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Caruso BA, Paniagua U, Hoffman I, Manji K, Saidi F, Sudfeld CR, Vernekar SS, Bakari M, Duggan CP, Kibogoyo GC, Kisenge R, Somji S, Kafansiyanji E, Mvalo T, Nyirenda N, Phiri M, Bellad R, Dhaded S, K A C, Koppad B, Nabapure S, Nanda S, Singh B, Yogeshkumar S, Fleming K, North K, Tuller DE, Semrau KEA, Vesel L, Young MF. Safe infant feeding in healthcare facilities: Assessment of infection prevention and control conditions and behaviors in India, Malawi, and Tanzania. PLOS GLOBAL PUBLIC HEALTH 2023; 3:e0001843. [PMID: 37289720 DOI: 10.1371/journal.pgph.0001843] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/03/2022] [Accepted: 03/29/2023] [Indexed: 06/10/2023]
Abstract
Infants need to receive care in environments that limit their exposure to pathogens. Inadequate water, sanitation, and hygiene (WASH) environments and suboptimal infection prevention and control practices in healthcare settings contribute to the burden of healthcare-associated infections, which are particularly high in low-income settings. Specific research is needed to understand infant feeding preparation in healthcare settings, a task involving multiple behaviors that can introduce pathogens and negatively impact health. To understand feeding preparation practices and potential risks, and to inform strategies for improvement, we assessed facility WASH environments and observed infant feeding preparation practices across 12 facilities in India, Malawi, and Tanzania serving newborn infants. Research was embedded within the Low Birthweight Infant Feeding Exploration (LIFE) observational cohort study, which documented feeding practices and growth patterns to inform feeding interventions. We assessed WASH-related environments and feeding policies of all 12 facilities involved in the LIFE study. Additionally, we used a guidance-informed tool to carry out 27 feeding preparation observations across 9 facilities, enabling assessment of 270 total behaviors. All facilities had 'improved' water and sanitation services. Only 50% had written procedures for preparing expressed breastmilk; 50% had written procedures for cleaning, drying, and storage of infant feeding implements; and 33% had written procedures for preparing infant formula. Among 270 behaviors assessed across the 27 feeding preparation observations, 46 (17.0%) practices were carried out sub-optimally, including preparers not handwashing prior to preparation, and cleaning, drying, and storing of feeding implements in ways that do not effectively prevent contamination. While further research is needed to improve assessment tools and to identify specific microbial risks of the suboptimal behaviors identified, the evidence generated is sufficient to justify investment in developing guidance and programing to strengthen infant feeding preparation practices to ensure optimal newborn health.
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Affiliation(s)
- Bethany A Caruso
- Hubert Department of Global Health, Emory University School of Public Health, Atlanta, Georgia, United States of America
| | - Uriel Paniagua
- Department of Epidemiology, Emory University School of Public Health, Atlanta, Georgia, United States of America
| | - Irving Hoffman
- Institute for Global Health and Infectious Diseases, University of North Carolina at Chapel Hill School of Medicine, Chapel Hill, North Carolina, United States of America
| | - Karim Manji
- Department of Pediatrics and Child Health, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Friday Saidi
- University of North Carolina Project Malawi, Lilongwe, Malawi
| | - Christopher R Sudfeld
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, United States of America
| | - Sunil S Vernekar
- Jawaharlal Nehru Medical College, KLE Academy of Higher Education and Research (Deemed-to-be-University), Belgaum, Karnataka, India
| | - Mohamed Bakari
- Department of Pediatrics and Child Health, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Christopher P Duggan
- Center for Nutrition, Boston Children's Hospital, Boston, Massachusetts, United States of America
- Division of Nutrition, Harvard Medical School, Boston, Massachusetts, United States of America
| | - George C Kibogoyo
- Department of Pediatrics and Child Health, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Rodrick Kisenge
