What struck me the most the first time I made observations of hand washing among healthcare professionals, was the sheer number of times they were expected to wash their hands with soap and water or alcohol-based hand rub when attending a patient. Handwashing, hundreds and hundreds of times a day. Whilst entering or leaving any patient room. Before and after conducting any procedure. And even before or after any type of general patient contact – such as touching a patient’s shoulder in sign of support.

Contamination and infection

Beyond washing hands, healthcare professionals have to ensure they are not recontaminating their hands in any way on unclean surfaces such as a trolley or their own gown before contact with a patient. It is left without saying that this is a demanding and time-consuming activity. It then might not be surprising that compliance to hand hygiene in healthcare facilities in high-income countries is rarely above 80%, and is usually on average 40%, and behaviour change worldwide has proven to be non trivial. Interventions need to be targeting different determinants and need to be context specific.

Compliance to hand hygiene in healthcare facilities in high-income countries is rarely above 80%, and is usually on average 40 per cent

Poor hand hygiene drives healthcare-associated infections and, consequently, antimicrobial resistance. Hands can transmit bacteria, as well as resistant bacteria, directly to the patient, or by contaminating surfaces around them such as beds or instruments. This is especially concerning when these items are used for invasive procedures, such as surgery. Formative research we have conducted in low-resource settings also suggests that antibiotic misuse is common, posing a substantial threat to resistance in the hospital-patient context.

The problem in low-resource labour settings

I conduct research to improve hand hygiene of healthcare professionals in the labour rooms, where mothers give birth, in low-resource settings where compliance to hand hygiene can be as low as 5-10 per cent.

Currently two-thirds of the 140 million births a year worldwide occur in healthcare facilities. However, facilities in low-resource settings are often poorly staffed, poorly equipped, and have little access to constant water supplies, which decreases the amount of hygiene and increase the spread of infections.

A recent analysis we conducted on nationally representative data in Eastern Africa suggested that less than one-third of facilities providing maternal services had reliable access to water in the labour room

With more and more women attending facilities for deliveries, it is common to see, especially in larger facilities, very crowded labour wards with insufficient delivery beds at hand and occasionally women have to deliver their babies on the floor. The lack of appropriate infrastructure does not make hand hygiene very easy.

Another aspect that makes hand hygiene at the time of delivery difficult is the very nature of delivery. For one, delivery is stochastic. Predicting when the delivery will exactly happen is challenging, and certainly not a precise science. It is very common to have four hours with no deliveries in a busy facility anywhere in the world, and then one hour where four women deliver almost simultaneously! Many facilities in resource-poor settings would likely only allocate one birth attendant during a shift like this and performing hand hygiene at least six times per delivery with four deliveries in an hour is a real mission.

It is common to see, especially in larger facilities, very crowded labour wards with insufficient delivery beds at hand and occasionally women have to deliver their babies on the floor

Other aspects that make hand hygiene complex during delivery, especially if a birth attendant is attending alone, is that you have to care for two human beings – both the woman and the baby – and juggling both at the same time can pose challenges for infection prevention. Finally, a delivery involves large quantities of blood which easily contaminates the hands of the healthcare provider and the environment.

Hand hygiene at the time of birth is especially important before a caesarian section or any other minor invasive procedure, such as an episiotomy. These are very direct routes for infection because hands are so closely in contact with patient blood. Caesarian sections are currently rising and in many countries consist 50% of deliveries.

A success story?

Hand hygiene efforts can, however, be considered a success story, in the sense that there have been effective interventions deployed to improve it, including in low and middle-income countries. This is not to say that there is a magic bullet for this; indeed the opposite is true. Even small gains require targeting several determinants of hand hygiene as the WHO Multimodal Strategy for Hand Hygiene highlights. It is certainly clear that knowledge and infrastructure for hand hygiene are not sufficient in themselves to improve compliance rates.

Healthcare workers need to really believe hand hygiene will make a difference to the health of their patients. Surveillance of healthcare-associated infections is used for this purpose as healthcare workers need to be aware of their own compliance rates in order to improve them. Monitoring hand hygiene and feeding this back to professionals has proven invaluable and perhaps these also work to influence institutional norms and peer sanctioning when the data is publicly available at the ward level.

Healthcare workers need to really believe hand hygiene will make a difference to the health of their patients

Hand hygiene should be made as easy as possible – for example, hand rub takes half of the time that water and soap do to use which achieves the same results in most circumstances and can be carried to or kept near the point of care.

The WHO hand hygiene campaign has achieved milestones by engaging healthcare workers worldwide in a fun way, such as dancing routines performed by millions around the worlds and are available on YouTube (here's one).

To quote the campaign “Fight Antibiotic resistance. It’s in your hands”.

The author, Giorgia Gon, is an Epidemiologist with degrees in human sciences and epidemiology. Her current area of focus is on improving infection prevention and control in maternity units in low and middle-income countries within the Soapbox Collaborative umbrella project. She began working for London School of Hygiene and Tropical Medicine in 2013 within the Merck for Mothers project. Prior to this she worked with Merlin in London and Juba, South Sudan, and as a Consultant for the OECD in the UK. She was also a Young Professional Intern at the HIV-AIDS Unit for UNODC in Jakarta, Indonesia.