clean.
Actionable information: unpacking the determinants of hand, cord and birth-surface hygiene in Zanzibar maternity units Giorgia Gon1, Catriona Towriss1, Catherine Kahabuka3, Said M. Ali4, Siti M. Ali5, Ali O. Ali5, Sue Cavill 6, Mohammed Dahoma5, Haji S. Haji4, Ibrahim Kabole6, Emma Morrison7, Rukaiya M. Said5, Amour Tajo4, Yael Velleman6, Susannah Woodd1, Wendy J. Graham1 1The
London School of Hygiene and Tropical Medicine 2 University of Cape Town 3CSK Research Solutions Corresponding author: [email protected]
4Public
Health Laboratory Ivo de Carneri 5The Ministry of Health of Zanzibar 6WaterAid 7The Soapbox Collaborative
We thank UK Aid from the Department of International Development (DFID) who fund the SHARE Research Consortium (www.SHAREresearch.org). We also thank WaterAid for funding the social scientist and the Soapbox Collaborative for funding the epidemiologist to undertake tool adaptation, data collection and analysis.
Introduction
Results
Poor standards of hygiene at birth in facilities in Tanzania have been revealed in recent national surveys.1 As more women opt for institutional delivery, improving basic hygiene becomes an essential preventative strategy for reducing puerperal and newborn sepsis. Our collaborative research in Zanzibar provides an in-depth picture of the state of hygiene on maternity wards to inform action.
Index results for clean hands, clean cord and clean birth surface are presented in Fig 1. With the exception of staffing levels, indices were met by 60% or fewer of the facilities. We discuss infrastructure as an example. Only 49% of facilities had the infrastructural requirements to enable clean hands, with the availability of constant running water particularly lacking. Almost two-thirds of facilities met the infrastructure requirement for clean cord; however, frequent stock-outs of disposable cord clamps often resulted in the use of potentially non-sterile thread.
Methods Hygiene was assessed in 2014 across all 37 facilities with a maternity unit in Zanzibar incollaboration with the Zanzibar MoH. We used a mixed methods approach, including structured and semi-structured interviews, observation, microbiological swab sampling and use of photographs.
Our first aim was to produce actionable information, meaning information that: a) is organized by WHO cleans necessary to reduce maternal and newborn infection acquired at the time of delivery. We investigated four of the WHO “six cleans”: clean hands, clean cord cutting and clumping, and a clean birth surface.2 b) clearly identifies the behavioural determinants of these clean practices that can be addressed through MoH interventions; and c) allows the root causes of the IPC gaps to be identified, using a mixed methods approach. For each “clean” we explored the following determinants: knowledge including training, infrastructure (including equipment), staffing levels (skilled birth attendants and orderlies), and policies. Summary indices were constructed as proxies for the behavioural determinants of the “cleans” from quantitative data. Results from the qualitative tools was used to complement this information.
Clean birth surface
Policies Staffing level Infrastructure Knowledge
Clean cord
Staffing level Infrastructure Knowledge
Clean hands
17 out of 37 facilities (46.0%) met the basic infrastructure requirements for a clean birth surface, with the weakest area being consistent availability of water. When interviewed, staff complained about a shortage of orderlies and only 46.0% of facilities had an orderly present in the maternity unit on the morning before the survey. This shortage was further aggravated by the fact that orderlies also performed healthcare-related tasks such as antenatal care, and assisting deliveries, which significantly reduced the time they spent on cleaning activities. 27% of facilities had policies/posters on the decontamination of areas contaminated with body fluids (Fig1). Box 1 describes how we engaged key stakeholders in a participatory workshop, which enabled us to translate this information into action. The findings were presented at a workshop with the MoH and other relevant stakeholders. Participants were able to agree priorities and action plans using well-established quality improvement exercises; “fish bone” diagrams and “plan, do, study and act” cycles.3,4
Policies Staffing levels Infrastructure Knowledge 0
20
Yes - met index components
40 60 Proportion of facilities No
80
100
Missing
Fig 1. Proportion of facilities meeting all basic conditions per determinant index and clean. Knowledge stands for knowledge & training
We illustrate how we combined the results of the quantitative analysis with the observation, interviews and microbiology to unpack the determinants of the cleans, by using clean birth surface as an example. Basic knowledge & training related to clean birth surfaces was found in 11 out of 37 facilities (29.73%). A weak area was the lack of training for orderlies, who are responsible for cleaning the bed surface. In six of the seven facilities where microbiological swabs were taken, the maternity beds were highly contaminated with multiple organisms, especially around the perineal area.
