstracts are listed under “Supplementary material.” The Supplementary material primarily provides additional details as well as expanded presentations of results that support the synthesized findings presented in the main manuscript. Where possible, findings specifically related to hand hygiene were distinguished from broader IPC-related findings during data synthesis and presentation, particularly regarding promoting and inhibiting factors.

3 Results

3.1 General information

The Searches in MEDLINE (via PubMed^®), the Cochrane Library, CINAHL (via EBSCO), Embase, and Scopus, as well as supplementary searches in WHO IRIS, BASE, Science.gov, the TRIP Database, and Consensus, yielded a total of 4,828 results. During the screening of titles and abstracts, 104 sources were deemed suitable. In the subsequent full-text screening, 72 sources were found to be suitable. Of the 72 identified sources, a final total of 33 sources were included across the categories of guidelines, full-text studies, and abstracts (conference and poster abstracts without associated full text), including five guidelines, 25 full-text studies, and three abstracts (40, 42, 43). The PRISMA flow diagram (Figure 1) illustrates the screening and selection process in greater detail (41).

3.2 Guidelines

A total of five guidelines met the inclusion criteria: four with international focus and one with a national focus on Singapore. Three of the four internationally applicable guidelines (11–13) originate from the WHO in Geneva and one from the WHO regional office in Europe (14). The guideline focusing on Singapore originates from the Ministry of Health Singapore [National Infection Prevention and Control (NIPC) Committee] (15). The included texts are an aide-mémoire (14), a training package consisting of three thematically successive parts (11–13), and a national standard (15) on the topics of cleaning and disinfection. None of the guidelines focus exclusively on hand hygiene for cleaning staff, but rather on IPC among cleaning staff in healthcare facilities in general, covering topics such as general education and training, occupational health and safety, personal hygiene, cleaning equipment, the use of personal protective equipment (PPE), surface cleaning, disinfection, waste as well as laundry management. Hand hygiene measures are considered part of an integrated approach. Table 1 lists information on publishing institutions (year of publication), continent, country (scope), document type, setting, population, thematic focus, and key findings.

The included guidelines consistently emphasize the importance of multimodal IPC approaches tailored to the practical realities of cleaning staff's work (11–15). Recommended implementation strategies include structured IPC training programs, regular workplace-based assessments, the integration of hand hygiene into routine cleaning and disinfection procedures, and the correct use of personal protective equipment (PPE) (11–15).

Hand hygiene is addressed in the context of infection chains, relevant hand hygiene moments, handwashing and hand disinfection techniques, common implementation errors, and the availability of necessary hygiene resources (11–15). Limited infrastructure, inadequate access to water and hygiene products, lack of time, skin irritation, insufficient hand hygiene knowledge, and low staff motivation are identified as major barriers to implementation (11–13).

The guidelines further recommend combining theoretical and practical training approaches while considering principles of adult education (11–13). Suggested strategies include practical exercises, visual teaching materials, workplace-based learning, and activities related to Global Hand Hygiene Day (5 May) (11–13). Specific recommendations regarding the adaptation of hand hygiene procedures to routine cleaning workflows were particularly highlighted in one guideline, including hand hygiene when entering and leaving wards, before contact with the patient environment and clean equipment, between patient contacts, and after contact with contaminated surfaces, equipment, or waste (13).

In addition, collaboration between cleaning staff and IPC specialists is repeatedly emphasized, particularly regarding the joint implementation of audits and the planning of IPC measures adapted to local working conditions (11, 13, 14).

