UCL Antimicrobial Resistance


Feedback Intervention Trial for Hand-hygiene

The Feedback Intervention Trial (FIT)—Improving Hand-Hygiene Compliance in UK Healthcare Workers: A Stepped Wedge Cluster Randomised Controlled Trial

This was a landmark study by UCL Departments of Medicine and Psychology  in collaboration with the Health Protection Agency. It remains the only long term multi-centre randomised controlled trial (RCT) of a hand-hygiene intervention to use the MRC framework for Evaluating Complex Interventions and behavioural science tools to design the intervention and investigate fidelity to intervention, implementation and mediators of change. As such, it provides a template for future trials of interventions to change healthcare workers’  infection prevention and control behaviours.

The trial lasted three years in 16 Intensive Therapy Units (ITUs) and 44 Acute Care of the Elderly wards (ACE) in 16 hospitals across England and Wales, routinely implementing a national cleanyourhands campaign, similar to the WHO’s multimodal intervention. Its duration and stepped wedge design allowed comparison with this intervention, examination of sustainability,  controlling for secular trends.

The intervention was based on “Goal-setting” and “Control” theories  which conceptualise behaviour as goal-driven and feedback-controlled, with goal-setting and action-planning augmenting the effect of feedback theories. Delivered by a trained member of ward staff, it comprised a repeating  4-week week audit cycle (20 minutes/week) of covert direct-observation of hand-hygiene followed by immediate personalised feedback (IPF) to healthcare workers, allied to individualized action-planning (IAP) e.g.  if  hands are not cleaned after touching patients, the action plan might be ‘After every patient contact, I will use alcohol hand-rub’. 

Despite difficulties in implementation (intervention implemented in 11/16 ITUs and 22/44 acute elderly wards (ACE)), the intention to treat analysis showed a significant 7–9% absolute increase in hand-hygiene compliance in ITUs. Per-protocol analyses showed absolute increases in compliance of 10–13% in ACE wards and 13–18% in ITUs, sustained for a mean of 16 months. Intention-to-treat and per-protocol analyses for ITUs measured by the Hand-Hygiene Observation Tool (HHOT) showed a significant 30% relative increase in the secondary outcome, soap procurement. There was a strong fidelity to intervention effect for both outcomes on ITUs (Ref 1).  There were also significant reductions in antibiotics used to treat MRSA, with fidelity to intervention effects (Ref 2).

Investigation of implementation suggested this would improve with intervention delivery in all wards by senior staff with existing feedback or appraisal roles, as an intrinsic part of hospitals’ clinical governance programmes, with provision of more training and monitoring of delivery by infection control nurses and provision of more training (Ref 3). 

Although a  further study is required to investigate if the intervention, implemented this way, can be routinely adopted in a wide variety of non-trial settings, hospitals keen to improve their hand-hygiene compliance could employ this intervention to supplement their current audit and appraisal systems and local hand-hygiene interventions. The case for this is strengthened by recent Cochrane reviews of RCTs of audit and feedback which show it is most effective if feedback is immediate and personalized (IPF) and coupled to individualized action plans (IAP) (Ref 4).

Footnote: Hand hygiene was measured in the FIT study by the validated, standardised Hand Hygiene Observation Tool (HHOT) which was shown to have good sensitivity, inter-rater reliability. This tool was, together with its full standard operating procedures (SOPs), made available on the National Patient Safety Agency’s cleanyourhands website for trusts to use in their hand hygiene audits during the national campaign (Ref 5).


  1. The Feedback Intervention Trial (FIT) — Improving Hand-Hygiene Compliance in UK Healthcare Workers: A Stepped Wedge Cluster Randomised Controlled Trial (2012) Fuller C, Michie S, Savage J, McAteer J, Besser S, Charlett A, Hayward A, Cookson BD, Cooper BS, Duckworth G, Jeanes A, Roberts J, Teare L, Stone, S. PLoSOne. 7(10), page e41617. doi:10.1371/journal.pone.0041617
  2. The Impact on Antibiotics
  3. Using psychological theory to understand the challenges facing staff delivering a ward-led intervention to increase hand hygiene behavior: A qualitative study. (2014) McAteer J, Stone S, Fuller C, Michie S. Am J Infection Control. 42(5), page 495. doi.org/10.1016/j.ajic.2013.12.022. 
  4. Time to Implement Immediate Personalized Feedback and Individualized Action Planning for Hand Hygiene (2018) Stone S. JAMA Netw open. 1(16), page e183422. doi:10.1001/jamanetworkopen.2018.3422
  5. Development of an observational measure of healthcare worker hand-hygiene behaviour: the hand-hygiene observation tool (HHOT) (2007) McAteer J, Stone S, Fuller C, Charlett A, Cookson B, Slade R, Michie S, NOSEC/FIT group. 68(3), 222-229. doi.org/10.1016/j.jhin.2007.12.009