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O039: Patient participation and performance feedback to improve hand hygiene adherence in the context of established multimodal hand hygiene promotion: initial results from a mixed-methods, cluster randomised trial


Hand hygiene (HH) compliance amongst healthcare workers is widely recognised as a key intervention in infection control. Given HH compliance remains sub-optimal despite standard multimodal promotion, there is an urgent need for evidence regarding the effectiveness of novel interventions.


To investigate the impact of optimised performance feedback (PF) and patient participation (PP) on HH compliance in the setting of a well-established multimodal HH promotion program.


Single-centre, cluster-randomised controlled trial. After a 15-month baseline phase from April 2009, 66 wards were allocated by stratified randomisation to one of three arms during a 24-month intervention phase: control; PF; or PF+PP. Multimodal promotion continued in all three arms. PF was provided via cards, posters and emails. PP involved a partnership whereby healthcare workers and patients agree to remind each other to perform HH. The primary outcome was HH performance measured using the WHO ‘My 5 Moments’ methodology and analysed using a mixed effect logistic regression model. Qualitative data was gathered by focus groups and interviews with healthcare workers.


Twelve observers recorded 12,627 HH opportunities during 1,358 sessions. HH compliance was similar between arms at baseline and increased in all three arms during the intervention phase (P=0.04): 65% to 73%, odds ratio 1.36 (CI95% 1.17-1.59); 64% to 74%, OR 1.59 (1.39-1.81); and 64% to 76%, OR 1.77 (1.54-2.04), respectively, in control, PF and PF+PP arms. Only PP+FB showed a significant effect on HH compliance in our trial (OR 1.33, P=0.04), with PF alone not sufficient (OR 1.17, P=0.25). Qualitative data showed that acceptance and implementation of PP was gradual, variable and primarily dependent on ward leadership. Exclusion from intervention arms motivated control wards to improve HH performance independently.


PP with PF may offer a means of improving HH compliance beyond standard multimodal promotion.

Disclosure of interest

None declared.

Author information

Correspondence to AJ Stewardson.

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This article is published under license to BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

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About this article


  • Healthcare Worker
  • Hand Hygiene
  • Performance Feedback
  • Patient Participation
  • Hand Hygiene Compliance