3.3 Current situation regarding hand hygiene

A total of 16 studies assessing the current situation regarding IPC, particularly hand hygiene, among cleaning staff in healthcare facilities were identified. Fourteen of these studies used a cross-sectional study design (16–28, 31) and two were methodological studies (29, 30). The studies originated in Pakistan, Saudi Arabia, China, Turkey, India, Germany, Southeast Africa (Republic of Malawi), East Africa (Uganda, Ethiopia), Australia, England, and the USA (Pennsylvania). Data collection methods included covert and open observations, interviews, questionnaires, focus group discussions, epidemiological, and microbiological methods. The core information recorded in the included studies can be divided into the following five categories: (1) Sociodemographic data of the target group, (2) Organizational data, e.g., training measures, especially IPC training, attendance, and participation in IPC committees, availability of equipment (hand hygiene, cleaning, protective clothing), vaccinations, (3) KAP regarding IPC in general, especially with regard to hand hygiene, (4) Factors that promote and inhibit infection prevention and control in general, especially hand hygiene, (5) Microbiological and epidemiological data, e.g., prevalence of colonization with Methicillin-resistant Staphylococcus aureus (MRSA), Enterobacteriaceae spp., Candida albicans, and incidences of MRSA per 100,000 hospital bed days. Two of the 16 studies focus on hand hygiene among cleaning staff (17, 24), while the remaining 14 studies address IPC among cleaning staff in healthcare facilities in general (16, 18–23, 25–31). Topics include general training and further training, cleaning organization, occupational health and safety, personal hygiene, cleaning equipment, the use of PPE, surface cleaning and disinfection, as well as waste and laundry management. Hand hygiene measures are considered part of an integrated approach. Table 2 lists information on author (year of publication), continent, country, study design, data collection, setting, population, sample size (n), thematic focus, relevant keywords, outcomes, and relevant key findings.

3.3.1 KAP of cleaning staff regarding hand hygiene

A total of 16 studies addressing the topics of KAP regarding IPC in general, and specifically the hand hygiene of cleaning staff in healthcare facilities, were identified. The content of the studies focusing on the current situation regarding IPC in general and hand hygiene among cleaning staff in particular is taken into account (see Table 2). Using 12 self-formulated items (Items A to L), the findings from the included studies were systematically recorded and presented in a matrix.

Table 3 shows that 13 of the 16 studies address hand hygiene in general (17, 18, 20–27, 30, 31). One study dealt exclusively with handwashing (30), while eight others addressed both hand hygiene in general and handwashing (20–22, 24–26, 30, 31). One study focused exclusively on hygienic alcohol-based hand disinfection (19). Another study addressed both handwashing and hygienic hand disinfection (16). One study addressed general hand hygiene, handwashing, and hygienic hand disinfection (27). Fourteen of the 16 included studies addressed KAP related to IPC in general and specifically regarding the hand hygiene of cleaning staff (16, 18–27, 29–31). Three studies addressed participation in the development and delivery of training measures (18, 24, 31). Twelve studies addressed the determination of the influence of training measures on IPC and hand hygiene behavior (16, 18, 20, 21, 23–27, 29–31).

The studies (29) and (30) are methodological studies describing the development and implementation of a questionnaire in order to assess KAP. Five of the 16 included studies assessed the availability and accessibility of IPC and hand hygiene equipment (18, 20, 25, 27, 30). One study used microbiological methods to assess hand hygiene (17). Three studies addressed the presence of factors potentially hindering hand hygiene (18, 30, 31). The studies addressed fingernail length, fingernail shape, the wearing of jewelry on fingers and forearms, and wound hygiene (18, 30, 31).

Eight of the 16 studies recorded the availability or use of protective gloves during working hours (16, 19–21, 26, 29–31).

Furthermore, hand hygiene practices taking into account work-related tasks were recorded (16, 19, 22, 26, 27, 29–31). The following 11 hand hygiene moments were considered: before putting on protective gloves (two studies (19, 30)), before cleaning (two studies (22, 30)), after contact with potentially contaminated surfaces (one study (27)), after contact with potentially infectious material (one study (19)), after contact with medical and potentially infectious waste (two studies (16, 31)), in the case of visible hand contamination (two studies (30, 31)), in the case of non-visible hand contamination (two studies (27, 30)), after using the bathroom (one study (22)), after removing protective gloves (one study (30)), after cleaning (three studies (19, 22, 26)), and in other situations (one study (19)). One study assessed adherence to the correct respective steps of a hand hygiene measure leading to even coating of the hands by the respective hand hygiene product; six individual steps were recorded (19). The selection and implementation of pathogen-specific hand hygiene measures were focus of a study in connection with the anaerobic, spore-forming bacterium Clostridioides difficile (27).

