Barriers and opportunities experienced by staff when implementing infection prevention and control guidelines during labour and delivery in healthcare facilities in Nigeria

Management of healthcare waste collection and segregation for developing countries

Healthcare waste (HCW) consists of hazardous material that may be radioactive, toxic or infectious. Inappropriate treatment and disposal of HCW may pose health risks to humans indirectly through the release of pathogens and toxic pollutants into the environment. The biggest problem in HCW management is its handling, which causes anxiety over sorting and categorizing the waste. Hence, the current study identifies and addresses the challenges towards sustainable environmental development by managing infectious HCW in developing countries. Fuzzy Delphi method is used in the present study to carefully examine the barrier drawn from the literature and experts' opinions. The number of barriers taken into consideration for study are 30, which are then grouped into four main categories, that is, social, environmental, technological and economic barriers. Additionally, a hybrid strategy based on the fuzzy decision-making trial and evaluation laboratory is developed in this work to examine the significance and interrelationships of the identified barrier. The research outcome is a hierarchy and classification model based on the relative importance of the barriers. The results of this study indicate that: 'Lack of segregation', 'Inconsistency in waste collection', 'Unregulated disposal site' and 'Inadequate programme for training and awareness' require quick action. The conclusions obtained through the study would facilitate the preparation of check sheets for documenting HCW management procedures by the healthcare administration and Pollution Control Boards. Understanding the priority cause-group barrier would improve the long-term protection of the hospital environment from the spread of infection caused by the HCW.

A seesaw of equilibrium, midwives' experiences of infection prevention and control guideline adherence: A qualitative descriptive study

Background

Infection prevention and control guidelines play a key role in preventing infections which can impact mothers and their newborn's quality of life. Despite the presence of evidenced-based infection prevention and control guidelines, midwives' adherence can be suboptimal internationally. The identification of facilitators and barriers to infection prevention and control guidelines can support practice and facilitate midwifery care.

Aim

To understand midwives' experiences of the barriers and facilitators when adhering to infection prevention and control guidelines.

Methods

A qualitative descriptive study using semi-structured interviews with 10 midwives from February to March 2022. The interviews were audio recorded, transcribed verbatim, and analysed utilising Braun and Clarke's thematic analysis framework involving the six steps of becoming familiar with the data, generating initial codes, generating themes, reviewing themes, defining and naming the themes, and presenting themes.

Findings

Two themes developed; seesaw for equilibrium and back to basics: learning on your feet. Midwives experienced conflicting emotional motivators in the need for professional integrity towards infection prevention and control guideline adherence. The work environment impacts on midwives' ability to adhere to guidelines and communication and education have a vital role to play in infection prevention and control guideline adherence.

Conclusions

While midwives have a strong sense of protection of professional integrity, work conditions such as environment, organisational structures, and management systems affect midwives' adherence to infection prevention and control guidelines. Effective education, training, and communication are required to promote infection prevention and control guideline adherence.

Barriers to infection prevention and control implementation in selected healthcare facilities in Nigeria

OBJECTIVE

While infection prevention and control are of paramount importance, up until recently an assessment of implementation challenges and performance gaps was lacking. This study explored the barriers to infection prevention and control implementation at selected healthcare facilities, the objective being to find ways to improve their programs.

MATERIAL AND METHOD

A qualitative approach was applied. Purposive sampling was used to select thirty-three healthcare facilities in Ekiti State, Nigeria. They were globally assessed, and an Infection Prevention and Control team, represented by the Infection Prevention and Control referent in each of the selected facilities trained the participants. Data were collected using the Key Informant Interview Guide and analyzed by means of content and thematic analyses using Atlas.ti software.

RESULTS

Inadequate infection prevention and control materials, poor waste management, non-compliance of patients with infection prevention and control protocols, and poor infrastructure were identified as major barriers to infection prevention and control implementation.

CONCLUSION

The study concluded that a number of identified factors hindering infection prevention and control implementation in healthcare facilities in Ekiti State needed to be addressed.