- Department of Pediatrics and Child Health, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Sarah Somji
- Department of Pediatrics and Child Health, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | | | - Tisungane Mvalo
- University of North Carolina Project Malawi, Lilongwe, Malawi
- Department of Pediatrics, University of North Carolina at Chapel Hill School of Medicine, Chapel Hill, North Carolina, United States of America
| | - Naomie Nyirenda
- University of North Carolina Project Malawi, Lilongwe, Malawi
| | - Melda Phiri
- University of North Carolina Project Malawi, Lilongwe, Malawi
| | - Roopa Bellad
- Jawaharlal Nehru Medical College, KLE Academy of Higher Education and Research (Deemed-to-be-University), Belgaum, Karnataka, India
| | - Sangappa Dhaded
- Jawaharlal Nehru Medical College, KLE Academy of Higher Education and Research (Deemed-to-be-University), Belgaum, Karnataka, India
| | - Chaya K A
- Bapuji Child Health Institute & Research Centre, Davangere, Karnataka, India
| | - Bhavana Koppad
- Jawaharlal Nehru Medical College, KLE Academy of Higher Education and Research (Deemed-to-be-University), Belgaum, Karnataka, India
| | - Shilpa Nabapure
- SS Institute of Medical Sciences & Research Centre, Davangere, Karnataka, India
| | - Saumya Nanda
- Shri Jagannath Medical College and Hospital, Puri, Odisha, India
| | - Bipsa Singh
- Shri Jagannath Medical College and Hospital, Puri, Odisha, India
| | - S Yogeshkumar
- Jawaharlal Nehru Medical College, KLE Academy of Higher Education and Research (Deemed-to-be-University), Belgaum, Karnataka, India
| | - Katelyn Fleming
- Ariadne Labs, Harvard T.H. Chan School of Public Health / Brigham and Women's Hospital, Boston, Massachusetts, United States of America
| | - Krysten North
- Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, United States of America
| | - Danielle E Tuller
- Ariadne Labs, Harvard T.H. Chan School of Public Health / Brigham and Women's Hospital, Boston, Massachusetts, United States of America
| | - Katherine E A Semrau
- Ariadne Labs, Harvard T.H. Chan School of Public Health / Brigham and Women's Hospital, Boston, Massachusetts, United States of America
- Department of Medicine, Harvard Medical School, Boston, Massachusetts, United States of America
| | - Linda Vesel
- Ariadne Labs, Harvard T.H. Chan School of Public Health / Brigham and Women's Hospital, Boston, Massachusetts, United States of America
| | - Melissa F Young
- Hubert Department of Global Health, Emory University School of Public Health, Atlanta, Georgia, United States of America
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Gon G, Szekely A, Lowe H, Tosi M. Hand Hygiene Social Norms Among Healthcare Workers During Early COVID-19: Results of a Global Survey. Int J Public Health 2022; 67:1604981. [PMID: 36506712 PMCID: PMC9729248 DOI: 10.3389/ijph.2022.1604981] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2022] [Accepted: 11/10/2022] [Indexed: 11/26/2022] Open
Abstract
Objectives: Poor hand hygiene among healthcare workers is an important driver of infectious disease transmission. Although social norms are considered a key determinant of hand hygiene behaviour, little is known about them among healthcare workers. This study describes hand hygiene social norms among health workers, assesses their predictors, and tests if social expectations increased during the early stages of COVID-19. Methods: We conducted a cross-sectional survey of healthcare workers from 77 countries (n = 1,233) from April to August 2020 assessing healthcare workers' hand hygiene social expectations, personal normative beliefs, punishment and reward, and demographic factors. Linear regressions and hierarchical linear modelling were used to analyse the responses. Results: We find high social expectations, personal beliefs, punishment, and rewards. Doctors tend to have lower social expectations than other occupation groups (e.g., nurses/midwives) and older respondents have higher social expectations. Social expectations increased during our survey, which may have been driven by COVID-19. Conclusion: Our findings suggest that hand hygiene social norms are strong among healthcare workers with variation across occupation and age; their strength increased during the COVID-19 pandemic. These have implications for behaviour change in healthcare environments that could leverage more norm-targeting interventions.