3.3.2 Factors influencing hand hygiene

Ten studies identified factors that either promote or inhibit the implementation of infection prevention principles with regard to IPC in general and hand hygiene among cleaning staff in particular (18, 20–25, 27, 30, 31). Figure 2 serves to graphically represent and classify the promoting and inhibiting factors.

Figure 2

The identified factors can be horizontally divided into four levels: (1) individual, (2) interpersonal, (3) organizational, and (4) societal. At the same time, these factors are vertically structured into five categories: (1) material resources, (2) education/training, (3) working conditions, (4) recognition, and (5) sociodemographic factors.

To improve clarity, Figure 2 distinguishes between findings exclusively relating to hand hygiene and those relating to IPC more generally. The different lines around the factors indicate whether the respective factor refers explicitly to knowledge of hand hygiene (solid line), general knowledge of IPC (dashed line), or both, i.e., explicit knowledge of hand hygiene and general knowledge of IPC (dashed and dotted lines). The underlined numbers in the figure indicate studies in which the respective influencing factor was explicitly investigated in connection to hand hygiene or its influence on hand hygiene, while the not underlined numbers indicate studies describing relevant influencing factors on IPC without specifically addressing hand hygiene. The following Figure 2, presents an overview and classification of the promoting and inhibiting factors identified in the included studies. The contents of Figure 2 are explained below.

A total of 15 promoting factors were identified, which can be classified at the individual, interpersonal, organizational and societal levels or between respective levels. The individual level includes the factors “positive attitude toward hand hygiene (18, 24),” “little or extensive professional experience (18, 21, 22),” and “female gender (18, 21–23).” The factors “job satisfaction (20)” and “high level of knowledge and education (18, 21–23, 31)” can be classified between the individual and interpersonal levels. There are no promoting factors assigned to the interpersonal level. The factors “support from colleagues and superiors (20, 24, 25)” and “training and further education (18, 21, 23, 31)” are classified between the interpersonal and organizational levels. The promoting factors at the organizational level include “availability of recommendations (31),” “regular feedback and audits (24, 25),” “work in specific areas and departments, such as work in surgery, pediatrics, obstetrics, and, to some extent, work in lower risk departments (18, 21, 23),” as well as “low time pressure, stress and workload (18, 25)” and “participation and involvement in training and the development of measures, particularly in the area of hand hygiene (18, 24).” The factors “access to materials and products, especially with regard to hand hygiene (18, 20, 25, 27)” and “target group-specific measures, especially with regard to hand hygiene (24)” are classified between the organizational and societal levels. One of the promoting factors at the societal level is “high social recognition and appreciation (24, 25).”

In addition, a total of 16 inhibiting factors were identified and classified at the individual, interpersonal, organizational, and societal levels or between levels. The individual level includes the factors “habituation effect (24),” “little or extensive work experience (18, 21, 22)” and “male gender (18, 21–23).” The factor “low level of knowledge and education (18, 21–23, 31)” can be classified between the individual and interpersonal levels. There are no inhibiting factors assigned to the interpersonal level. The factor “too much conflicting information about IPC in general and hand hygiene in particular (24)” can be classified between the interpersonal and organizational levels. The inhibiting factors “insufficient training and instruction (29, 30),” “lack of qualified and suitable training personnel (25),” “lack of feedback and audits (20),” “accidents at work (20),” “disrespect in the workplace (20, 24),” “work in certain areas and wards, e.g., some of the work in middle and high-risk departments (23)” and “lack of time, stress, high workload and additional tasks (18, 20, 25).” Between the organizational and societal levels, the factors “lack of equipment and materials, including for hand hygiene (20, 25, 27),” “no target group-specific measures (24)” and “hierarchical structures (27)” are classified. One of the inhibiting factors at the societal level is “low social esteem and recognition (24, 25).”

The graphical representation of the promoting and inhibiting factors shows a broadly comparable distribution. A large proportion of the identified factors can be located in the horizontal levels at the individual level (level 1) and the organizational level (level 3) and in the vertical categories of education/training (category 2), working conditions (category 3) and socio-demographic factors (category 5). Few factors are assigned to the horizontal levels interpersonal (level 2), societal (level 4) and the vertical category material resources (category 1). This can be deduced from the gaps in the graph.

