Hand hygiene practices in extreme resource limited situations: an integrative review of the literature

Peta-Anne Zimmerman1,2,3,4, Jocelyne M Basseal5, Sophie Dennis6 and Sharon Salmon7

1 School of Nursing and Midwifery, Griffith University, QLD, Australia; 2 Menzies Health Institute Queensland, Griffith University, QLD, Australia; 3 Gold Coast Hospital and Health Service, QLD, Australia; 4 Collaborative for the Advancement of Infection Prevention and Control, QLD, Australia; 5 Sydney Infectious Diseases Institute, University of Sydney, NSW, Australia; 6 Bristol Medical School, University of Bristol, UK; 7 UNSW Medicine, University of New South Wales, NSW Australia


As the COVID-19 pandemic affects more than one hundred million people, worldwide prevention measures, particularly hand hygiene (HH), are crucial to control and limit spread of disease. Yet access to clean water and soap or hand sanitiser may be scarce or unattainable in some situations. This integrative review, based on the framework of Whittemore and Knafl and the quality assessment performed in-line with the Mixed Methods Assessment Tool, aims to identify alternative HH agents and water sources that have demonstrated some efficacy in extreme resource limited situations. Four articles met inclusion criteria, with agents that create friction and repurposed water identified as alternatives to soap and water or hand sanitiser, resulting in reduced microbial load. Sand combined with repurposed cooking water, for example, can be used as an alternate HH measure in extreme resource limitations. Long term effects on skin integrity, compliance, and sustainability of these strategies must be considered.

Keywords: Hand hygiene, hand disinfection, hand washing, infection control, hand sanitiser, health resources


Citation: Int J Infect Control 2022, 18: 21586 –

Copyright: © 2022 Peta-Anne Zimmerman et al. This is an Open Access article distributed under the terms of the Creative Commons Attribution 4.0 International License (, allowing third parties to copy and redistribute the material in any medium or format and to remix, transform, and build upon the material for any purpose, even commercially, provided the original work is properly cited and states its license.

Received: 4 May 2021; Revised: 23 July 2021; Accepted: 6 September 2021; Published: 30 August 2022

Competing interests and funding: No authors identify any conflict of interest in the production of this paper or in the study.

Peta-Anne Zimmerman, School of Nursing and Midwifery Griffith University, 2.43 G16, Parklands Drive, Southport, QLD, 4215, Australia. E-mail:, Ph: +61755528780


Communities are frequently faced with a lack of resources to perform traditional hand hygiene (HH). As such alternative options must be identified. This review provides best available evidence of alternative materials for performing HH. Alternative materials for HH can be effectively used until appropriate water, sanitation and hygiene (WASH) alternatives are available.


On 30 January 2020, the World Health Organization (WHO) announced that the COVID-19 outbreak was a Public Health Emergency of International Concern (PHEIC). Initially, most cases were reported from China and those with travel history to China, however to date, this is no longer the case. COVID-19 is an acute respiratory illness caused by a novel human coronavirus (SARS-CoV-2) which causes higher mortality in people aged ≥60 years and those with underlying medical conditions such as cardiovascular disease, chronic respiratory disease, diabetes, and cancer. Prevention and control of infection transmission in the community is therefore imperative (1).

The principles of infection prevention and control (IPC) are the same in all situations, however implementation is dependent on context and resource availability (2). IPC practices are not limited to only healthcare settings; IPC practices are equally important for prevention of infection within the community and need to be practised by the general public. Practising effective HH is one of the key strategies to prevent disease transmission in any setting (3). Hand hygiene practice in its simplest form refers to any action of hand cleansing, but more traditionally includes the use of water and soap, or alcohol-based hand rub (ABHR) (3).

The WHO recently released interim guidelines to assist Member States to improve compliance of HH to prevent the transmission of COVID-19 in the community by: “Providing universal access to public HH stations and making their use obligatory on entering and leaving any public or private commercial building and any public transport facility.” (1) In most situations this is achievable yet these principles and practices do, however, cause an impost on available resources and rely on basic infrastructure and a reliable supply chain. This becomes an issue not only in the current COVID-19 situation but also for future outbreaks and pandemics.

In 2017, WHO and UNICEF reported that 71% of the world’s population has access to safe water sources (4). In extreme resource limited settings where there may be no water and soap or ABHR to perform HH, how can these communities practice HH?


The aim of this integrative review is to identify HH agents that have shown some efficacy, and could be used as an alternative to, soap and water or ABHR in extreme resource limited situations that have resulted in an absence of normal HH materials.


