Abstract
<jats:p>Background Hand hygiene is a core component of infection prevention and control, yet evidence on the effectiveness of hand hygiene interventions in health-care facilities in low-income and middle-income countries has not been comprehensively synthesized alongside implementation barriers and enablers. We assessed the effectiveness of hand hygiene interventions in these settings and examined implementation conditions shaping success. Methods We conducted a systematic review drawing on a University of North Carolina evidence map of environmental health services in low-income and middle-income country health-care facilities, which searched PubMed, Scopus, and Global Health and was supplemented by hand-searching. Hand-hygiene-specific records were restricted to peer-reviewed English-language studies published between Jan 1, 2015, and Nov 28, 2025; backward citation chasing identified additional eligible records. Random-effects meta-analysis was done for studies with extractable pre-intervention and post-intervention hand hygiene compliance data. Other outcomes were synthesized using effect-direction methods. Barriers and enablers were synthesized thematically. The protocol was registered with PROSPERO, CRD420251252831. Findings We screened 656 records and included 57 studies from 32 low-income and middle-income countries. Fifteen studies contributed to meta-analysis. Hand hygiene interventions were associated with higher post-intervention than pre-intervention compliance (pooled risk ratio 1·45, 95% CI 1·20–1·74), with substantial heterogeneity (I2=98%). Most studies used non-randomized designs. Multimodal WHO-style strategies and system-change interventions focused on alcohol-based hand rub availability, placement, or related infrastructure were the most common intervention categories. Effect-direction synthesis suggested favorable effects for compliance and system-related outcomes, whereas evidence for reductions in health-care-associated infections was less consistent. Common barriers included supply shortages, weak audit and data systems, staffing and workload pressures, and WASH infrastructure constraints; common enablers included training, monitoring and feedback, leadership support, reliable supplies, and implementation support. Conclusion Hand hygiene interventions can improve observed compliance in low-income and middle-income country health-care facilities, but sustained gains depend on system supports that make hand hygiene feasible at the point of care. Programs should pair training and behavior-change strategies with reliable supplies, functional WASH infrastructure, audit-and-feedback routines, leadership accountability, and protected implementation time.</jats:p>