Journal of Hospital Infection 100 (2018) 195e201

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Journal of Hospital Infection

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Impact of hand sanitizer format (gel/foam/liquid) and

dose amount on its sensory properties and
acceptability for improving hand hygiene compliance
R.E. Greenaway a, *, K. Ormandy b, C. Fellows b, T. Hollowood a
a
Sensory Dimensions Ltd, Cowlairs, Nottingham, UK
b
Deb Group Ltd, Denby, UK

A R T I C L E I N F O S U M M A R Y

Article history: Background: Effective alcohol-based hand rubs (ABHRs) and healthcare worker compli-
Received 7 March 2018 ance with hand hygiene guidelines are important in the prevention of infection trans-
Accepted 7 July 2018 mission in healthcare settings. Compliance to hand hygiene guidelines is affected by many
Available online 17 September factors including education, ABHR availability, time pressure, skin health, and user
2018 acceptance of the sensory properties of ABHRs during and after application.
Aim: To examine the effect of ABHR format (gel/foam/liquid) and dose (0.7 mL, 1.5 mL,
Keywords: 3 mL) on its sensory properties and acceptability, and to consider how this might affect
Alcohol-based hand rub healthcare workers’ hand hygiene compliance.
Healthcare professionals Methods: Sensory descriptive analysis established key sensory differences between ten
Hand hygiene market-leading ABHRs (three gels, four foams, two liquids, one aerosol foam). Focus
Skin feel groups reinforced these differences.
Focus group Findings: All formats were less desirable at the highest dose as they were more difficult to
Sensory descriptive analysis handle than the lower doses. Foams and gels became stickier, less clean-feeling and
slower to dry at higher doses. Liquids gave a cleaner, smoother, more moisturized feel, but
the increased difficulty in handling and applying the product negated these benefits.
Overall, the gel and foam formats were more desirable than the liquid. The key desirable
properties include: fast absorption, soft/moisturized hand feel, not sticky, clean feel, and
low smell.
Conclusion: The 1.5 mL dose yielded the most acceptable properties with no extreme
negative consequences. The foam provided the benefits of both the liquid and gel and
combined them into a more widely acceptable format that may lead to greater hand
hygiene compliance.
ª 2018 The Healthcare Infection Society. Published by Elsevier Ltd. All rights reserved.

Introduction

Healthcare worker compliance with hand hygiene guidelines

* Corresponding author. Address: Sensory Dimensions Ltd, Southglade
Business Park, Unit B4, Cowlairs, Nottingham NG5 9RA, UK. Tel.: þ44
(0)7729 307341.
E-mail address: ruthgreenaway@sensorydimensions.com (R.
E. Greenaway).
is important in the prevention of infection transmission. How-
ever, the level of hand hygiene compliance by healthcare
workers is low, reported at 30e57% [1e6].
Alcohol-based hand rubs (ABHRs) are now widely used in
healthcare settings to enhance hand hygiene among healthcare