An integrative review methodology was used as it includes various perspectives on a subject or topic and is currently the broadest type of research review which has been advocated as important to health science and research (5). The framework developed by Whittemore and Knafl (5) guided this review and includes: problem identification, literature search, data evaluation, data analysis, and presentation of the data. The ability to include both experimental and non-experimental research and the use of quality scores to evaluate the overall quality of studies allows for a comprehensive understanding of the topic and a more detailed evaluation of the strategies to implement IPC practices in extreme resource limited contexts (5). To assist in structuring a clinical question, the Population, Intervention, Comparison, Outcome and Context (PICOC) framework was used as it is regarded as a valuable tool to assist with developing evidenced-based medicine (6).

Population: humans

Intervention: alternative HH strategies/agents

Comparison: ABHR, water, soap and water

Outcome: bioburden reduction on hands using alternative HH strategies/agents

Context: resource limitations

Search methods

An electronic database search was conducted including a search of Cumulative Index for Nursing and Allied Health Literature (CINAHL), Embase, and National Library of Medicine (Medline) and included peer reviewed, published literature with no age, human, language limit or geographical restrictions. This search was performed up to and including June 2020. The search terms used included the following MeSH, keywords and Boolean terms of “hand hygiene” OR “hand washing” OR “handwashing” OR “hand rubbing” OR “handrub*” OR “hand disinfection” OR “hand wash” OR “handwash” OR “hand cleaning” OR “hand decontamination” AND “bacteria” OR “virus*” OR “disease” OR “infect*” OR “communicable disease” AND “chlorine” OR “hypochlorite” OR “ash” OR “mud” OR “sand” OR “rice” OR “seawater” OR “dirt” NOT “water supply” OR “water purification” OR “waste water” OR “drinking water”. These search terms represented the most commonly accepted and utilised terminology related to HH practices as reported in the literature. As this study specifically worked to identify non-traditional hand cleansing agents, traditional agents such as soap and ABHR were not sought in this study. Only primary research was included with literature review articles excluded due to risk of missing key pieces based on those reviews specific search strategies.

Articles were screened based on title and abstract with the further review conducted on articles that met the inclusion criteria, by the first author. Reference lists of the selected articles were reviewed to allow for the inclusion of additional articles that may not have initially been identified from the database search. Only literature that met the inclusion criteria was included in the review which were: 1) all alternative HH agents to soap, water, and ABHR, 2) relevant to humans, 3) in vivo experiments and, 4) published in peer-review journals. Exclusion criteria included: 1) studies using soap and water or ABHR, 2) animal studies, 3) in-vitro studies, 4) environmental studies and, 5) studies related to therapy. Included studies were considered to provide valid information in addressing the initial aim of the review to identify alternative strategies for HH in the absence of traditional HH materials or resources.

The initial search identified a total of 125 titles in which one was excluded due to duplication (Figure 1). After an initial screening of the 124 titles and abstracts, a total of 107 articles were excluded as they did not relate specifically to alternative strategies/agents for HH. Of the 17 articles remaining, a further 13 were excluded due to not meeting the inclusion criteria. When required, clarification of article inclusions was made with the second author. A total of four articles were included in the final review that specifically related to the use of alternative HH agents in the absence of traditional HH materials such as soap or ABHR. A systematic flow diagram (Figure 1), based on the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) was used to display the search strategy and provides a breakdown of the search results (7).

Fig 1
Fig. 1. Article selection flowchart (adapted from Moher et al.7)

Data extraction and synthesis

Articles were reviewed, and information was included on the study method, aim, sample size, HH agent(s) investigated, and overall results. Data extraction was conducted by the first author and reviewed by the second author. The findings from each study were then compared and contrasted to identify themes, similarities or discrepancies to allow for specific themes to be developed from the articles. Analysis of the data resulted in the development of one primary category of note: the use of friction with an abrasive agent.

In order to assess the quality of the articles included in the review the Mixed Methods Appraisal Tool (MMAT) version 2018 was used as it, unlike other appraisal tools, allows for a variety of studies to be included in its assessment including quantitative, qualitative, and mixed methods research designs (8). The MMAT has been reported to have reliability and efficiency with interrater reliability scores ranging from moderate to perfect agreement (8). The MMAT utilises a set of five categories, each with five associated specific criteria, including a qualitative set, a randomised set, a non-randomised set, an observational descriptive set, and a mixed method set. The MMAT version 2018 does not recommend scoring against the category criteria, rather a description of what was met or not met (8). The included studies were appraised independently by the first and second authors, with discrepancies adjudicated by the third author, based on the MMAT version 2018 criteria with no studies excluded based on the quality assessment. Results of the critical appraisal of the papers using the MMAT version 2018 ranged from papers meeting between three and five (out of five) of the criteria.