Analysis of water, sanitation, and hygiene facilities using the WASH-FIT approach and its relation to patient satisfaction and maternal mortality at hospitals in Indonesia

Introduction

The provision of Water, Sanitation, and Hygiene (WASH) is critical to reducing infection and enhancing the quality of health care services. The study aims to assess WASH facilities in Indonesian hospitals using the Water, Sanitation, and Hygiene Facility Improvement Tool (WASH-FIT) approach and examine their association with customer satisfaction and maternal mortality owing to infection.

Methods

We utilized the national scale Health Facilities Research dataset in Indonesian hospitals in 2019. WASH status is determined using WASH-FIT indicators, i.e., water, sanitation, waste management, hand hygiene, environmental cleaning, and management services, and then divided into three levels: poor, adequate, and good categories.

Results

The majority of hospitals in Indonesia had a good category, i.e., the range of hospitals with a good category was 79-97% nationally, in 6 aspects: water, sanitation, hand hygiene, environmental cleaning, and management services, except for waste management services (13%). Good WASH service facilities are more frequently found in government hospitals than in private and specialized hospitals, while lower-level hospitals tend to have poor levels of all WASH-FIT indicators. There are significant relationships between adequate sanitation services (β = 0.724), adequate and good categories of hand hygiene services (β = 0.712 and 0.866, respectively), environmental cleaning (β = -0.501 and -0.503, respectively), and management (β = -0.645 and 0.446, respectively), with the proportion of maternal mortality owing to infection. Furthermore, there was no relationship between WASH-FIT indicators and patient satisfaction, except for good hand hygiene services (β = 0.453).

Discussion

Despite good conditions in almost all WASH-FIT indicators, the improvement of waste management is urgently needed to improve the WASH services in hospitals in Indonesia, as also found in other developing countries.

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

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.

How clinicians manage routinely low supplies of personal protective equipment

BACKGROUND

Recommended personal protective equipment (PPE) is routinely limited or unavailable in low-income countries, but there is limited research as to how clinicians adapt to that scarcity, despite the implications for patients and workers.

METHODS

This is a qualitative secondary analysis of case study data collected in Liberia in 2019. Data from the parent study were included in this analysis if it addressed availability and use of PPE in the clinical setting. Conventional content analysis was used on data including: field notes documenting nurse practice, semi-structured interview transcripts, and photographs.

RESULTS

Data from the majority of participants (32/37) and all facilities (12/12) in the parent studies were included. Eighty-three percent of facilities reported limited PPE. Five management strategies for coping with limited PPE supplies were observed, reported, or both: rationing PPE, self-purchasing PPE, asking patients to purchase PPE, substituting PPE, and working without PPE. Approaches to rationing PPE included using PPE only for symptomatic patients or not performing physical exams. Substitutions for PPE were based on supply availability.

CONCLUSIONS

Strategies developed by clinicians to manage low PPE likely have negative consequences for both workers and patients; further research into the topic is important, as is better PPE provision in low-income countries.

A mixed-methods analysis of personal protective equipment used in Lassa fever treatment centres in Nigeria

Background

Lassa fever (LF) is a viral haemorrhagic fever endemic in West Africa. Lassa virus is maintained in and spread to humans from rodents, with occasional secondary human-to-human transmission. Present recommendations for personal protective equipment (PPE) for care of patients with LF generally follow those for filovirus diseases. However, the need for such high-level PPE for LF, which is thought to be considerably less transmissible between humans than filoviruses, is unclear.

Aim

In Nigerian Lassa Treatment Centres (LTCs) we aimed to describe current PPE practices, identify barriers and facilitators to implementation of existing guidance, and assess healthcare workers' understanding. This would inform the development of future PPE guidelines for LF.

Methods

We performed a mixed-methods study, including short cross-sectional surveys of PPE used in LTCs, observations of practice, and in-depth interviews with key informants. We described the quantitative data and we conducted a thematic analysis of qualitative data.

Findings

Our survey of 74 HCWs found that approximately half reported problems with recommended PPE. In three LTCs PPE was used highly variably. Full PPE, as recommended in Nigeria CDC guidelines, was used in less than a quarter (21%) of interactions. In-depth interviews suggested this was based on availability and HCWs' own risk assessments.