3.4 Target group-specific interventions

A total of nine studies meeting the inclusion criteria and addressed hand hygiene interventions for cleaning staff were identified. Four of the included studies had a pre-post study design, two had a quasi-experimental study design, one had a combination of a prospective semi-experimental study design and a pre-post study design, one had a cross-sectional study design, and one was a case study review. The studies originated in Egypt, England, Saudi Arabia, Turkey, China, the USA (New York), Australia (Brisbane), Cambodia, Gambia, Myanmar, Tanzania, Nigeria, and Vietnam. Data collection methods included questionnaires (before, during, and after the intervention), interviews (structured, semi-structured), observations (direct, indirect, covert, and video-based), effectiveness evaluation tools, and literature reviews. The outcomes collected in the included studies can be divided into the following five categories: (1) sociodemographic data of the target group, (2) organizational data, e.g., Occupational health and safety, training measures, especially IPC training, ergonomics, (3) KAP on IPC- topics in general, especially with regard to hand hygiene (six new moments of hand hygiene, “one before, five after”), (4) microbiological, biochemical (ATP measurement) and epidemiological data. Two of the nine studies focus on hand hygiene interventions for cleaning staff (5, 6), while the remaining seven studies address IPC interventions for cleaning staff in healthcare facilities in general. Topics include general education and training, cleaning organization, occupational health and safety, personal hygiene, cleaning equipment, the use of PPE, surface cleaning and disinfection, and waste and laundry management. Table 4 lists information on author (year of publication), continent, country, study design, data collection, setting, population, sample size (n), thematic focus, relevant keywords, outcomes, and relevant key findings.

The subsequent Figure 3, serves to visualize the subdivision and classification of the identified interventions, based on a concept map. The content of Figure 3 is explained in the following section.

Figure 3

The identified interventions can be divided into the following four categories: (1) Target group-specific hand hygiene training measures, (2) Provision of workbooks and training material, (3) Simulation-based training, (4) Multimodal approaches and training programs. Category 1, “Target group-specific hand hygiene training measures,” comprises two studies (5, 6). Taking into account target group-specific activities, hand hygiene moments are redefined, theoretical and practical training is provided, and the effectiveness of the interventions is determined through before-and-after comparisons (6) or comparisons with control groups (5). Category 2, “Provision of workbooks and training material,” comprises one study (32). As part of the intervention, a workbook focusing on infection prevention and environmental hygiene, based on individual topics such as hand hygiene, puncture and cut injuries, and the use of PPE, is implemented, and its effect is determined through a before-and-after comparison. Category 3, “Simulation-based training,” includes one study (33). This simulation-based training for cleaning staff, focusing on infection prevention (including hand hygiene, biological spills, PPE, and cleaning procedures), is based on practical exercises. Effectiveness is determined through a pre-post comparison, considering patient satisfaction. Category 4, “Multimodal approaches and training programs,” includes five studies (34–38). All are based on addressing several relevant aspects of infection control for cleaning staff, as well as on several individual interventions. Relevant focus areas include aspects of occupational safety (34), ergonomics (34), and aspects of infection prevention, among others. Nosocomial infections (36, 37), transmission routes, hand hygiene (34–38), personal hygiene (35), use of personal protective equipment (34–38), waste management (36), cleaning measures of frequently touched hand, and skin contact surfaces (36, 37). Effectiveness is assessed by before-and-after comparisons and, in some cases, by examining the cleaning status of surfaces using ATP measurement (37).

4 Discussion

This scoping review provides a systematic overview of the available evidence on KAP, as well as facilitating and inhibiting factors for IPC in general and hand hygiene in particular among healthcare cleaning staff. Furthermore, interventions aimed at improving hand hygiene behavior and infection prevention practices in this target group were identified. The results show that the current state of research is fragmented, heterogeneous, and predominantly based on descriptive study designs. The identified facilitating and inhibiting factors in the context of IPC and hand hygiene can be clearly attributed to individual, organizational, and societal levels. Intervention approaches specifically tailored to cleaning staff, considering their needs and working conditions, are limited as of now. Interventions focusing exclusively on optimizing hand hygiene for this occupational group are even rarer (5, 6).

