October 17, 2018

The Chicken or The Egg: Hand Hygiene Infrastructure vs. Behaviors in Healthcare Facilities

Written by Lindsay Denny

Three newborn babies wrapped in blankets

Photo credit: Lindsay Denny: Global Water 2020/Emory University

Twenty-five tiny newborns were crammed three and four to a bed. The only sink was filled with dirty water with no soap in sight. An empty bottle of hand sanitizer was hung from a string attached to the door. The scene before me in the neonatal intensive care unit of a major hospital in Ethiopia wasn’t the worst I had seen, but it was no less impactful. An intern on duty told me it was not uncommon for one of the babies to contract an infection, which then rapidly spread to the others. I wasn’t surprised. Healthcare-associated infections in newborns are three to 20 times higher in resource-limited settings, like this one in Ethiopia, compared to more developed country contexts.[1] However, when handwashing and clean birthing practices are in place, newborn survival rates increase by up to 44% in the settings.[2]

Hands held under running water at a sink

Photo credit: Tom Greenwood: WaterAid

Ethiopia is hardly alone in this situation. A recent study drawing data from national surveys in more than 120,000 healthcare facilities in 78 low- and middle-income countries found that 50% of healthcare facilities had piped water and only 44% of healthcare facilities had both soap and running water available for handwashing. A third of these facilities had neither alcohol-hand rub nor soap and water.[3] But the reality on the ground is even worse. These surveys do not consider the proximity of the handwashing facility in relation to the patients receiving care or whether the sinks are functional. The surveys also cannot tell us how many staff use each sink for handwashing. Researchers from Johns Hopkins found in their surveyed facilities as many as 74 nurses/midwives to every sink with soap and water.[4]

Without question, handwashing infrastructure is a problem. But what happens when soap and water are available? The data show that clinicians still do not routinely washing their hands. In Cambodia, Emory University’s team of researchers at the Center for Global Safe WASH surveyed clinicians on their knowledge and attitudes related to hand hygiene and then observed their handwashing practices. These clinicians worked in hospitals where hand hygiene materials were readily available in most wards. The average score for knowledge of infection prevention and handwashing was 74%; the average score for favorable attitudes around infection prevention was 58%; however, the average hand hygiene compliance at key moments was 36%.

So, which should be addressed first in these resource-limited contexts – handwashing infrastructure or behaviors? It is a bit of a trick question. Training on hand hygiene in healthcare facilities that lack the necessary resources does little to support behavior change. Meanwhile, installing new sinks without addressing prevailing attitudes and poor habits is unlikely to make marked improvement in handwashing. Finally, designing interventions for infrastructure and behaviors without considering the accountability and monitoring systems from the healthcare facility level up to the Ministry of Health may leave improvements unsustainable.

A health care worker washing her hands

Photo credit: Tom Greenwood: WaterAid

Proper hand hygiene is crucial in order for healthcare facilities across the developing world to provide safe, quality care. To drive progress, we must understand and address the multiple barriers to hand hygiene within these facilities. We must combine “hardware” and “software” activities, coupled with systems for monitoring and accountability, to create a holistic approach to improving hand hygiene among clinicians.

Interested in more discussion on how we can support clinicians to wash their hands in resource-limited settings? On Wednesday, October 24th (9AM EDT), Emory University will host a webinar session “Overcoming Hurdles in Handwashing: A Clinician’s Perspective on Driving Change in Healthcare Facilities,” as part of the WASH in Healthcare Facilities Initiative. The webinar will feature Jacob Nkwan of Cameroon Baptist Convention Health Services and the Infection Control Africa Network. He will be joined by Dr. Lim Khankryka, Deputy Chief of Quality Assurance at the Cambodian Ministry of Health. Register here to participate!

[1] Zaidi, A. 2005. Hospital-acquired neonatal infections in developing countries. Lancet.[2] Rhee, V. 2008. Impact of Maternal and Birth Attendant Hand-washing on Neonatal Mortality in Southern Nepal. Archives of Pediatric and Adolescent Medicine.

[3] Cronk, R. 2018. Environmental conditions in health care facilities in low- and middle-income countries: Coverage and inequalities. International Journal of Hygiene and Environmental Health.

[4] Johns Hopkins Bloomberg School of Public Health. 2017. PMA2020 WASH BRIEF: PMA2017/ETHIOPIA-R5. https://www.pma2020.org/sites/default/files/PMA-Ethiopia-R5-WASH-brief.pdf