Hand Hygiene During Facility-Based Childbirth in Cambodia: A Theory-Driven, Mixed-Methods Observational Study

Abstract

Background Despite current efforts to improve hand hygiene in health care facilities, compliance among birth attendants remains low. Current improvement strategies are inadequate, largely focusing on a limited set of known behavioural determinants or addressing hand hygiene as part of a generalized set of hygiene behaviours. To inform the design of a facility –based hand hygiene behaviour change intervention in Kampong Chhnang, Cambodia, a theory-driven formative research study was conducted to investigate the context specific behaviours and determinants of handwashing during labour and delivery among birth attendants. Methods This formative mixed-methods research followed a sequential explanatory design and was conducted across eight healthcare facilities. The hand hygiene practices of all birth attendants present during the labour and delivery of 45 women were directly observed and compliance with hand hygiene protocols assessed in analysis. Semi-structured, interactive interviews were subsequently conducted with 20 key healthcare workers to explore the corresponding cognitive, emotional, and environmental drivers of hand hygiene behaviours. Results Birth attendants’ compliance with hand hygiene protocol was 18% prior to performing labour, delivery and newborn aftercare procedures. Hand hygiene compliance did not differ by facility type or attendants’ qualification, but differed by shift with adequate hand hygiene less likely to be observed during the night shift (p = 0.03). The midwives’ hand hygiene practices were influenced by cognitive, psychological, environmental and contextual factors including habits, gloving norms, time, workload, inadequate knowledge and infection risk perception. Conclusion The resulting insights from formative research suggest a multi-component improvement intervention that addresses the different key behaviour determinants to be designed for the labour and delivery room. A combination of disruption of the physical environment via nudges and cues, participatory education to the midwives and the promotion of new norms using social influence and affiliation may increase the birth attendants’ hand hygiene compliance in our study settings.

Hand Hygiene during the Early Neonatal Period: A Mixed-methods Observational Study in Healthcare Facilities and Households in Rural Cambodia

“…This manuscript focuses on the findings for the PNC room and the home environment. Findings related to hygiene during childbirth have been reported in an earlier publication [19].…”

“…The study followed an explanatory sequential design where quantitative direct observations data informed subsequent in-depth qualitative data collection. The overall study context, aims and study site selection and sampling have been described in an earlier publication [19].…”

“…Enrolment procedures and sample size for the observation data collection are described in Nalule et al [19]. Hand hygiene specific to newborn care was assessed through structured observations.…”

“…In addition to the direct observations, facility-level and household structured assessments were conducted to assess water, sanitation and hygiene (WASH) conditions of the HCF and the household. The facility-level tools have been described in the earlier publication [19]. Structured household assessments were conducted by the data collectors either upon arrival or at the end of the home observation.…”

“…Each of these environments constitutes different contexts, with different primary caregivers, and different environmental, social and psychological drivers of hand hygiene practices important for newborn health [11,[14][15][16][17][18]. For example, healthcare worker compliance with hand hygiene protocols are influenced by institutional factors, such as high workload and limited staff, inadequate infrastructure, and poor gloving practices [11,14,15,19] while maternal handwashing in the home environment is influenced by emotions (nurture, disgust), availability and convenience to handwashing materials, handwashing norms, prohibitive gender norms and roles, and the level of extended family support [20][21][22][23]. As hygiene behaviours are critical at both the HCF and home environment during this critical period, there is a need for innovative, contextualized behaviour-centered approaches that can effectively target both settings.…”