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Behavioural Sciences Change Health Care Workers Hand Hygiene Behaviour

A major three-year trial led by researchers at , in partnership with the Health Protection Agency, has shown that giving one-to-one feedback to makes them twice as likely to clean their hands or use soap.

The Feedback Intervention Trial (FIT) is the first such trial to be done in a large number of hospitals anywhere in the world. Carried out across 60 wards in 16 hospitals that were already implementing the English and Welsh Cleanyourhands campaign, the study showed that an intervention that coupled feedback to action planning improved hand-hygiene compliance by up to 18 per cent on Intensive Therapy Units (ITUs) and 13 per cent on Acute Care of the Elderly (ACE) wards. It was also found that soap use increased by 30%.

The study is published in PLOS ONE, and the main findings were presented at a national summit held by GovToday to consider national strategy following discontinuation of the Cleanyourhands campaign.

“This is a landmark trial, as until now there has been no randomised controlled trial evidence showing which interventions improve hand hygiene compliance in modern hospitals,” said principle investigator Dr Sheldon Stone ( at the Royal Free Hospital). “It is also the first trial to use behavioural sciences to change health care workers hand hygiene behaviour.”

Sustained improvements in hand-hygiene are key to the World Health Organisation’s SAVES LIVES strategy to reduce health-care associated infection, yet hand-hygiene compliance amongst workers remains poor, with levels of 25-40% being common.

“The study suggests that the NHS should explore using the FIT intervention and learn how best to implement it, as used properly it can be a really powerful tool,” said Dr Stone. “The intervention, which couples feedback to personalised action planning, could be included in infection control teams’ audit and appraisal systems in order to reduce the burden of healthcare associated infection on hospital wards.”

The intervention process involved a four-week audit cycle, with healthcare workers observed for 20 minutes. Immediate feedback was given after the period of observation, and the person was then helped to form a personal action plan for better hand hygiene. The effect was stronger on ITUs than ACEs, where it was easier to implement. The more frequently wards carried out the intervention, the stronger its effect.

In addition to observing and measuring hand-hygiene compliance, the amount of soap and alcohol hand-rub used each month was also collected as another measure of hand-hygiene compliance for each ward. This also gave a better picture of the total weekly usage, as such data was not subject to any observational bias.

“Although audit and feedback is often suggested as a way of improving hand hygiene, this study puts its use on a firmer footing than previous non-randomised studies, providing the strongest evidence yet that this is an effective way to improve hand hygiene when coupled with a repeating cycle of personalised goal-setting and action planning,” said Dr Stone.


’The Feedback Intervention Trial (FIT) – Improving Hand-Hygiene Compliance in UK Healthcare Workers: A Stepped Wedge Cluster Randomised Controlled Trial’ is published online in the PLOS ONE. Copies of the paper are available from UCL Media Relations.
The Cleanyourhands campaign ensured provision of Alcohol hand-rub next to beds in all hospital wards, with posters and patient empowerment materials encouraging healthcare workers to clean their hands. In addition, audit and feedback of hand-hygiene compliance was given at least once every 6 months. The campaign, which was introduced in December 2004, was extremely increased soap and alcohol hand rub procurement by a factor of three and made a direct contribution to the falls in MRSA and Clostridium difficile. The campaign was discontinued by the Government in December 2010.
The study was funded mainly by the Department of Health (Patient Safety Research Programme) and by the Royal Free Trustees, with a contribution from GOJO industries.
University College London