The descriptive approach utilized in most studies allows for the systematic assessment of KAP, and context-specific enabling and inhibiting factors within the working environment of the target group. Therefore, the approach can be carried out with comparatively low personnel, material, time, and financial resources. They are particularly valuable for needs assessments, which form an essential basis for developing targeted interventions. However, while descriptive studies can identify associations, they do not allow causal inferences and are prone to various sources of bias, including observer bias, interview bias, recall bias, social desirability bias, and the Hawthorne effect, often resulting in low internal and external validity. Moreover, depending on the specific design, they frequently provide only cross-sectional glimpses, limiting generalizability, especially when sample sizes are small, non-representative, or context specific. Consequently, a substantial proportion of the included studies offers only limited explanatory power, underscoring the need for further research, particularly through qualitative approaches and rigorously designed intervention studies (26).

The included studies exhibit heterogeneity in both their designs and data collection methods. The resulting methodological challenges complicate the comparability of results and the assessment of the strength of evidence, as the validity of the findings depends on the study design. Furthermore, differences in measurement instruments and data collection procedures pose additional challenges in synthesizing and interpreting the findings, and may also lead to inconsistent definitions and evaluation criteria.

Regarding the sample sizes of both descriptive (n_d = 7–1,176) (27, 40) and interventional studies (n_i = 50–807) (32, 37) on the target group of cleaning staff, considerable variability can be observed, which limits the comparability of the studies (20, 27). The diverging sample sizes are particularly relevant with regard to statistical power, the precision of effect estimates, and the external validity of results. This heterogeneity reduces the robustness and interpretability of the available evidence (20, 24, 27). The issue is especially pertinent for intervention studies, where heterogeneous sample sizes complicate the comparison of reported intervention effects. None of the nine included intervention studies reported a formal sample size calculation based on statistical power. Instead, sample sizes were determined by the number of cleaning staff available in the participating hospitals (5, 6, 32–38). The interventions included also have different implementation periods, ranging from 1 month to 1 year. This variability can affect the effectiveness of the measures and further complicates a systematic comparison of the interventions. Other factors that also influence the quality and comparability of intervention studies, such as different study designs, no blinding, often no control groups, and often no follow-up period, are also present (5, 6, 32–38). Consequently, the reported intervention effects should be interpreted with caution, as robust conclusions regarding efficacy are only possible to a limited extent.

Much of the literature reviewed focuses primarily on IPC in general. This is particularly true for the findings, including those concerning promoting and inhibiting factors, KAP, as well as recommended and implemented interventions, which do not specifically address hand hygiene among cleaning staff. This limits the validity of the available evidence, particularly regarding the generalizability and transferability of the results, and consequently the derivation of differentiated, target-group-specific recommendations. At the same time, this indicates a research gap, as target-group-specific determinants and interventions for improving hand hygiene among cleaning staff are currently limited and have rarely been investigated systematically (5).

Across all included sources focusing solely on cleaning staff, a significant proportion of the evidence regarding infection control, particularly hand hygiene, originates predominantly from low- to middle-income countries. Research from high-income countries on cleaning staff is comparatively rare, and this applies to the included guidelines, descriptive studies, and interventional studies alike. Researchers primarily focus on cleaning staff in countries with limited resources, pronounced structural IPC problems, significant threats of nosocomial infections and a higher need for research. There are several possible reasons for the small number of studies from high-income countries. Most hand hygiene measures seem to focus on healthcare professionals in direct contact with patients. Furthermore, particularly in some high-income country settings, outsourcing arrangements, the use of external service providers, and differing organizational responsibilities might complicate researchers' access to cleaning staff and consequently reduce opportunities for research involving this occupational group. Another possible explanation might be that healthcare facilities in high-income countries often adhere to national and international standards, which may blur the need for research and interventions. A focus on other research priorities in HICs, such as the development of novel medical, diagnostic, and technological approaches, could also provide a possible explanation. Furthermore, there is also the possibility of publication bias. Despite the inclusion of gray literature, it is possible that local, institution-specific or non-indexed data collections and reports exist that were not found during the search. At the same time, it is possible that intervention studies with proven efficacy are more likely to be published and indexed, which could also explain the low number of identified studies from HICs.