https://doi.org/10.1016/j.jhin.2018.07.011
0195-6701/ª 2018 The Healthcare Infection Society. Published by Elsevier Ltd. All rights reserved.
196 R.E. Greenaway et al. / Journal of Hospital Infection 100 (2018) 195e201
workers [7]. The World Health Organization (WHO) developed
the ‘five moments of hand hygiene’ guidelines to help manage
patient and healthcare worker safety, recommending a
maximum ABHR drying time of 30 s for effective hand disin-
fection [8,9]. Compliance with hand hygiene guidelines is
affected by many factors including education, ABHR avail-
ability, time pressure, skin health, and user acceptance of the
sensory properties of ABHRs during and after application,
which may be affected by dosage or format of the ABHR (gel,
liquid, or foam) [5,8,10e14].
International standards such as EN 1500 have been devel-
oped to assess the efficacy of ABHRs that are claimed to have
an antimicrobial action, and most gel, liquid, and foam formats
on the market meet this requirement [15]. EN 1500 compares a
manufactured product to a reference standard of 6 mL propan-
2-ol 60% (v/v) for a contact time of 60 s following a standard
hand-rub protocol (applied in 2  3 mL, 30 s rub-in per 3 mL)
[8,15,16]. Manufacturers can define the dose of their product
to use in the test, but the contact time is limited to 30 or 60 s.
The EU Biocidal Product Regulation requires manufacturers to
support their label claims with data that are principally
compliant with EN 1500. Therefore, although EN 1500 was not
designed to define product dosage, it has increasingly become
normal practice for manufacturers to recommend a dosage of
3 mL for effective hand disinfection. Nevertheless, market
research shows that 3 mL is not the dosage typically used by
healthcare workers throughout the day [17].
Using the EN 1500 standard, Wilkinson et al. investigated
the relationship between ABHR volume and efficacy, and they
examined impact of drying time on user acceptability [18].
Results suggested that volumes of ABHR that dry in 20e30 s
(1.5e2 mL) are unlikely to fulfil the EN 1500 requirements, and
a 3 mL dose takes 35e45 s to dry, which participants thought
was too long. This work concluded that the EN 1500 is a good
standard to test efficacy under laboratory conditions, but that
a different standard is required to help provide recommenda-
tions for dose and contact time in line with WHO guidelines and
acceptable for healthcare workers to adhere to daily.
One might expect that different doses of ABHRs would
affect their sensory properties, which, in turn, may affect
whether healthcare workers comply with WHO guidelines in
their usage.
The objectives of this study were to determine the sensory
characteristics of a range of leading foam, gel, and liquid
ABHRs; to understand the impact of dose on sensory attributes
and the relative differences and similarities between ABHRs; to
understand from healthcare workers what the positive and
negative sensory attributes are and what would drive usage
leading to increased hand hygiene compliance; and to identify
the key sensory attributes that manufacturers should consider
when developing new products that will drive acceptability.
Methods
Focus groups and sensory descriptive analysis were used to
address the research objectives.
Focus groups
Two focus groups were conducted with nurses from two
different National Health Service (NHS) hospital trusts.
Participants were all full-time female nurses, aged between
18 and 60 years, with no allergies/sensitivities to products
applied to the skin. All worked 22 h per week, applying
ABHRs 5 times per hour in a working day and all had used at
least two of the three categories (gel/foam/liquid) of
ABHRs.
Participants were informed that the purpose of the focus
group was to understand the positive and negative aspects of
different formats of ABHRs from a nurse’s perspective. Nurses
were chosen for focus groups as they interact with ABHRs most
often in a hospital environment. Informed consent was ob-
tained from all nurses prior to participation and each received
£30 incentive following the focus group.
Two focus groups were held to obtain wider insight into a
nurse’s perspective of ABHRs. In group 1, all five nurses were
from the same workplace where gel is the format of ABHR used
(although most had experienced foams and liquids in other
healthcare settings). In group 2, comprising 11 members from a
different workplace to group 1, all had recently experienced
gels and foams in a work environment as their hospital switched
from gel to foam six months prior to the focus group.
The focus group was led by a facilitator who followed a
discussion guide (see Appendix A), designed to answer the
following questions:
e Which properties of ABHRs do nurses perceive as being
positive and negative?
e How do nurses feel about using the recommended dosage?
Are there any barriers to using the full dose? If so, which
product qualities affect this?
e Which format do nurses prefer? What are the positive
properties associated with this?
e Which qualities would nurses like designed into (or out of)
ABHRs if they had a choice?
During the discussions, words describing the positive and
negative characteristics of ABHRs were recorded and arranged
from most to least important. The focus group identified the
positive and negative properties of the foam, gel, and liquid
formats and discussed which properties were most affected by
dose.
Sensory descriptive analysis
Samples
Ten market-leading ABHRs were assessed; three gels (A, B,
C), four foams (A, B, C, D), two liquids (A, B), and one aerosol
foam. Each was assessed for its skin-feel properties at three
dose levels: 0.7 mL, 1.5 mL, and 3 mL.
Method
Thirteen trained sensory descriptive panellists participated
in the study; informed consent was obtained from all panellists
prior to participation. Each panellist attended seven 2 h
training sessions in which quantitative descriptive analysis
style methodology (sensory descriptive analysis) was used to
identify and define 30 key sensory attributes that describe each
ABHR [19,20]. The panel attended a further thirteen 2 h rating
sessions in which they assessed the products for these attri-
butes (Table I). A balanced design across samples and doses was
used and each sample was seen in triplicate. The panel was
divided into three groups, each assessing a different dose per
 R.E. Greenaway et al. / Journal of Hospital Infection 100 (2018) 195e201 197