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Affiliation(s)
- Giorgia Gon
- London School Hygiene and Tropical Medicine, London, United Kingdom,*Correspondence: Giorgia Gon,
| | - Aron Szekely
- Collegio Carlo Alberto, Turin, Italy,Institute of Cognitive Sciences and Technologies, Italian National Research Council, Rome, Italy
| | - Hattie Lowe
- Institute for Global Health, University College London, London, United Kingdom
| | - Marco Tosi
- Department of Statistical Sciences, University of Padua, Padova, Italy
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Nalule Y, Pors P, Samol C, Ret S, Leang S, Ir P, Macintyre A, Dreibelbis R. A controlled before-and-after study of a multi-modal intervention to improve hand hygiene during the peri-natal period in Cambodia. Sci Rep 2022; 12:19646. [PMID: 36385113 PMCID: PMC9666993 DOI: 10.1038/s41598-022-23937-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2021] [Accepted: 11/08/2022] [Indexed: 11/17/2022] Open
Abstract
Adequate hand hygiene practices throughout the continuum of care of maternal and newborn health are essential for infection prevention. However, the hand hygiene compliance of facility-based birth attendants, parents and other caregivers along this continuum is low and behavioural-science informed interventions targeting the range of caregivers in both the healthcare facility and home environments are scarce. We assessed the limited efficacy of a novel multimodal behaviour change intervention, delivered at the facility, to improve the hand hygiene practices among midwives and caregivers during childbirth through the return to the home environment. The 6-month intervention was implemented in 4 of 8 purposively selected facilities and included environmental restructuring, hand hygiene infrastructure provision, cues and reminders, and participatory training. In this controlled before-and-after study, the hand hygiene practices of all caregivers present along the care continuum of 99 women and newborns were directly observed. Direct observations took place during three time periods; labour, delivery and immediate aftercare in the facility delivery room, postnatal care in the facility ward and in the home environment within the first 48 h following discharge. Multilevel logistic regression models, adjusted for baseline measures, assessed differences in hand hygiene practices between intervention and control facilities. The intervention was associated with increased odds of improved practice of birth attendants during birth and newborn care in the delivery room (Adjusted odds ratio [AOR] = 4.7; 95% confidence interval [CI] = 2.7, 7.7), and that of parental and non-parental caregivers prior to newborn care in the post-natal care ward (AOR = 9.2; CI = 1.3, 66.2); however, the absolute magnitude of improvements was limited. Intervention effects were not presented for the home environment due COVID-19 related restrictions on observation duration at endline which resulted in too low observation numbers to warrant testing. Our results suggest the potential of a facility-based multimodal behaviour change intervention to improve hand hygiene practices that are critical to maternal and neonatal infection along the continuum of care.
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Affiliation(s)
- Yolisa Nalule
- grid.8991.90000 0004 0425 469XDisease Control Department, London School of Hygiene and Tropical Medicine, London, WC1E 7HT UK
| | | | | | | | - Supheap Leang
- grid.436334.5National Institute of Public Health, Phnom Penh, Cambodia
| | - Por Ir
- grid.436334.5National Institute of Public Health, Phnom Penh, Cambodia
| | | | - Robert Dreibelbis
- grid.8991.90000 0004 0425 469XDisease Control Department, London School of Hygiene and Tropical Medicine, London, WC1E 7HT UK
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Nalule Y, Buxton H, Ir P, Leang S, Macintyre A, Pors P, Samol C, Dreibelbis R. Hand hygiene during facility-based childbirth in Cambodia: a theory-driven, mixed-methods observational study. BMC Pregnancy Childbirth 2021; 21:429. [PMID: 34139995 PMCID: PMC8212449 DOI: 10.1186/s12884-021-03901-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2021] [Accepted: 05/26/2021] [Indexed: 12/14/2022] Open
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. Supplementary Information The online version contains supplementary material available at 10.1186/s12884-021-03901-7.
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Affiliation(s)
- Yolisa Nalule
- Disease Control Department, London School of Hygiene and Tropical Medicine, London, WC1E 7HT, UK.
| | - Helen Buxton
- Division of Psychiatry, University College London, London, W1T 7BN, UK
| | - Por Ir
- National Institute of Public Health, Phnom Penh, Cambodia
| | - Supheap Leang
- National Institute of Public Health, Phnom Penh, Cambodia
| | | | | | | | - Robert Dreibelbis
- Disease Control Department, London School of Hygiene and Tropical Medicine, London, WC1E 7HT, UK
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Graham WJ, Okomo U, Gon G, Aiken AM. Cleaning Neonatal Units in Low-resource Settings: A Hot-topic in Waiting? Pediatr Infect Dis J 2021; 40:S1-S4. [PMID: 34042903 DOI: 10.1097/inf.0000000000002927] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Globally, about 3-quarters of births now occur in healthcare facilities, with the proportion being 50% for sub-Saharan Africa, where healthcare-associated infections among newborns are typically 3-20 times higher than in facilities in high-income countries. As this upward trend in institutional deliveries continues, the demand for specialized neonatal care also rises, with dedicated units often only available in tertiary referral hospitals in the case of low- and middle-income countries. Preventing nosocomial infections among vulnerable newborns requires effective and feasible control strategies and interventions. The role of cleaning and cleaners in reducing risks and maintaining a clean safe environment has until very recently been neglected at policy, program, practice, and research levels. There is now an opportunity to reposition cleaning within global and national initiatives related to Water, Sanitation and Hygiene, Infection Prevention and Control, and Antimicrobial Resistance. The evidence base should also be strengthened on cost-effective bundles of cleaning interventions, particularly in the context of low-resource settings. Here increasing overcrowding and shortages of staff and supplies present major threats to neonatal survival and well-being and heighten the case for optimizing the use of low-cost, back-to-basics interventions like cleaning.