Action plans agreed and follow-up during 2015-2016: 1) Training for all health orderlies on waste management, cleaning techniques and cleaning and maintaining equipment. A curriculum was developed by the Zanzibar MoH and 30 orderlies were trained. 2) Ensure that at least one functional sink is available in every maternity unit. In collaboration with WaterAid Tanzania, the Zanzibar MoH developed a staggered implementation plan to accomplish this across all nine facilities where no functional sink was previously available. Box 1 The process of translating information into action
Conclusions
This mixed methods approach, and analytical framework based on the WHO “cleans” framework and the behavioural determinants, yielded practical information of direct relevance to action at local and ministerial levels. References 1.Benova L, Cumming O, Gordon BA, Magoma M, Campbell OMR. Where There Is No Toilet: Water and Sanitation Environments of Domestic and Facility Births in Tanzania. PLoS ONE. 2014 Sep 5;9(9):e106738. 2.Blencowe H, Cousens S, Mullany LC, Lee ACC, Kerber K, Wall S, et al. Clean birth and postnatal care practices to reduce neonatal deaths from sepsis and tetanus: a systematic review and Delphi estimation of mortality effect. BMC Public Health. 2011;11 Suppl 3:S11. 3.NHS Institute for Innovation and Improvement. Cause and Effect (Fishbone) [Internet]. 2008 [cited 2015 Nov 29]. Available from: http://www.institute.nhs.uk/quality_and_service_improvement_tools/quality_and_service_improvement_tools/cause_and_effect.html 4.NHS Institute for Innovation and Improvement. Plan, Do , Study, Act (PDSA) [Internet]. 2008 [cited 2015 Nov 29]. Available from: http://www.institute.nhs.uk/quality_and_service_improvement_tools/quality_and_service_improvement_tools/plan_do_study_act.html
London School of Hygiene and Tropical Medicine 2 University of Cape Town 3CSK Research Solutions Corresponding author: [email protected]
4Public
Health Laboratory Ivo de Carneri 5The Ministry of Health of Zanzibar 6WaterAid 7The Soapbox Collaborative
We thank UK Aid from the Department of International Development (DFID) who fund the SHARE Research Consortium (www.SHAREresearch.org). We also thank WaterAid for funding the social scientist and the Soapbox Collaborative for funding the epidemiologist to undertake tool adaptation, data collection and analysis.
Introduction
Results
Poor standards of hygiene at birth in facilities in Tanzania have been revealed in recent national surveys.1 As more women opt for institutional delivery, improving basic hygiene becomes an essential preventative strategy for reducing puerperal and newborn sepsis. Our collaborative research in Zanzibar provides an in-depth picture of the state of hygiene on maternity wards to inform action.
Index results for clean hands, clean cord and clean birth surface are presented in Fig 1. With the exception of staffing levels, indices were met by 60% or fewer of the facilities. We discuss infrastructure as an example. Only 49% of facilities had the infrastructural requirements to enable clean hands, with the availability of constant running water particularly lacking. Almost two-thirds of facilities met the infrastructure requirement for clean cord; however, frequent stock-outs of disposable cord clamps often resulted in the use of potentially non-sterile thread.
Methods Hygiene was assessed in 2014 across all 37 facilities with a maternity unit in Zanzibar incollaboration with the Zanzibar MoH. We used a mixed methods approach, including structured and semi-structured interviews, observation, microbiological swab sampling and use of photographs.
