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.

Saneamento, Higiene e Limpeza Ambiental para o Desenvolvimento Infantil

“…Infrastructure alone will not address the risk of infection to mothers and newborns; good hygiene practices are also necessary. Even when the necessary infrastructure is in place, hand hygiene can be limited during labour and delivery (Nalule et al 2021).…”

WASH facilities prevalence and determinants: Evidence from 42 developing countries

“…A systematic review conducted in 2014 found a significant association between poor WASH practice and maternal mortality (Benova, et al, 2014). Furthermore, the historical link between hygiene and childbirth and the effect of clean water accessibility on safe delivery is well recognized (Semmelweis and Semmelweis, 1983;Gould, 2010;Nalule, Y. et al, 2021). Therefore, improved WASH is crucial to promote health and sustainable development, as evidenced by the studies described above.…”

A controlled before-and-after study of a multi-modal intervention to improve hand hygiene during the peri-natal period in Cambodia

“…Hygiene interventions spanning both healthcare facility (HCF) and home environments are scarce with limited evidence around their effectiveness at changing handwashing behaviour 11 , 24 . Hand hygiene studies to-date mostly focus on individual care periods, particularly birth 13 , 17 , 18 , 25 – 27 or the late post-natal period (> 7 days of life) 8 , 20 , 21 , 28 . Postnatal care in the critical days following facility-based birth remains under investigated 11 , 12 .…”

“…For the purposes of this intervention, caregivers included midwives during childbirth, midwives, mothers, and non-maternal caregivers during post-natal care of the new-born, and mothers and other non-maternal caregivers in the home environment. Formative work in this setting documented low hand hygiene compliance in both the facilities and in the home and identified various psychosocial, physical and contextual factors influencing these practices 18 , 19 . Despite availability of functioning hand hygiene infrastructure and materials and demonstrated understanding of infection risk due to inadequate hand hygiene, barriers to effective hand hygiene adherence from midwives included limited understanding of hand or glove recontamination risk, habits and norms around inappropriate gloving practices, perceived lack of time from high workloads and low staffing, and low perception of newborn infection risk 18 .…”

“…Formative work in this setting documented low hand hygiene compliance in both the facilities and in the home and identified various psychosocial, physical and contextual factors influencing these practices 18 , 19 . Despite availability of functioning hand hygiene infrastructure and materials and demonstrated understanding of infection risk due to inadequate hand hygiene, barriers to effective hand hygiene adherence from midwives included limited understanding of hand or glove recontamination risk, habits and norms around inappropriate gloving practices, perceived lack of time from high workloads and low staffing, and low perception of newborn infection risk 18 . Among household members, barriers to effective hand hygiene included inadequate and inaccessible hygiene infrastructure in the facility, inadequate knowledge around hand hygiene opportunities and adequate hygiene protocol during newborn care, bypassing handwashing steps due to excitement or rushing to alleviate the newborn’s perceived distress (nurture), and restrictive gender norms and family hierarchies resulting in limited influence of the mother to inform other relatives’ hand hygiene practices 19 .…”