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Affiliation(s)
- Wendy J Graham
- From the Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Uduak Okomo
- Vaccines and Immunity theme, Medical Research Council Unit, The Gambia at London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Giorgia Gon
- From the Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Alexander M Aiken
- From the Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, United Kingdom
- Imperial College Healthcare NHS Trust, United Kingdom
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Nalule Y, Buxton H, Macintyre A, Ir P, Pors P, Samol C, Leang S, Dreibelbis R. Hand Hygiene during the Early Neonatal Period: A Mixed-Methods Observational Study in Healthcare Facilities and Households in Rural Cambodia. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:4416. [PMID: 33919264 PMCID: PMC8122667 DOI: 10.3390/ijerph18094416] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 03/19/2021] [Revised: 04/16/2021] [Accepted: 04/17/2021] [Indexed: 11/16/2022]
Abstract
BACKGROUND Globally, infections are the third leading cause of neonatal mortality. Predominant risk factors for facility-born newborns are poor hygiene practices that span both facilities and home environments. Current improvement interventions focus on only one environment and target limited caregivers, primarily birth attendants and mothers. To inform the design of a hand hygiene behavioural change intervention in rural Cambodia, a formative mixed-methods observational study was conducted to investigate the context-specific behaviours and determinants of handwashing among healthcare workers, and maternal and non-maternal caregivers along the early newborn care continuum. METHODS Direct observations of hygiene practices of all individuals providing care to 46 newborns across eight facilities and the associated communities were completed and hand hygiene compliance was assessed. Semi-structured interactive interviews were subsequently conducted with 35 midwives and household members to explore the corresponding cognitive, emotional and environmental factors influencing the observed key hand hygiene behaviours. RESULTS Hand hygiene opportunities during newborn care were frequent in both settings (n = 1319) and predominantly performed by mothers, fathers and non-parental caregivers. Compliance with hand hygiene protocol across all caregivers, including midwives, was inadequate (0%). Practices were influenced by the lack of accessible physical infrastructure, time, increased workload, low infection risk perception, nurture-related motives, norms and inadequate knowledge. CONCLUSIONS Our findings indicate that an effective intervention in this context should be multi-modal to address the different key behaviour determinants and target a wide range of caregivers.
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Affiliation(s)
- Yolisa Nalule
- Department of Disease Control, London School of Hygiene and Tropical Medicine, London WC1E 7HT, UK;
| | - Helen Buxton
- Division of Psychiatry, University College London, London W1T 7BN, UK;
| | - Alison Macintyre
- Policy and Programs Division, WaterAid Australia, Melbourne 3002, Australia;
| | - Por Ir
- National Institute of Public Health, Phnom Penh, Cambodia; (P.I.); (S.L.)
| | - Ponnary Pors
- WASH and Health Division, WaterAid Cambodia, Phnom Penh, Cambodia; (P.P.); (C.S.)
| | - Channa Samol
- WASH and Health Division, WaterAid Cambodia, Phnom Penh, Cambodia; (P.P.); (C.S.)
| | - Supheap Leang
- National Institute of Public Health, Phnom Penh, Cambodia; (P.I.); (S.L.)
| | - Robert Dreibelbis
- Department of Disease Control, London School of Hygiene and Tropical Medicine, London WC1E 7HT, UK;
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de Barra M, Gon G, Woodd S, Graham WJ, de Bruin M, Kahabuka C, Williams AJ, Konate K, Ali SM, Said R, Penn-Kekana L. Understanding infection prevention behaviour in maternity wards: A mixed-methods analysis of hand hygiene in Zanzibar. Soc Sci Med 2021; 272:113543. [PMID: 33578309 PMCID: PMC7938378 DOI: 10.1016/j.socscimed.2020.113543] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Revised: 11/17/2020] [Accepted: 11/18/2020] [Indexed: 12/16/2022]
Abstract
RATIONALE Although women in low- and middle-income countries are increasingly encouraged to give birth at facilities, healthcare-associated infection of both the mother and newborn remain common. An important cause of infection is poor hand hygiene. There is a need to understand how environmental, behavioural, and organisational factors influence hygiene practice. OBJECTIVE To understand variations between facilities and between people in hygiene behaviour and to explore potential intervention targets in four labour wards in Zanzibar. METHODS Site visits including observation of deliveries and of day-to-day workings of the facilities. Thirty-three semi-structured interviews, totalling more than 46 hours, with birth attendants, orderlies, managerial staff and mothers. Transcribed interviews and observation notes were read and coded by two authors. Themes were developed and analysed in light of existing research. RESULTS The physical preconditions for hand hygiene were met more regularly in the two highvolume facilities, where soap, water, gloves were almost always available. However, in all of the facilities, hand hygiene appeared impeded by poor ergonomics, like, for example, physical distance between water taps, gloves, or delivery beds. Recontamination of gloved hands following good hand hygiene was commonly observed, a pattern that the birth attendants attributed to high and unpredictable workload and equipment shortages. Interviews and focus groups suggested that birth attendants typically understood when and why hand hygiene should be implemented, and that they were aware of low handwashing rates among co-workers. In poorer performing facilities, managers were less inclined to visit wards and more likely to perceive hand hygiene as beyond their influence. CONCLUSIONS Observations and interviews suggest improvements in the ergonomic design of delivery rooms, including convenient availability of sinks, soap, hand gel, hand towels and gloves, may be a low-cost way to reduce the infection burden from poor hand hygiene.
