Objective To conduct a qualitative process evaluation within a cluster-randomised trial of an educational resource intervention to promote hand washing in primary schools and thus reduce absenteeism by reducing the transmission of respiratory and gastrointestinal infections.

Design Focus groups with pupils including drawings of hand washing facilities, semi-structured interviews with teachers, direct observation of intervention delivery and hand washing facilities.

Setting State primary schools within six local authority areas in the South West of England (n=178) were randomised to receive the “Hands up for Max!” intervention in October 2009 (intervention schools) or in Autumn 2010 after all trial follow-up data are collected (control schools). Four intervention and four control schools were selected for the process evaluation from the 24 schools participating in a substudy to collect enhanced absenteeism data.

Participants Pupils in years 2 to 6 (n=95), and key stage 1 (n=8) and key stage 2 (n=8) teachers.

Main Outcome Measures The process evaluation examined how the “Hands up for Max!” educational resource was delivered in intervention schools and explored responses to the intervention among pupils and staff. Ideas, attitudes, knowledge and behaviours relating to hand hygiene and hand washing facilities were explored, and hand washing facilities were observed in both intervention and control schools.

Results The “Hands up for Max!” resource was well received by the intervention schools, although some teachers made useful suggestions for improvements. Schools differed in the way they delivered the intervention and the number of elements of the resource package they used. Pupils in intervention schools recalled learning about the importance of hand washing in reducing the spread of infections and were able to describe, in detail, how to wash their hands properly. In the focus groups, pupils provided insight into reasons why they may not wash their hands, and what might help people wash their hands properly. Use of drawings in the focus groups facilitated discussion about what pupils liked and did not like about the facilities where they washed their hands. Results of the process evaluation were also used to inform development of questionnaires to obtain quantitative data from pupils and staff in all 178 schools participating in the trial.

Conclusion Information from the process evaluation will be useful in understanding any observed differences in quantitative outcomes related to absenteeism and knowledge, attitudes and behaviours related to hand washing, between intervention and control schools.