Table I
List of attributes assessed by trained descriptive panellists at various stages of alcohol-based hand-rub application
Attribute Assessment stage
Before Visual Tactile Post dispense/ During Immediately after 2 min after
application pre-rub rub in application application
Tightness ✓ ✓ ✓
Moisturized feel ✓ ✓ ✓
Aerated ✓
Thickness ✓ ✓
Denseness ✓
Intensity aroma ✓ ✓
Intensity alcohol aroma ✓ ✓
Change of state ✓
Temperature ✓ ✓
Handleability ✓
Drying time ✓
Spreadability ✓
Skin feel ✓
Stickiness ✓ ✓ ✓
Soapiness ✓
Ease of full-dose application ✓
Clean feel ✓ ✓
Smooth feel ✓ ✓
Panellists followed a strict protocol developed in training sessions and defined by the lexicon (see Appendix A for full lexicon).

day. Samples were blind-coded with three-digit codes to pre-
vent bias.
For neat attribute ratings, ABHRs were dispensed directly
from the manufacturer’s dispensers (dispensers and product
branding were disguised to avoid bias) into sample pots to one-
third full.
For skin application ratings, samples were dispensed in one
of three ways to ensure consistency:
e liquids and gels: syringed to the correct dose
e foams: pumped from ‘pump dispensers’ designed to deliver
an exact dose
e aerosol foam: weighed to the correct dose.
Assessors rated the intensity of each attribute for each
sample in individual sensory evaluation booths designed to ISO
8589:2007. Assessments were made on unstructured line scales
with verbal anchors suitable for each sensory attribute. Before
each sample assessment, panellists rated the tight and mois-
turized feel of their skin, then washed their hands using Sanex
Zero% Sensitive Skin (0% fragrance) shower gel following the
NHS handwash procedure.
Panellists applied the ABHRs to their hands over a white
melamine tray; this allowed any spillage to be recorded, which
was important for assessing ease of handling and application at
higher doses.
Between sample assessments, panellists cleansed their
hands with non-fragranced soap and water and took a 10 min
break to allow their hands to recover.
Data analysis
An inductive thematic analysis technique was used to
analyse focus group data [21].
Sensory descriptive analysis data were collected using Eye
Question (Logic 8, Netherlands) version 3.9.7. A two-factor
analysis of variance (ANOVA) (with fixed model) was used to
analyse the data and identify any significant differences be-
tween the samples. TukeyeKramer HSD multiple comparison
test explored these differences in more detail. A significance
level of 5% was applied to the data (P ¼ 0.05). Principal
component analysis (PCA) summarized how the samples
compared to each other and identified the key sensory attri-
butes that characterized them; these results were interpreted
using ANOVA data.
Results
Focus groups
Themes that evolved from the focus group discussions are
described below; Figure 1 summarizes the results.
Theme 1: preference for ABHR format related to
familiarity
Alcohol-based hand-rub format preference was related to
the product participants were familiar with at work. Those who
used foam regularly preferred foams, those who used gels
preferred gels. Positive features of the gels include: low res-
idue/stickiness (at the familiar dose), clean smell, fast drying,
cold feeling during application, ease of dispensing. The cold-
ness was considered important as it helped them monitor
whether the product completely covered their hands and it left
a cleaner/fresher feeling. Negative features of the gel include
dry-skin feeling after use and a stinging sensation if applied to
broken skin.
Positive features of the foam include: softer feel, ‘kinder to
skin’ properties, and weaker smell. One nurse in focus group 1
198 R.E. Greenaway et al. / Journal of Hospital Infection 100 (2018) 195e201
Figure 1. Combined results for positive and negative characteristics of alcohol-based hand rubs as perceived by focus groups 1 and 2.
Stars represent product qualities affected by dose.
thought that foams were usually only given to staff with skin
conditions due to this skin-caring perception, and this led the
group to believe that the foam was a more expensive format.
Both focus groups chose liquid as their least favourite
format, mainly because of difficulty to apply with low coverage
due to fast evaporation in lower doses and excessive dripping,