Regarding the hand hygiene aspects mentioned in the included data sources, a connection can be established between the level of detail of these hand hygiene aspects and the consideration of cleaning staff as an independent occupational group with a differentiated range of activities. Sources explicitly addressing cleaning staff formulate detailed, target-group-oriented hand hygiene moments reflecting the realities of work of this occupational group (5, 6). The guidelines for cleaning staff, particularly the WHO intervention package, include detailed, target-group-, and workplace-specific hand hygiene moments for cleaning staff, which are also incorporated into comprehensive cleaning schedules. The descriptive studies, overall, demonstrate a wide variety of different, activity-oriented hand hygiene moments; however, none of the included studies covers the total of the identified moments. This fragmented and incomplete representation of target group-specific hand hygiene moments demonstrates that while knowledge exists, comprehensive approaches and recommendations might not yet be sufficiently established in the daily work of cleaning staff.

Intervention studies focusing on target group-oriented hand hygiene moments occupy an intermediate position. They define task-related moments but categorize them and present them in a more condensed and less detailed manner. Guidelines and studies on mixed target groups are based on the WHO's classic “Five Moments of Hand Hygiene” (7, 44, 45). This leads to general recommendations primarily geared toward direct patient care activities and therefore not fully encompassing the range of tasks performed by cleaning staff (5). This is a critical issue, as transferring these hand hygiene moments to individual work processes requires extensive expertise in IPC. A lack of specificity can have implications for practical applicability, HHC, and the effectiveness of measures, highlighting the need for target group- and context-sensitive moments in hand hygiene (5, 6).

A large proportion of the descriptive studies included fail to adequately differentiate between hygienic, often alcohol-based, hand disinfection, and handwashing. In those studies that do differentiate, the focus is frequently on handwashing. This contradicts current research and existing recommendations, which, for visibly contaminated hands, emphasize the priority of hygienic hand disinfection over handwashing, due in part to a broader spectrum of activity (especially against non-enveloped viruses) and less skin irritation (1, 2, 12). One potential reason for the increased emphasis on handwashing could be partly due to context-specific factors such as culturally ingrained preferences and structural limitations, e.g., the limited availability of hand sanitizers. This is particularly relevant in low-income countries. Beyond the identification of individual determinants, the interaction between facilitating and inhibiting factors remains insufficiently understood. The identified facilitating and inhibiting factors can be assigned to different levels, e.g., individual, interpersonal, organizational, and societal, and thematic categories, e.g., material resources, education and training, working conditions, recognition, and sociodemographic factors. The available evidence, however, is not yet sufficient to support the development of a robust conceptual framework explaining their interrelationships. Most included studies examined individual determinants in isolation, whereas potential interactions between factors received little attention. In addition, a substantial proportion of the identified determinants originates from studies focusing on IPC more broadly rather than on hand hygiene specifically. Consequently, the evidence regarding relationships between hand hygiene-related determinants remains limited. Given that hand hygiene is embedded within institutional structures and routine work processes, interactions between determinants across different levels and categories appear plausible. This may be particularly relevant for factors associated with education and training. Cleaning staff often constitute a heterogeneous occupational group, characterized by diverse educational backgrounds, varying levels of knowledge regarding infection prevention and hand hygiene, and differing language proficiencies. In this context, language barriers, limited formal education, and insufficient consideration of factors relevant to this specific target group might interact with organizational and workplace-related factors, thereby influencing HHC. These considerations highlight the complexity of the subject and underscore the limitations of approaches that focus solely on individual determinants. Future research should therefore focus not only on identifying relevant determinants but also on investigating their interdependencies and potential mechanisms of influence. Based on a stronger empirical foundation, a multi-layered conceptual framework could be developed to illustrate these relationships and reflect the complexity of hand hygiene behavior among cleaning staff more accurately. In the long term, such a framework may support the design of more targeted, context-sensitive, and practice-oriented interventions.