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Affiliation(s)
| | - Giorgia Gon
- London School of Hygiene and Tropical Medicine, UK
| | | | - Wendy J Graham
- University of Aberdeen, UK; London School of Hygiene and Tropical Medicine, UK
| | - Marijn de Bruin
- University of Aberdeen, UK; IQ Healthcare, Radboud University Medical Centre, the Netherlands
| | | | | | | | - Said M Ali
- Public Health Laboratory Ivo de Carneri, Zanzibar
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Zorrilla-Vaca A, Marmolejo-Posso D, Caballero-Lozada AF, Miño-Bernal JF. Sterility and Infection Prevention Standards for Anesthesiologists in LMICs: Preventing Infections and Antimicrobial Resistance. CURRENT ANESTHESIOLOGY REPORTS 2021. [DOI: 10.1007/s40140-021-00441-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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Gon G, Ali SM, Aunger R, Campbell OM, de Barra M, de Bruin M, Juma M, Nash S, Tajo A, Westbrook J, Woodd S, Graham WJ. A Practical Guide to Using Time-and-Motion Methods to Monitor Compliance With Hand Hygiene Guidelines: Experience From Tanzanian Labor Wards. GLOBAL HEALTH: SCIENCE AND PRACTICE 2020; 8:827-837. [PMID: 33361245 PMCID: PMC7784080 DOI: 10.9745/ghsp-d-20-00221] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/13/2020] [Accepted: 08/19/2020] [Indexed: 12/05/2022]
Abstract
Understanding hand hygiene behaviors is critical in hospitals. We developed the HANDS at birth tool—and provide information on its design and implementation–to capture the complex patterns of health care workers’ hand hygiene including hand rubbing/washing, glove use, and recontamination. Background: Good-quality evidence on hand hygiene compliance among birth attendants in low-resource labor wards is limited. The World Health Organization Hand Hygiene Observation Form is widely used for directly observing behaviors, but it does not support capturing complex patterns of behavior. We developed the HANDS at Birth tool for direct observational studies of complex patterns of hand rubbing/washing, glove use, recontamination, and their determinants among birth attendants. Understanding these behaviors is particularly critical in wards with variable patient volumes or unpredictable patient complications, such as emergency departments, operating wards, or triage and isolation wards during epidemics. Here we provide detailed information on the design and implementation of the HANDS at Birth tool, with a particular focus on low-resource settings. We developed the HANDS at Birth tool from available guidelines, unstructured observation, and iterative refinement based on consultation with collaborators and pilot results. We designed the tool with WOMBAT software, which supports collecting multidimensional time-and-motion data. Our analysis of the tool’s performance centered on interobserver agreement and convergent validity and the implications of the data structure for data analysis. The HANDS at Birth tool encompasses various hand actions and context-relevant information. Hand actions include procedures relevant during labor and delivery; hand hygiene or glove actions; and other types of touch. During field implementation, we used the tool for continuous observation of the birth attendant. Interobserver agreement was good (kappa range: 0.7–0.9), and the tool showed convergent validity. Using the HANDS at Birth tool is a feasible way to obtain useful information about compliance with hand hygiene procedures. The tool could be used after simple training and allows for collection of reliable information about the complex pattern of hygiene behaviors. Future studies should explore using this tool to observe behavior in labor wards in other settings and in other types of wards.