creating a potential slip hazard and damage to uniforms in
larger doses. The liquid dispenser was also more difficult to use
than the gel and foam dispensers.
Theme 2: negative perception of higher dose
Attributes affected by dose (see starred attributes,
Figure 1) became more negative as dose level increased.
The largest dose (3 mL) was rejected by all participants
based on a general perception that ‘there is not enough time to
apply such large doses whilst working on a busy ward’. Partici-
pants also felt that a large quantity of the higher dose would
either drip down on to the floor (slip hazard) or that users may
wipe excess on to their uniform to dry (unhygienic). There was
also concern that more germs may be transferred to partially
dry hands, as wet skin might pick up more germs when touching
a door handle, for example. Higher doses were also more
difficult to apply, so instead of getting into the habit of using
the ABHR regularly, participants thought that users might find it
easier to wash their hands at the sink instead. Higher doses
were also perceived to cause more irritation to skin and create
more residue.
Participants thought that higher doses may make users think
they are more protected, lulling them into a false sense of
security, resulting in a lower frequency of usage.
Theme 3: barriers to hand hygiene compliance
Participants were asked if they knew of any situations when
nurses do not apply the full dose of ABHRs. Some nurses did not
like touching the dispenser as they felt ‘it could harbour bac-
teria, especially as they didn’t know who had previously used
the dispenser (such as the general public)’. Nurses thought that
automatic dispensers solve this issue but involve waiting for the
full dose to be dispensed and, as they rush to their next task,
often only part of the dose is taken with the rest falling to the
floor (described as ‘automatic fly past’). The temptation to tip
excess product on to the floor or to avoid using it as frequently
if difficult to handle was also mentioned. Other comments that
may drive down usage included:
 R.E. Greenaway et al. / Journal of Hospital Infection 100 (2018) 195e201
e dispenser dislike
e not understanding the benefits of using ABHRs
e sticky feel.
Some participants also mentioned historic issues of sticky
residues that may still be influencing usage behaviour today.
Low stickiness was desirable as it ‘feels cleaner and prevents
dirt/germs sticking to the skin’.
Focus group 2 discussed problems with dermatitis and the
necessity to use ABHRs rather than soap and water because
they contain emollients [22,23]. They also noted that too much
emollient leaves a greasy coating, which makes it difficult to
‘hold the pen and write notes’. Most agreed that although the
moisturized feel from emollient containing ABRHs is desirable,
use of a skin moisturizer is as effective.
Theme 4: most important characteristics of ABHRs
Both focus groups thought that killing germs was the most
important characteristic of ABHRs above any practicality is-
sues. All participants were aware of protecting themselves and
patients from spread of diseases. Interestingly, when asked
Figure 2. Principal component (PC) analysis biplot showing PC1 versus PC2 including results for all alcohol-based hand rubs tested at the
three dose levels (0.7 mL, 1.5 mL, and 3 mL).
199
individually to write down the key qualities they would like
designed into ABHRs, the most common responses were:
e fast absorption
e soft/moisturized hand feeling
e not sticky
e clean feel
e no smell.
The focus groups helped us to understand the impact of
ABHR properties on compliance to hand hygiene. Key sensory
differences between the different ABHR formats at the
different dose levels were quantified using sensory descriptive
analysis.
Sensory descriptive analysis
In Figure 2, a PCA plot summarizes the relative differences
between samples tested. Each point on the plot represents a
different ABHR. The axes of the PCA plot represent different
‘dimensions’ of the multivariate sample space that explain as
200 R.E. Greenaway et al. / Journal of Hospital Infection 100 (2018) 195e201
much variation in the samples as possible. Dimension 1 explains
the majority of variation between the samples; dimension 2
explains the next largest amount of sample variation [20]. In