Both the majority of the identified studies on interventions and all the guidelines included are multifactorial in their focus. These holistic approaches promote a basic understanding of infection control, have greater consideration for existing workflows, and enable synergistic effects between individual aspects, such as the use of PPE, hand hygiene measures, and cleaning procedures. At the same time, they might also overwhelm the target group, especially if they have little prior knowledge or training. Reduced capacity to absorb information and information overload are potential consequences. Multimodal intervention programs potentially also carry the risk of critical individual aspects, such as hand hygiene, not receiving adequate attention due to their broad scope and insufficient implementation due to incommensurate focus. The necessary personnel, time, material, and financial resources may be higher compared to single-pronged interventions. Furthermore, the multifactorial structure of the intervention programs makes it difficult to assess effect sizes of individual components in isolation. Interventions in the form of target group-specific hand hygiene training (5, 6) as well as multimodal approaches and training programs (34–38) appear promising for increasing HHC among cleaning staff. Adapting hand hygiene interventions and training content to the specific workflows and responsibilities of cleaning personnel increases contextual relevance and promotes behavioral changes. Furthermore, these interventions generally require comparatively few personnel, material, time, and financial resources, which increases their feasibility and scalability, particularly in resource-constrained settings (5, 6). Multimodal approaches and training programs are often holistic and promote a comprehensive understanding of infection prevention, considering existing workflows and leveraging synergies between individual components, such as the use of PPE, hand hygiene, and cleaning procedures (34–38). Moreover, interventions should take into account the diverse backgrounds of cleaning staff. Differences regarding prior knowledge of IPC, and specifically HHC, as well as educational levels, literacy skills, and language proficiency should be addressed during the design of these training programs. Knowledge transfer can be facilitated through practical demonstrations, visual learning materials, workplace-based learning approaches, and the use of simple, understandable language, thereby improving the implementation of hand hygiene measures in daily work routines. These considerations also align with the recommendations set forth in the included WHO guidelines (11–14). A combination of both intervention approaches, i.e., target group-specific hand hygiene training and multimodal approaches, could therefore represent a meaningful approach for future intervention development. However, due to the pronounced heterogeneity regarding study designs, outcome measures, statistical analysis methods, interventions, and the limited number of studies investigating the different intervention approaches, this suggestion should be interpreted with caution. Previous systematic reviews on hand hygiene in other healthcare professions have reached similar conclusions. These reviews also revealed significant heterogeneity in the identified sources, which hampered the ability to draw conclusions regarding the effectiveness of clinically relevant improvements in HHC and the reduction of infection and colonization rates (7, 44, 45). Therefore, the planning of future intervention studies should focus on higher study quality to improve methodological rigor and comparability. This applies to studies on this topic and setting across all relevant professions.

Several limitations of this scoping review must be acknowledged, particularly regarding its design and methodology. Suitable sources were identified through a single search of the relevant scientific databases; therefore, publications released after May 16, 2025, were not considered. Due to limited human resources, only 25% of the full texts were reviewed by two reviewers as part of the full-text screening process. This approach carries an increased risk of selection bias and misclassification, while also increasing the scope for interpretation when deciding on suitability. Although the two reviewers showed a high level of agreement when reviewing the titles and abstracts (95.9% / κ = 0.78), indicating consistent application of the predefined inclusion and exclusion criteria, the risk of bias cannot be completely ruled out. Only translation tools were used in the translation process, and no native speakers were consulted for verification. This means that bias may occur as a result of the translation algorithms. It should be noted that this is only relevant for one of the final sources included (6). The methodological and format-related diversity of the included evidence makes it difficult to do equal justice to the different publication types and their respective specifics (39). This heterogeneity was addressed as best as possible by structuring the results into subchapters, separate tables, and, in some cases, graphic visualizations regarding the research questions.