Four articles met inclusion criteria for the final review, three quantitative and one mixed method study. All included articles were published between 1985 and 2015, with two of the articles published within the last seven years. One of the studies was from a low-income setting, with other studies from the USA and Germany exploring novel strategies for HH in the absence of traditional materials. All studies focused specifically on the use of alternative HH agents that are available in the environment such as sand, soil, ash, or other abrasives that may be found in local stores with small amounts of water and the effect of microbial load on hands. Overall strategies identified from the four articles in the final review included abrasive agents that create friction as alternatives to traditional soap and water, or ABHR, as HH agents. All studies reported reduction of microbial load using the abrasive agent with little water (Table 1). In all studies, small amounts of water were required with each of the agents, followed by rinsing. In one study from Bangladesh, the quality of the water used was variable and often repurposed from other uses such as laundry or dish washing, or using pond water (9). The studies from the USA and Germany utilised available running water from municipal water sources (1012). Importantly, there were no published studies that investigated HH in the complete absence of water or other forms of wetting agents.

Table 1. Summary of studies
Reference Study design/method Sample size Aim Population Hand hygiene (HH) agent Results Limitations/MMAT (2018)(8)
Schurmann et al. (12) (1985) Germany Quantitative in vivo experimental Three Establish efficacy of HH agents to remove poliovirus from hands Polio immunised participants



-Aluminium hydroxide powder/water

Washing agents more effective than soap & water were:
sand log10 reduction 3.7 and aluminium hydroxide powder log10 reduction 3.2, compared to soap and water log10 reduction 1.9, suggesting that friction was more important than emulsification.
Large numbers of virus particles used, perhaps not real-life contamination/All quality criteria met for quantitative studies
Hoque et al. (1995) Bangladesh (9) Mixed methods

-Observation of practice

-Measurement of faecal coliforms on hands

90 participants Understanding effect of HH practices on faecal coliform counts Women




-Water only

Lower coliform counts with increased rubbing frequency.
Increased volumes of rinse water lowers coliform counts, dependent on water quality.
All agents showed comparable results.
Compared left with right hands, no average coliform count over both/Criteria 5.3 and 5.5 for mixed methods studies not met
Edmonds et al. (2013) USA (10) Quantitative experimental nine To compare the efficacy of various hand washing preparations at removing C. difficile. Experiment participants


-Various soaps/waters

-Sodium tetraborate decahydrate powder/water

-Ink & stain remover/water

-Ink & stain remover + brush/water

BoraxTM log10 reduction 1.18 (P<.05), ink & stain remover log10 reduction 1.21(P<.001), ink & stain remover + brush log10 reduction 1.47 (P<.0001), water log10 reduction 0.76, with soap and water log10 reduction 0.78 (P>.05). Number of samples tested for each agent was not uniform/All quality criteria met for quantitative studies
Isaacson et al. (2015) USA (11) Quantitative experimental 14 participants Measure efficacy of five HH agents against Clostridium difficile Healthcare workers

-Water rub/rinse

-Triclosan soap/water


-Oil/baking powder/dish detergent/water

-60-second water rinse

Sand/water had greatest average log difference compared with water rub/rinse (P=.019) and triclosan soap/water (P=.003)
Friction important for removal of spores.
Triclosan not sporicidal. Only tested against spore forming organism/All quality criteria met for quantitative studies

The use of friction for hand hygiene

In the four studies identified from this review alternative HH agents to soap and water and ABHR included the use of either: 1) ash (9), 2) soil (9), 3) sand (11,12), 4) oil/baking powder/dish detergent (11), 5) aluminium hydroxide powder (10), 6) sodium tetraborate decahydrate powder (BoraxTM) (10), 7) ink and stain remover +/- brush (10), or 8) water only (912), and compared these with a soap and water strategy (9,11). The most successful agents used in these studies were physically abrasive and were of a powder or grit consistency, or in the case of the study by Edmonds and colleagues (10), actively used a brush to create friction with an ink and stain remover agent. All the agents created friction with use of a wetting agent such as water to decontaminate hands and were found to be superior to using soap and water or only water in some cases based on the testing methods reported in the papers, which were not standardised across all studies. Table 2 indicates reduction of microbial load count using friction only.