this case the first two dimensions explain 78% of total variation
between the products, indicating a good overall representation
of the product differences.
Attributes correlated with each dimension of the plot are
recorded at the edges of the plot. The plus symbol (D) rep-
resents attributes thought to be positive, the minus symbol (e)
represents more negative attributes as defined within the focus
groups (Figure 1). Samples that are clustered together within
the plot have similar properties.
All doses of liquids are found at the top right-hand (RH) side
of the plot. Most foams and gels are in the middle with higher
doses of gels standing out on the left-hand side and the aerosol
foams at the bottom. For the foam and gel ABHR formats, the
lower doses are positioned towards the right-hand side of the
plot, whereas the higher doses are positioned towards the left-
hand side. For the liquids, the opposite pattern exists (higher
doses on the right, lower doses on the left).
Considering dimension 1, the higher doses of foams and gels
(left-hand side) were easier to spread over the whole hands,
slower to dry, left a stickier hand feel both during, immediately
and 2 min after application, and had a soapier consistency. The
opposite characteristics were found for lower doses (right-hand
side). The lower doses also left hands feeling cleaner,
smoother, and more moisturized.
Interestingly for liquids, all doses were difficult to apply
compared to foams and gels. The impact of dose was opposite
to that for foams and gels whereby the higher dose left skin
feeling cleaner, more refreshed, smoother and more moistur-
ized compared to lower doses which often evaporated before
complete application. Larger doses of foams and gels left more
residue and a slightly stickier feel which led to the lower clean
feeling both immediately and 2 min after application.
Dimension 2 separated samples based on their alcohol
content. High doses of the gels and all doses of the liquids left a
colder hand feel both prior to and during rub-in, had a stronger
overall aroma and left a tighter skin feel both immediately and
2 min after application (top of plot). The opposite character-
istics were present in the foam samples which had the greatest
moisturized skin feel 2 min after application, the least cold
hand feel, least tight skin feel, and lowest overall aroma and
alcohol aroma (bottom of plot).
Dimension 3 (see supplementary information) explained an
additional 9% of variation between the samples; this dimension
separated products based on their handleability. In general,
lower doses were much easier to handle than higher doses, as
they stayed in the palm of the hands without spilling prior to
and during rub-in. Not surprisingly for each dose, liquids were
considered harder to handle than their gel and foam
equivalents.
In summary, at higher doses, more negative sample attri-
bute characteristics were perceived, whereas at lower doses
more positive sample properties were perceived.
Discussion
Focus groups identified key characteristics of ABHRs that are
of importance to nurses. Sensory descriptive analysis data
quantified these differences. Discussions in the focus groups
revealed that familiarity with a product can positively impact
liking. Although this may be considered a limiting bias, having
tested the different formats during the focus group discussions,
both groups were open to the other formats and identified
positive properties of each type. However, the liquid was most
negatively perceived by both groups, mostly due to practi-
cality, being more difficult to handle and apply in the larger
dose.
In general, nurses applied between five and 42 applications
of ABHR per shift, which could be between two and 15 doses
per hour; therefore, drying time is very important [8]. Exces-
sive drying time or poor handleability are impractical and may
cause frustration, leading to poor hand hygiene compliance.
Drying time is dependent on ABHR dose, hand size, and skin
condition; however, in all applications the liquid was fastest to
dry, with the foam and gel having similar drying times.
Nevertheless, the liquid’s poor handleability resulted in
spillage during application, leaving less product in the hand and
therefore a false perception of faster drying time. If the