This scoping review also has several strengths: it was conducted according to the PRISMA-ScR guidelines, thus following a structured and methodologically transparent approach that meets current scientific standards (8, 9). By focusing on cleaning staff as the sole target group and excluding sources relating to mixed population groups, the review can also ensure greater target group specificity and consistency. Although the number of included studies was significantly reduced as a result of this adjustment, no substantial changes to the review's main findings were observed. The excluded studies contained only limited specific information regarding the target group of cleaning staff; typically, the results focused on mixed occupational groups without providing separate analyses for cleaners. Consequently, their exclusion did not alter the overall conclusions. Furthermore, no language restrictions were imposed during the search and screening process, enabling the inclusion of a broad spectrum of international literature (10). To the authors' current knowledge, this scoping review represents the first comprehensive and systematic overview of hand hygiene among cleaning staff in healthcare settings. The study design of a scoping review allows for the exploration of a previously under-researched topic, taking into account the specific target group. In addition, various publication formats, including guidelines, descriptive and interventional full-text studies, and abstracts without available full texts, are taken into consideration (8, 9). It also incorporated diverse thematic focuses within hand hygiene, including facilitating and inhibiting factors, KAP, as well as recommended and already implemented intervention approaches. Furthermore, the scoping review enabled the systematic identification of substantial gaps in the evidence that limit the validity of the current state of research (8, 9). These findings form the basis for the implications and recommendations for future research projects presented below.

As demonstrated in this review, there remains a need for methodologically diverse research that systematically classifies, deepens, and expands upon existing knowledge. This includes both descriptive studies examining the current situation and studies on the development and evaluation of target group-specific interventions. Due to the current, highly heterogeneous quality of studies, greater attention should be paid to ensuring higher study quality during planning in order to enable the use of existing critical appraisal tools when conducting systematic reviews and meta-analyses. Future research projects should address the limited geographical scope of currently available research. Studies on the implementation and effectiveness of interventions are currently required from countries of all income levels. To increase the methodological diversity and significance of the collected data, the integration of microbiological testing methods, particularly of anonymized samples from employees' hands and, if necessary, also from gloves and surfaces, can be considered (17). This applies to both descriptive studies on the status quo and the evaluation of intervention effects. For example, contact plate and swab tests are suitable, as they are simple and cost-effective to perform in practice. In addition to determining the total bacterial count (bacteria, yeasts, and molds) on the sampled surface, selective testing methods for the detection of specific microorganisms, such as relevant pathogens of nosocomial infections, can also be integrated. In both descriptive and interventional studies, future research should focus more on a differentiated analysis of handwashing, hand disinfection, and the pathogen- and situation-dependent combination of both hand hygiene methods. If possible, the priority of hand disinfection over handwashing should be emphasized (1, 2, 12).

With regard to descriptive studies, it should be noted that cross-sectional studies based on one-off data collections only represent glimpse. Future research should increasingly utilize longitudinal study designs examining the target group over a longer period and at multiple measurement points, thus revealing changes in behavior and the surrounding circumstances (25, 31). Furthermore, future research projects should focus more intently on specific aspects such as hand hygiene, thereby enabling a more in-depth investigation. This would allow the investigation of influencing factors for which there currently is no information regarding hand hygiene among the target group of cleaning staff specifically. Future intervention studies should focus more strongly on individual aspects of IPC, particularly hand hygiene, so as to consider specific, context-sensitive, and target-group-appropriate mechanisms of action (5, 6, 22, 32–36, 38). At the same time, hand hygiene interventions should not be implemented in isolation but rather integrated into existing workflows and cleaning processes (5, 6). Future intervention-related research projects should also give greater consideration to the social, cultural, and linguistic characteristics of the target group, for example, by integrating vocational training and low-threshold, language-sensitive training approaches (2, 11, 12).

5 Conclusion

This scoping review highlights the central, yet under-researched role of hand hygiene in infection prevention among cleaning staff in the healthcare sector. Current available evidence regarding KAP, as well as factors that promote or hinder hand hygiene, is fragmented, thematically and methodologically heterogeneous, and predominantly descriptive. The findings further emphasize the need for internationally recognized and target group-specific guidelines that account for the working conditions of cleaning staff and clearly define relevant hand hygiene practices. Future research should focus on the development and evaluation of context-sensitive interventions to support sustainable improvements in hand hygiene among cleaning staff.

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