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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 - June 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:

After conducting preparatory activities and encountering significant COVID-related delays in 2020 and early 2021, work on this project gained momentum thanks to a stakeholders’ inception workshop held at the Ridah Hotel in Seeta, Uganda, May 5-6, 2021. The workshop, which attracted about 30 participants from government departments and ministries, nongovernmental organizations, and academia, was used to disseminate findings from the formative study phase and co-design the hand-hygiene intervention and design principles. Following the meeting, Dr. Mugambe and his team worked further with specialists to develop mhealth messages and environmental cues, as well as develop the information system that will be used for sending mhealth messages. They trained research assistants on aspects of ethics, community entry, and data collection tools in preparation for the baseline, mid-line, and end-line surveys. The researchers carried out pre-visits to selected healthcare facilities to understand needs and select the intervention and control healthcare facilities. The team pretested and refined the data collection tools and on May 24-30, 2021, they conducted the baseline survey. In addition, they conducted a baseline study of among healthcare workers to understand knowledge and attitudes on hand-hygiene, as well as adherence to hand-hygiene practices.

In the third quarter of 2021, the project team worked with the managers of the intervention and control health facilities involved in the study to identify conspicuous walls, where the environmental cues were subsequently posted. In addition, stakeholders approved the final mhealth messages that will be shared with the health workers during the intervention phase. Dr. Mugambe and his co-authors also finalized a manuscript titled “Barriers and facilitators to hand hygiene among healthcare workers in the Greater Kampala Metropolitan region” for submission to a journal. Also on the outreach side, the PI reports that his team’s research is informing the Uganda National Water, Sanitation, and Hygiene (WASH) guidelines for healthcare facilities that are currently being developed. He and his colleagues are part of the National WASH in Healthcare Facilities Task Force at the Ugandan Ministry of Health, and they have been involved in reviewing the terms of reference for the consultant and drafting guidelines. Their research is also informing WASH in healthcare facilities programs for some NGOs in Uganda.

In the last quarter of 2021 and early 2022, the project team will carry out the planned intervention over a period of four months, working in partnership with WaterAid, the Ministry of Health, the Kampala Capital City Authority, the Ministry of Water and Environment, and the selected healthcare facilities. Midline and endline surveys will also be conducted to aid in evaluating the intervention. A no-cost extension has been issued through June 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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