Conclusion

Without specific guidance on Lassa, the current approach is both resource and labour-intensive, where these are both limited. This has led to low adherence by health care workers, whose own experience indicates lower risk. The evidence-base to inform PPE required for LF must be improved to inform a more tailored approach.

Hand hygiene during facility-based childbirth in Cambodia: a theory-driven, mixed-methods observational study

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.

Hand Hygiene during the Early Neonatal Period: A Mixed-Methods Observational Study in Healthcare Facilities and Households in Rural Cambodia

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.

Barriers and facilitators to infection prevention and control in a neonatal unit in Zimbabwe - a theory-driven qualitative study to inform design of a behaviour change intervention

BACKGROUND

Hospital-acquired infection (HAI) is an increasing cause of neonatal morbidity/mortality in low-income settings. Hospital staff behaviours (e.g., hand hygiene) are key contributors to HAI. Understanding the drivers of these can inform interventions to improve infection prevention and control (IPC).

AIM

To explore barriers/facilitators to IPC in a neonatal unit in Harare, Zimbabwe.

METHODS

Interviews were conducted with 15 staff members of neonatal and maternity units alongside ethnographic observations. The interview guide and data analysis were informed by the COM-B (Capability, Opportunity, Motivation-Behaviour) model and explored individual, socio-cultural, and organizational barriers/facilitators to IPC. Potential interventions were identified using the Behaviour-Change Wheel.

FINDINGS

Enablers within Capability included awareness of IPC, and within Motivation beliefs that IPC was crucial to one's role, and concerns about consequences of poor IPC. Staff were optimistic that IPC could improve, contingent upon resource availability (Opportunity). Barriers included: limited knowledge of guidelines, no formal feedback on performance (Capability), lack of resources (Opportunity), often leading to improvization and poor habit formation. Further barriers included the unit's hierarchy, e.g., low engagement of cleaners and mothers in IPC, and staff witnessing implementation of poor practices by other team members (Opportunity). Potential interventions could include role-modelling, engaging mothers and staff across cadres, audit and feedback and flexible protocols (adaptable to water/handrub availability).

CONCLUSIONS

Most barriers to IPC fell within Opportunity, whilst most enablers fell under Capability and Motivation. Theory-based investigation provides the basis for systematically identifying and developing interventions to address barriers and enablers to IPC in low-income settings.

Hygiene along the continuum of care in the early post-natal period: an observational study in Nigeria

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.

Status of Infection Prevention and Control in Tanzanian Primary Health Care Facilities: Learning From Star Rating Assessment

Background

The WHO estimates 10–30% of hospital admissions are associated with poor infection prevention and control (IPC). There are no reliable data on IPC status in Tanzanian healthcare facilities; hence the Star Rating Assessment (SRA) was established to address this. This study compared the health facility performances on adherence to IPC principles using baseline and reassessment data of SRA.

Methods

A retrospective analysis of data from eight randomly selected regions across Tanzania. Data was gathered from an SRA database in which records of baseline assessments (2015/16) and reassessments (2017/18) were documented. Each healthcare facility's ownership and service level were investigated as independent variables.

Results

A total of 2,131 healthcare facilities at baseline and 2,185 at reassessment were analysed. Median adherence to IPC principles increased from 31% (IQR: 20%, 46%) to 57% (IQR: 41.4%, 73.2%) after interventions (p<0.001).

Privately-owned facilities had higher adherence to IPC principles compared to publicly-owned facilities during baseline (p<0.001) however, the difference was not significant after intervention (p=0.751). On average, hospitals scored highest followed by health centres and then dispensaries during both assessments.

Being a privately-owned facility was a predictor of attaining a recommended IPC score of 80% at baseline (POR=1.92 CI=1.06–3.48) but not after the intervention. Facility level was not a predictor during baseline assessment; however after intervention hospitals were twice as likely to attain the recommended score compared to dispensaries (POR=2.27 CI=1.15–4.45).

Conclusion

Assessment and rating of quality and organization of health services plus management support to healthcare facilities, leads to improved adherence to IPC principles.