Our first aim was to produce actionable information, meaning information that: a) is organized by WHO cleans necessary to reduce maternal and newborn infection acquired at the time of delivery. We investigated four of the WHO “six cleans”: clean hands, clean cord cutting and clumping, and a clean birth surface.2 b) clearly identifies the behavioural determinants of these clean practices that can be addressed through MoH interventions; and c) allows the root causes of the IPC gaps to be identified, using a mixed methods approach. For each “clean” we explored the following determinants: knowledge including training, infrastructure (including equipment), staffing levels (skilled birth attendants and orderlies), and policies. Summary indices were constructed as proxies for the behavioural determinants of the “cleans” from quantitative data. Results from the qualitative tools was used to complement this information.
Clean birth surface
Policies Staffing level Infrastructure Knowledge
Clean cord
Staffing level Infrastructure Knowledge
Clean hands
17 out of 37 facilities (46.0%) met the basic infrastructure requirements for a clean birth surface, with the weakest area being consistent availability of water. When interviewed, staff complained about a shortage of orderlies and only 46.0% of facilities had an orderly present in the maternity unit on the morning before the survey. This shortage was further aggravated by the fact that orderlies also performed healthcare-related tasks such as antenatal care, and assisting deliveries, which significantly reduced the time they spent on cleaning activities. 27% of facilities had policies/posters on the decontamination of areas contaminated with body fluids (Fig1). Box 1 describes how we engaged key stakeholders in a participatory workshop, which enabled us to translate this information into action. The findings were presented at a workshop with the MoH and other relevant stakeholders. Participants were able to agree priorities and action plans using well-established quality improvement exercises; “fish bone” diagrams and “plan, do, study and act” cycles.3,4
Policies Staffing levels Infrastructure Knowledge 0
20
Yes - met index components
40 60 Proportion of facilities No
80
100
Missing
Fig 1. Proportion of facilities meeting all basic conditions per determinant index and clean. Knowledge stands for knowledge & training
We illustrate how we combined the results of the quantitative analysis with the observation, interviews and microbiology to unpack the determinants of the cleans, by using clean birth surface as an example. Basic knowledge & training related to clean birth surfaces was found in 11 out of 37 facilities (29.73%). A weak area was the lack of training for orderlies, who are responsible for cleaning the bed surface. In six of the seven facilities where microbiological swabs were taken, the maternity beds were highly contaminated with multiple organisms, especially around the perineal area.
Action plans agreed and follow-up during 2015-2016: 1) Training for all health orderlies on waste management, cleaning techniques and cleaning and maintaining equipment. A curriculum was developed by the Zanzibar MoH and 30 orderlies were trained. 2) Ensure that at least one functional sink is available in every maternity unit. In collaboration with WaterAid Tanzania, the Zanzibar MoH developed a staggered implementation plan to accomplish this across all nine facilities where no functional sink was previously available. Box 1 The process of translating information into action
Conclusions
This mixed methods approach, and analytical framework based on the WHO “cleans” framework and the behavioural determinants, yielded practical information of direct relevance to action at local and ministerial levels. References 1.Benova L, Cumming O, Gordon BA, Magoma M, Campbell OMR. Where There Is No Toilet: Water and Sanitation Environments of Domestic and Facility Births in Tanzania. PLoS ONE. 2014 Sep 5;9(9):e106738. 2.Blencowe H, Cousens S, Mullany LC, Lee ACC, Kerber K, Wall S, et al. Clean birth and postnatal care practices to reduce neonatal deaths from sepsis and tetanus: a systematic review and Delphi estimation of mortality effect. BMC Public Health. 2011;11 Suppl 3:S11. 3.NHS Institute for Innovation and Improvement. Cause and Effect (Fishbone) [Internet]. 2008 [cited 2015 Nov 29]. Available from: http://www.institute.nhs.uk/quality_and_service_improvement_tools/quality_and_service_improvement_tools/cause_and_effect.html 4.NHS Institute for Innovation and Improvement. Plan, Do , Study, Act (PDSA) [Internet]. 2008 [cited 2015 Nov 29]. Available from: http://www.institute.nhs.uk/quality_and_service_improvement_tools/quality_and_service_improvement_tools/plan_do_study_act.html
