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Cycle 8 (2019 Deadline)

Improving hand hygiene practice among healthcare workers through mhealth and environmental cues in Kampala Metropolitan Area

PI: Richard Kibirango Mugambe (, Makerere University School of Public Health
U.S. Partner: Christine Moe, Emory University
Project Dates: April 2020 - November 2022

Project Overview:
Water, sanitation, and hygiene (WASH) in healthcare facilities (HCF) are critical in the provision of quality health care. It has been argued that good WASH infrastructure and practices in HCF should reduce health-care acquired infections (HAI), increase trust and uptake of healthcare services, and increase efficiency and improve staff morale. This research team headed by PI Dr. Richard Kibirango Mugambe has designed their PEER project to address two key questions: (1) why healthcare workers (HCWs) don’t adhere to hand hygiene guidelines in Uganda, and (2) what are the simple, effective, and inexpensive interventions to enhance hand-hygiene practices among HCWs in Uganda. Specifically, the project aim is to determine the impact of mobile phone WASH text messages and environmental cues on hand hygiene practices among healthcare workers in the Greater Kampala Metropolitan Area (GKMA). Researchers will determine the barriers and opportunities for enhancing healthcare workers’ hand hygiene practices in HCFs in the GKMA and determine the impact of WASH mobile text information and reminders (MTIR) and environmental cues on hand hygiene practices among health workers. The expected outcomes include an improved ratio of completed hand hygiene events/hand hygiene opportunities (number of times hand hygiene is observed to be done at critical times out of the total number of observed hand hygiene opportunities) and increased knowledge on hand hygiene practices, which will be explored using questions related to hand hygiene benefits and procedure. U.S. partner Dr. Christine Moe will provide critical assistance in the project by training faculty from the Makerere University School of Public Health and staff from the Ministry of Health on using the specified hand hygiene interventions, monitoring outcomes, and conducting laboratory procedures for determining microbial contamination on the hands of HCWs. The partnership will also enable Dr. Mugambe and Dr. Moe to build on their ongoing research on WASH-related factors associated with sepsis in neonates reporting at selected HCFs in Kampala.

The planned project activities are a response to critical WASH gaps in Uganda and will support efforts towards achieving Sustainable Development Goal (SDG) 6. This research specifically contributes towards achieving target 6.1, which seeks to achieve universal and equitable access to safe and affordable drinking water for all by 2030, as well as target 6.2, which seeks to ensure access to adequate and equitable sanitation and hygiene for all and ending open defecation by the year 2030. The study also fits into the USAID Water and Development Country Plan for Uganda, in particular by helping to drive a systematic and evidence-based social and behavior change program in households and in institutions (including schools and HCFs); support HCF hygiene audits and action planning in supported districts; and supporting the establishment and strengthening ofcommunity, district, and regional institutions to develop the necessary capabilities to enable sustainable WASH outcomes in home, school, and HCF settings.

Summary of Recent Activities:

As of the time of their last quarterly report in July 2022, Dr. Mugambe and his team were well under way with their intervention, having posted environmental cues on the walls of selected intervention healthcare facilities earlier in the year. The Alcohol Based Hand rub (ABHR) for hand hygiene in the health care facilities was also procured and distributed, as were the materials for laboratory analysis of hand rinsates. The team had some delays in starting the planned intervention due to the COVID-19 pandemic, the closure of some institutions, and the slow reopening of institutions at the beginning of 2022, but the intervention began in March 2022. They also recently completed a mid-line evaluation of the intervention. The team anticipates completing the intervention by the end of July 2022 and completing the end-line survey by the fall of 2022.

As for dissemination, the researchers presented the results of the baseline evaluation of the study in a webinar organized by the Infection Control Africa Network (ICAN) and presented findings from the study at the Environmental Health Department of the Ugandan Ministry of Health. They have submitted two manuscripts to peer-reviewed journals and addressed initial review comments. They have also worked with WaterAid Uganda staff to support the Ministry of Health in finalizing the revision and integration of healthcare facilities’ WASH indicators in the health management information system.

Dr. Mugambe and his team will continue monitoring the implementation of the intervention during the next quarter (July – September 2022). After the intervention ends, the team will complete an end-line evaluation, analyze their data, and prepare additional manuscripts for publication. A no-cost extension has been issued through November 2022.


Mugambe, R.K., Mselle, J.S., Ssekamatte, T. et al. 2021. Impact of mhealth messages and environmental cues on hand hygiene practice among healthcare workers in the greater Kampala metropolitan area, Uganda: study protocol for a cluster randomized trial. BMC Health Serv Res 21, 88 (2021).

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