product spills easily then the recommended dose is not
completely applied, potentially resulting in a lower level of
skin disinfection that could lead to infection transmission
[15,24]. The aerosol foam had the slowest drying time, espe-
cially in the higher dose, taking up to 2 min to dry completely e
this was considered impractical by nurses.
Skin feel during and after use all had a large impact on
preference for ABHR. Nurses liked ABHRs that moisturized their
hands to combat dryness from repeated handwashing during
the day [9,5,25]. Irritated skin is considered one of the main
reasons for failure to comply with the hand hygiene guidelines,
and irritated or dry skin is more difficult to disinfect, leading to
risk of increased infection transmission [5,10,11,26]. At lower
doses (0.7 mL and 1.5 mL) the aerosol foam imparted the most
moisturized skin feel following use, whereas the other products
were equivalent to each other. At the higher dose, less dif-
ference was apparent e though, at 3 mL, the gel imparted the
least moisturized feel overall, resulting in more negative
perception at this dose. Dose also affected clean feel: whereas
3 mL of liquid delivered the cleanest overall skin feel, all
products left skin feeling relatively clean and the difficulty in
applying the full dose of the liquid (3 mL) outweighed the
positive skin feel.
The impracticality observed from higher doses of all formats
is important to consider and further work is recommended to
determine whether a lower dose fully disinfects the hands,
ensuring that infection transmission is controlled in a hospital
environment. Adapting the EN 1500 guidelines to reflect the
dose of ABHRs routinely used by healthcare workers in line with
the WHO guidelines is recommended [15].
Although the focus group sample size in this research is
small, we believe the results have identified key areas to
consider when selecting ABHRs for use in hospitals. Many
themes from the focus groups reflect literature regarding hand
hygiene compliance, and descriptive panel data quantified and
confirmed the differences at different doses [1e6].
In conclusion, results from the focus groups and sensory
descriptive analysis showed that the negative characteristics of
all ABHR formats tested were enhanced at the highest (and
recommended) 3 mL dose: they became stickier, slower to dry,
and more difficult to hold in the palm of the hand, leaving the
skin feeling less clean, less smooth, and less moisturized. The
lowest dose (0.7 mL) had the most desirable skin-feel
 R.E. Greenaway et al. / Journal of Hospital Infection 100 (2018) 195e201
properties; however, this dose does not provide complete
disinfection of skin due to lack of coverage of the whole hands
(including between fingers). The 1.5 mL dose had more
acceptable properties than 3 mL, which makes it a good
compromise regarding skin coverage. Further work is recom-
mended to understand whether the lower and more typical
doses used by healthcare workers disinfect the skin to a clini-
cally acceptable level.
At 3 mL, the aerosol foam, although highly moisturizing,
took a long time to dry. Liquids left a high clean feeling and
were faster to dry, but these benefits were negated by poor
handleability.
The nurses more widely accepted the gels and foams over-
all; however, at a dose of 3 mL, the gels were perceived as
stickier. Overall, the data showed that foams delivered no
extreme negative properties and so, as a compromise, appear
to provide the benefits of liquids and gels and to combine these
benefits in a more widely acceptable format that may lead to
greater hand hygiene compliance.
Conflict of interest statement and funding
This research project was undertaken by Sensory Di-
mensions Ltd and funded by Deb Group Ltd. The samples
included in the research are representative of the current
marketplace; some of the samples are Deb products and
some are competitor products. There is no financial benefit
for Sensory Dimensions in publishing the data and all sample
IDs have been removed from the publication to avoid any
commercial value conflict of interest for Deb.
Appendix A. Supplementary data
Supplementary data related to this article can be found at
https://doi.org/10.1016/j.jhin.2018.07.011.
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