Author ORCID Identifier

Date of Award


Degree Type


Degree Name

Master of Public Health (MPH)


Public Health

First Advisor

Terri Pigott

Second Advisor

Heather Bradley


INTRODUCTION: Despite its importance and having few significant technological barriers, hand hygiene continues to pose a serious problem in public health. In addition to the highly public impact of hand hygiene promotion accompanying the COVID-19 pandemic, inadequate compliance with recommended hand- washing and -sanitizing procedures contributes substantially to healthcare associated infections, food-borne illness and seasonal flu transmission, school- and workplace-based outbreaks, and other arenas of preventable disease. “Nudges” – simple, inexpensive cues or selection-environment features that are designed with cognitive biases in mind – are used frequently to promote compliance in a variety of health-related activities, including hand hygiene compliance.

AIM: To systematically review the literature discussing the efficacy of nudging in promoting hand hygiene, and to statistically summarize the results of those studies.

METHODS: Consistent with PRISMA and Cochrane guidelines for completing a systematic review and meta-analysis (SRMA), this study performs a planned and detailed review of literature through multiple appropriate databases and external resources, selects studies based upon predetermined inclusion and exclusion criteria, sequentially screens titles, abstracts, and full-texts for relevance and usability, extracts data systematically, and summarizes statistical results and effect sizes. Technological assistance is used to promote thoroughness and evaluative integrity. Specifically, Zotero is used in the selection and screening of studies, and R, R Markdown, and the R packages metafor[i] and clubSandwich[ii] are used for conducting a meta-analysis using a correlated and hierarchical effects model.[iii]

RESULTS: 14 studies contributing 34 effect sizes were analyzed using a multivariate random effects model with Robust Variance Estimation. The mean log odds ratio (LOR) was 1.416, with a mean odds ratio and 95% confidence interval of 4.12 [2.295 – 7.4] for hand hygiene within nudge-conditions compared to controls.

DISCUSSION: Nudges significantly increase hand hygiene compliance in a variety of populations and socio-cultural contexts, though publication bias may exaggerate their efficacy


File Upload Confirmation