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Is handwashing enough? New study investigates why birth attendants fail to practice proper hand hygiene in tanzania

Sasha Baumann, MARCH Centre A-Theme Student Liaison

Health worker compliance with the World Health Organization’s (WHO) hand hygiene guidelines is driven by individual and workplace factors in Zanzibar labour wards, concludes new study by UK and Tanzanian researchers. Findings suggest need for distinct interventions to address birth attendant glove recontamination and handwashing omission prior to aseptic procedures to prevent infection at time of childbirth.

With the spread of novel diseases like COVID-19 and the rise of antimicrobial resistance, proper hand hygiene is promoted as a low-cost, actionable behaviour with a big payoff. Hand hygiene among health workers is particularly important; each year, 46 million people worldwide contract healthcare-associated infections. This has major implications for patient length of stay, prolonged pain or disability, antibiotic overuse, risk of complications and fatality, and accrued costs.  

The significance of health worker hand disinfection and disease transmission in maternity wards was identified over 175 years ago, by Hungarian scientist Ignaz Semmelweis. Around the same time, English statistician and nurse Florence Nightengale promoted hand washing and other sanitation measures at the frontline of the Crimean War to reduce spread of infection among soldiers. Nightengale’s efforts are honoured on the London School of Hygiene & Tropical Medicine’s (LSHTM) building plaque.  

Today, most women give birth in facilities, leaving mothers and newborns particularly vulnerable to healthcare-associated infections. WHO estimates 1/10 maternal deaths and 1/5 neonatal deaths are due to infection around the time of delivery. Patients in low- and middle-income countries face even worse perils. The MARCH Centre is no stranger to the burden of maternal infection; see recent posts about Dr. Susannah Woodd’s findings on peripartum infection and LSHTM’s involvement in the Bold Action to Stop Infection in Clinical Settings (BASICS) initiative. The good news: according to BASICS, proper health worker hand hygiene can reduce risk of infection by 50%.  

The recent paper, authored by LSHTM’s Giorgia Gon in partnership with the University of Aberdeen and the Public Health Laboratory-Ivo de Carneri, comes from the Hand-hygiene of Attendants for Newborn Deliveries and Survival (HANDS) project: a mixed-methods study investigating determinants of birth attendant hand hygiene. HANDS ran from 2015 to 2017 in the 10 highest-volume labor wards in Zanzibar, Tanzania.  

Per WHO guidelines, lack of hand washing or rubbing with antiseptic and glove recontamination are lumped into a single measurement. However, the HANDS project monitored hand cleaning and glove recontamination separately. Birth attendant opportunities to complete each of these two behaviours prior to aseptic procedures, one of the WHO’s “5 Moments for Hand Hygiene,” were observed. 

Findings showed birth attendants correctly washed or rubbed their hands 1/4 of the time and avoided glove recontamination for nearly 2/3 of hand hygiene opportunities. Multiple individual and environmental factors were seen to contribute to proper hand hygiene. Attendants with a lower workload, an available single use drying material, demonstrated knowledge of washing technique, and a workspace with hand hygiene reminders were more likely to wash their hands or rub with antiseptic. Avoiding glove recontamination was linked to shorter time elapsed since putting on gloves.  

Authors suggest that hand hygiene interventions that neglect behaviour-specific drivers may limit behaviour change. Rather, targeted interventions would be more effective. Proposed strategies included increased health worker training and salient workplace reminders to promote proper hand washing and moving gloving stations closer to the procedure location to reduce recontamination. 

The need for rigorous infection prevention is paramount. Keeping healthcare clean by improving water, sanitation, and hygiene on the facility-level is on the WHO list of urgent, global health challenges for 2020: the first year in the “decade of action.”  

Read the complete publication here.  

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