Table 2. Comparison of friction generating hand hygiene (HH) agents (cfu= colony forming units, NA=not applicable to study)
Study Sand Ash Soil Oil/baking powder/detergent Aluminium hydroxide powder Sodium tetraborate decahydrate powder Ink & stain remover + brush Water Soap & water
Schurmann et al. (12) Log10 3.7 reduction NA NA NA Log10 3.2 reduction NA NA NA Log10 1.9 reduction
Hoque et al. (9) NA 98 cfu 129 cfu NA NA NA NA 288 cfu 195 cfu
Edmonds et al. (10) NA NA NA NA NA Log10 1.18 reduction
Log10 1.47 reduction
Log10 0.76 reduction Log10 0.78 reduction
Isaacson et al. (11) -0.50 average log difference
(to soap and water)
NA NA -0.37 average log difference
(to soap and water)
NA NA NA -0.14 average log difference
(to soap and water)


This integrative review demonstrates that whilst there is a paucity of literature available that provides evidence on HH agents that may be readily accessible in resource limited settings, those studies that are available demonstrate that an agent that creates friction to clean the hands, using a lubricating agent such as water, is arguably effective to perform HH in the absence of soap and clean water (912). This has been supported elsewhere indicating the action of creating friction for at least 20 seconds even with water alone decreases the biological burden of contaminated hands (13).

What these studies were not able to identify however is the sustainability of these agents from a compliance perspective and what the effect may be of their long-term use, such as dermatitis which could lead to infection due to poor skin integrity and wounds. Other studies have identified that the more caustic or abrasive a HH agent is such as chlorine or other chemicals, the less likelihood there is of sustained adoption of practices (3, 1416).

All the studies presented required the use of water to complete the HH practice and were more often than not used as a lubricant with the agent to provide the friction to clean and also rinse the hands. Given that 71% of the global population has access to improved safe water sources, this appears to be a reasonable strategy (4). Even so, three of the studies were conducted using municipal water (1012), with one using repurposed waste or pond water with an unknown bioburden (9). Interestingly, the use of potentially contaminated water in conjunction with the friction generating HH agent still reduced the number of colony forming units on the hands of participants (9), which has also been reported elsewhere (1722). This then begs the question as to how other sources of water could be repurposed for use for HH, such as seawater, as has been proposed in a study to create a 0.05% hypochlorite solution for HH using sodium chloride-based water (23). The health outcomes of using alternative water sources were not reported. This is an important consideration as the use of contaminated water, particularly with coliforms, can result in outbreaks of diarrhoeal disease with poor individual and community health outcomes (4). Where clean water is lacking in limited resource environments, it is therefore possible to consider alternate water sources, the cleaner the better, to be used in HH practices.

In an effort to address these issues and specific requests for advice, the World Health Organization Regional Office for the Western Pacific (WPRO) sought to provide advice to their member states on how to achieve HH in the absence of traditional materials such as clean water, soap, or ABHR. This resulted in the production and dissemination of “Considerations for community HH practices in low-resource situations,” (24) and the associated visual resource “Handwashing in low resource settings.” (25). The visual material has now been translated into five languages (Khmer, Laos, Bahasa Melayu, Samoan, and Papa New Guinean) and used in communities where access to traditional HH materials is problematic, such as Papua New Guinea.

Another important aspect of HH not included in any of these articles was the drying of hands after cleaning. Drying of hands is an important part of the HH process as moisture on hands can contribute to transmission of organisms. This has been demonstrated in a community based study where transmission of organisms was reduced by up to 99.8% if hands were dried effectively after cleaning (26). This now introduces the next question: how can hands be dried effectively with limited resources?

A limitation of this review is a clear lack of available literature that investigates the use of HH resources alternative to traditional materials, identifying the need for further research, preferably in the field of how HH practice can be adapted to extreme resource limitations, and prevent transmission of communicable disease in vulnerable communities.


Supporting and implementing HH practices in the community, regardless of resource availability, is crucial in the prevention and control of communicable diseases, and particularly important given increasing emerging and re-emerging pathogens. The principles of HH, like all IPC practices, are always the same; it is how we apply them to specific situations and contexts using available resources that is essential to successful and sustainable implementation. The use of sand as a friction generating agent in conjunction with water from a source that is as clean as possible, based on the available limited evidence, demonstrates efficacy against soap and water. There is, however, no evidence of the sustainability of this strategy to clean hands or what the long-term effect is on skin integrity.

Engaging with communities to identify and promote local methods to perform HH is required, including the recognition of alternative safe water sources and traditional agents/indigenous flora such as leaves, roots, and other friction generating substances in the environment.


The authors wish to acknowledge the untiring work of WPRO who produced the regional guidance (24) and visual aid (25) based on this review of the literature, particularly the Infection Prevention and Control and Risk Communication and Community Engagement teams with special thanks to Mr Antonio Perez, the designer and illustrator of the visual aid.

Ethics and consent

Not applicable.


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