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Affiliation(s)
- Giorgia Gon
- London School of Hygiene and Tropical Medicine, London, United Kingdom.
| | - Said M Ali
- Public Health Laboratory-Ivo de Carneri, Pemba, Zanzibar, Tanzania
| | - Robert Aunger
- London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Oona M Campbell
- London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Mícheál de Barra
- Brunel University London, Department of Life Sciences, Uxbridge, United Kingdom
| | - Marijn de Bruin
- Institute of Applied Health Sciences, University of Aberdeen, Aberdeen, United Kingdom.,Department of IQ Healthcare, Radboud University Medical Center, Radboud Institute for Health Sciences, Nijmegen, The Netherlands
| | - Mohammed Juma
- Public Health Laboratory-Ivo de Carneri, Pemba, Zanzibar, Tanzania
| | - Stephen Nash
- London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Amour Tajo
- Public Health Laboratory-Ivo de Carneri, Pemba, Zanzibar, Tanzania
| | | | - Susannah Woodd
- London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Wendy J Graham
- London School of Hygiene and Tropical Medicine, London, United Kingdom
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Gon G, de Barra M, Dansero L, Nash S, Campbell OMR. Birth attendants' hand hygiene compliance in healthcare facilities in low and middle-income countries: a systematic review. BMC Health Serv Res 2020; 20:1116. [PMID: 33267879 PMCID: PMC7713338 DOI: 10.1186/s12913-020-05925-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2019] [Accepted: 11/15/2020] [Indexed: 12/13/2022] Open
Abstract
Background With an increasing number of women delivering in healthcare facilities in Low and Middle Income Countries (LMICs), healthcare workers’ hand hygiene compliance on labour wards is pivotal to preventing infections. Currently there are no estimates of how often birth attendants comply with hand hygiene, or of the factors influencing compliance in healthcare facilities in LMICs. Methods We conducted a systematic review to investigate the a) level of compliance, b) determinants of compliance and c) interventions to improve hand hygiene during labour and delivery among birth attendants in healthcare facilities of LMICs. We also aimed to assess the quality of the included studies and to report the intra-cluster correlation for studies conducted in multiple facilities. Results We obtained 797 results across four databases and reviewed 71 full texts. Of these, fifteen met our inclusion criteria. Overall, the quality of the included studies was particularly compromised by poorly described sampling methods and definitions. Hand hygiene compliance varied substantially across studies from 0 to 100%; however, the heterogeneity in definitions of hand hygiene did not allow us to combine or compare these meaningfully. The five studies with larger sample sizes and clearer definitions estimated compliance before aseptic procedures opportunities, to be low (range: 1–38%). Three studies described two multi-component interventions, both were shown to be feasible. Conclusions Hand hygiene compliance was low for studies with larger sample sizes and clear definitions. This poses a substantial challenge to infection prevention during birth in LMICs facilities. We also found that the quality of many studies was suboptimal. Future studies of hand hygiene compliance on the labour ward should be designed with better sampling frames, assess inter-observer agreement, use measures to improve the quality of data collection, and report their hand hygiene definitions clearly.
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Affiliation(s)
- Giorgia Gon
- London School of Hygiene and Tropical Medicine, Keppel Street, London, WC1E 7HT, UK.
| | - Mícheál de Barra
- Brunel University London, Department of Life Sciences, Uxbridge, UK
| | | | - Stephen Nash
- London School of Hygiene and Tropical Medicine, Keppel Street, London, WC1E 7HT, UK
| | - Oona M R Campbell
- London School of Hygiene and Tropical Medicine, Keppel Street, London, WC1E 7HT, UK
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Nalule Y, Buxton H, Flynn E, Oluyinka O, Sara S, Cumming O, Dreibelbis R. Hygiene along the continuum of care in the early post-natal period: an observational study in Nigeria. BMC Pregnancy Childbirth 2020; 20:589. [PMID: 33023531 PMCID: PMC7541299 DOI: 10.1186/s12884-020-03282-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2020] [Accepted: 09/24/2020] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND Newborns delivered in healthcare facilities in low- and middle-income countries are at an increased risk of healthcare associated infections. Facility-based studies have focused primarily on healthcare worker behaviour during labour & delivery with limited attention to hygiene practices in post-natal care areas and largely ignore the wide variety of actors involved in maternal and neonatal care. METHODS This exploratory mixed-methods study took place in six healthcare facilities in Nigeria where 31 structured observations were completed during post-natal care, discharge, and the first 6 hours after return to the home. Frequency of hand hygiene opportunities and hand hygiene actions were assessed for types of patient care (maternal and newborn care) and the role individuals played in caregiving (healthcare workers, cleaners, non-maternal caregivers). Qualitative interviews with mothers were completed approximately 1 week after facility discharge. RESULTS Maternal and newborn care were performed by a range of actors including healthcare workers, mothers, cleaners and non-maternal caregivers. Of 291 hand hygiene opportunities observed at health facilities, and 459 observed in home environments, adequate hand hygiene actions were observed during only 1% of all hand hygiene opportunities. Adequate hand hygiene prior to cord contact was observed in only 6% (1/17) of cord contact related hand hygiene opportunities at healthcare facilities and 7% (2/29) in households. Discharge advice was infrequent and not standardised and could not be remembered by the mother after a week. Mothers reported discomfort around telling non-maternal caregivers to practice adequate hand hygiene for their newborn. CONCLUSIONS In this setting, hand hygiene practices during post-natal care and the first 6 hours in the home environment were consistently inadequate. Effective strategies are needed to promote safe hand hygiene practices within the post-natal care ward and home in low resource, high-burden settings. Such strategies need to target not just mothers and healthcare workers but also other caregivers.
