Development of a hand hygiene intervention to reduce bacterial infections among newborns & mothers delivered in maternity units in Tanzania

In low-income countries today, an unacceptably high number of babies still fail to survive the first month of life and many women continue to die from preventable causes related to pregnancy and childbirth. Reducing these deaths is a priority within the new sustainable development goals, which were agreed by the UN member states in 2015 and are to be achieved over the next 15 years.
Over 700,000 of the deaths to babies and mothers are linked with bacterial infections acquired at the time of birth or during the 4-6 weeks afterwards. Good hygiene, and in particular hand washing, by both those health workers attending births in maternity units as well as mothers caring for themselves and their babies, can lead to significant reductions in these infections. As the majority of births in many low-income countries now occur in health facilities, this provides an excellent opportunity to educate health workers and mothers on the importance of good hygiene practices.
The link between hygiene at or close to birth and the risks of infection has been known about for over two centuries. Nevertheless, sustaining improvements in hand washing and other hygiene practices remains challenging in both high and low-income settings, and novel new approaches to achieving behaviour change are needed. In our study, we will use group interviews, questionnaires and observations of behaviour to identify the key factors influencing good hand hygiene among health workers on maternity units and recently-delivered mothers in the low-income context of Zanzibar, Tanzania. We will use pictures and story-telling to help participants explain what drives their behaviour, and then work with local stakeholders and creative artists to design a practical intervention to improve hand hygiene. In a subsequent phase, we plan to evaluate the impact of this intervention on both behaviour and levels of infections in babies.

Neonatal and maternal mortality remains unacceptably high in many low-income countries and an acknowledged priority in the post-2015 sustainable development agenda. Bacterial infections acquired at birth and in the postnatal period are estimated to account for over 700,000 such deaths each year, as well as significant short and long-term morbidity. The hygiene practices of care providers and mothers have a major impact on these infections, and have been highlighted for attention in recent international initiatives, such as the Every Newborn Action Plan. With the increasing global trend towards institutional delivery, now estimated at 87 million births annually, identifying feasible and effective interventions which can be implemented through this point of care represents a major opportunity to reduce the burden of preventable bacterial infections in both newborns and mothers.
The current proposal is for an early phase study to inform the design and subsequent evaluation (effectiveness and cost-effectiveness) of a novel complex intervention targeting the hand hygiene of birth attendants in health institutions and mothers during the postnatal period, particularly in relation to cord care for their newborn. The HANDS study (Hand-hygiene of Attendants for Newborn Deliveries and Survival) aims to develop a sound explanatory model of the key determinants of hand hygiene among these actors, to select appropriate behavioural and organisational change techniques for influencing the determinants, to develop pragmatic strategies and materials for the intervention, and to evaluate their feasibility and acceptability. The research will rely on a mixed-methods approach, with novel elements such as scenario techniques and intervention co-creation with key stakeholders. The research will be conducted in Zanzibar, Tanzania, and in contexts which are broadly generalizable to other maternity units in sub-Saharan African countries.