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Affiliation(s)
- Yolisa Nalule
- Disease Control Department, London School of Hygiene and Tropical Medicine, London, WC1E 7HT, UK
| | - Helen Buxton
- Disease Control Department, London School of Hygiene and Tropical Medicine, London, WC1E 7HT, UK
| | - Erin Flynn
- Infection and Immunity, South Australian Health and Medical Research Institute, Adelaide, 5000, Australia
| | - Olutunde Oluyinka
- Maternal and Child Survival Program (MCSP)/Save the Children Nigeria, Abuja, Nigeria
| | - Stephen Sara
- Maternal and Child Survival Program (MCSP)/Save the Children US, Washington, DC, 20036, USA
| | - Oliver Cumming
- Disease Control Department, London School of Hygiene and Tropical Medicine, London, WC1E 7HT, UK
| | - Robert Dreibelbis
- Disease Control Department, London School of Hygiene and Tropical Medicine, London, WC1E 7HT, UK.
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Powell-Jackson T, King JJC, Makungu C, Spieker N, Woodd S, Risha P, Goodman C. Infection prevention and control compliance in Tanzanian outpatient facilities: a cross-sectional study with implications for the control of COVID-19. Lancet Glob Health 2020; 8:e780-e789. [PMID: 32389195 PMCID: PMC7202838 DOI: 10.1016/s2214-109x(20)30222-9] [Citation(s) in RCA: 59] [Impact Index Per Article: 14.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2020] [Revised: 04/20/2020] [Accepted: 04/22/2020] [Indexed: 01/19/2023]
Abstract
BACKGROUND As coronavirus disease 2019 (COVID-19) spreads, weak health systems must not become a vehicle for transmission through poor infection prevention and control practices. We assessed the compliance of health workers with infection prevention and control practices relevant to COVID-19 in outpatient settings in Tanzania, before the pandemic. METHODS This study was based on a secondary analysis of cross-sectional data collected as part of a randomised controlled trial in private for-profit dispensaries and health centres and in faith-based dispensaries, health centres, and hospitals, in 18 regions. We observed provider-patient interactions in outpatient consultation rooms, laboratories, and dressing rooms, and categorised infection prevention and control practices into four domains: hand hygiene, glove use, disinfection of reusable equipment, and waste management. We calculated compliance as the proportion of indications (infection risks) in which a health worker performed a correct action, and examined associations between compliance and health worker and facility characteristics using multilevel mixed-effects logistic regression models. FINDINGS Between Feb 7 and April 5, 2018, we visited 228 health facilities, and observed at least one infection prevention and control indication in 220 facilities (118 [54%] dispensaries, 66 [30%] health centres, and 36 [16%] hospitals). 18 710 indications were observed across 734 health workers (49 [7%] medical doctors, 214 [29%] assistant medical officers or clinical officers, 106 [14%] nurses or midwives, 126 [17%] clinical assistants, and 238 [32%] laboratory technicians or assistants). Compliance was 6·9% for hand hygiene (n=8655 indications), 74·8% for glove use (n=4915), 4·8% for disinfection of reusable equipment (n=841), and 43·3% for waste management (n=4299). Facility location was not associated with compliance in any of the infection prevention and control domains. Facility level and ownership were also not significantly associated with compliance, except for waste management. For hand hygiene, nurses and midwives (odds ratio 5·80 [95% CI 3·91-8·61]) and nursing and medical assistants (2·65 [1·67-4·20]) significantly outperformed the reference category of assistant medical officers or clinical officers. For glove use, nurses and midwives (10·06 [6·68-15·13]) and nursing and medical assistants (5·93 [4·05-8·71]) also significantly outperformed the reference category. Laboratory technicians performed significantly better in glove use (11·95 [8·98-15·89]), but significantly worse in hand hygiene (0·27 [0·17-0·43]) and waste management (0·25 [0·14-0·44] than the reference category. Health worker age was negatively associated with correct glove use and female health workers were more likely to comply with hand hygiene. INTERPRETATION Health worker infection prevention and control compliance, particularly for hand hygiene and disinfection, was inadequate in these outpatient settings. Improvements in provision of supplies and health worker behaviours are urgently needed in the face of the current pandemic. FUNDING UK Medical Research Council, Economic and Social Research Council, Department for International Development, Global Challenges Research Fund, Wellcome Trust.
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Affiliation(s)
- Timothy Powell-Jackson
- Department of Global Health and Development, London School of Hygiene & Tropical Medicine, London, UK,Correspondence to: Dr Timothy Powell-Jackson, Department of Global Health and Development, London School of Hygiene & Tropical Medicine, London WC1H 9SH, UK
| | - Jessica J C King
- Department of Global Health and Development, London School of Hygiene & Tropical Medicine, London, UK
| | | | | | - Susannah Woodd
- Department of Infectious Disease Epidemiology, London School of Hygiene & Tropical Medicine, London, UK
| | - Peter Risha
- PharmAccess Tanzania, Dar es Salaam, Tanzania
| | - Catherine Goodman
- Department of Global Health and Development, London School of Hygiene & Tropical Medicine, London, UK
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Gon G, Virgo S, de Barra M, Ali SM, Campbell OM, Graham WJ, Nash S, Woodd SL, de Bruin M. Behavioural Determinants of Hand Washing and Glove Recontamination before Aseptic Procedures at Birth: A Time-and-Motion Study and Survey in Zanzibar Labour Wards. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2020; 17:ijerph17041438. [PMID: 32102276 PMCID: PMC7068290 DOI: 10.3390/ijerph17041438] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/21/2020] [Revised: 02/18/2020] [Accepted: 02/19/2020] [Indexed: 11/16/2022]
Abstract
Recent research calls for distinguishing whether the failure to comply with World Health Organisation hand hygiene guidelines is driven by omitting to rub/wash hands, or subsequently recontamination of clean hands or gloves prior to a procedure. This study examined the determinants of these two behaviours. Across the 10 highest-volume labour wards in Zanzibar, we observed 103 birth attendants across 779 hand hygiene opportunities before aseptic procedures (time-and-motion methods). They were then interviewed using a structured cross-sectional survey. We used mixed-effect multivariable logistic regressions to investigate the independent association of candidate determinants with hand rubbing/washing and avoiding glove recontamination. After controlling for confounders, we found that availability of single-use material to dry hands (OR:2.9; CI:1.58–5.14), a higher workload (OR:29.4; CI:12.9–67.0), more knowledge about hand hygiene (OR:1.89; CI:1.02–3.49), and an environment with more reminders from colleagues (OR:1.20; CI:0.98–1.46) were associated with more hand rubbing/washing. Only the length of time elapsed since donning gloves (OR:4.5; CI:2.5–8.0) was associated with avoiding glove recontamination. We identified multiple determinants of hand washing/rubbing. Only time elapsed since washing/rubbing was reliably associated with avoiding glove recontamination. In this setting, these two behaviours require different interventions. Future studies should measure them separately.
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Affiliation(s)
- Giorgia Gon
- London School of Hygiene and Tropical Medicine, Faculty of Epidemiology and Population Health, London WC1E 7HT, UK; (O.M.C.); (W.J.G.); (S.N.); (S.L.W.)
- Correspondence:
| | - Sandra Virgo
- University of Kent, Higher Education Access Tracker, Catenrbury CT2 7NZ, UK;
| | - Mícheál de Barra
- Department of Life Sciences, Brunel University London, Uxbridge UB8 3PH, UK;
| | - Said M. Ali
- Public Health Laboratory-Ivo de Carneri, Chake Chake, Pemba, Zanzibar 9820, Tanzania;
| | - Oona M. Campbell
- London School of Hygiene and Tropical Medicine, Faculty of Epidemiology and Population Health, London WC1E 7HT, UK; (O.M.C.); (W.J.G.); (S.N.); (S.L.W.)
| | - Wendy J. Graham
- London School of Hygiene and Tropical Medicine, Faculty of Epidemiology and Population Health, London WC1E 7HT, UK; (O.M.C.); (W.J.G.); (S.N.); (S.L.W.)
| | - Stephen Nash
- London School of Hygiene and Tropical Medicine, Faculty of Epidemiology and Population Health, London WC1E 7HT, UK; (O.M.C.); (W.J.G.); (S.N.); (S.L.W.)
| | - Susannah L. Woodd
- London School of Hygiene and Tropical Medicine, Faculty of Epidemiology and Population Health, London WC1E 7HT, UK; (O.M.C.); (W.J.G.); (S.N.); (S.L.W.)
| | - Marijn de Bruin
- Institute of Applied Health Sciences, University of Aberdeen, Aberdeen AB24 3FX, UK;
- Radboud University Medical Center, Radboud Institute for Health Sciences, IQ healthcare, 6525 GA Nijmegen, The Netherlands
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