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.

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.

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.

A qualitative exploration of the sexual and reproductive health knowledge of adolescent mothers from indigenous populations in Ratanak Kiri Province, Cambodia.

INTRODUCTION: Adolescents from indigenous populations in Ratanak Kiri Province in Cambodia experience worse sexual and reproductive health (SRH) outcomes when compared to their urban counterparts. However, few qualitative studies have been conducted to identify factors that may explain the poor SRH outcomes experienced by this population group. METHODS: The socioecological model was used as the analytical lens to explore the SRH knowledge and sources of SRH information of adolescent mothers (aged 15-19 years) from indigenous populations in north-eastern Cambodia. Adolescent mothers from the Tompoun and Jarai indigenous population groups (n=22) were purposively recruited from seven villages in two districts of Ratanak Kiri Province. All adolescent mothers engaged in a combined body mapping exercise and semi-structured interview; this approach was considered the most appropriate qualitative data collection method to use in this context as it reduced language, cultural and social barriers that have previously restricted qualitative exploration of sensitive issues among this population group. The body maps and semi-structured interview transcripts were analysed using thematic analysis. RESULTS: Adolescent mothers demonstrated limited SRH knowledge including that pertaining to the anatomy of the female reproductive body, the physiology of human reproduction, fertility and pregnancy. Adolescents' primary source of SRH information was interaction with female family members and friends within their community. Adolescents' limited SRH knowledge was influenced by factors on individual (eg educational attainment, child marriage), relationship (eg social interaction with female family members and friends), community (eg access to educational and healthcare services) and societal (eg barriers to accessing national SRH programs and initiatives) levels. CONCLUSION: The%u202Ffindings support the need for SRH education in the primary and secondary school curriculum. In 2018 the Cambodia Ministry of Education, Youth and Sports introduced a Comprehensive Sexuality Education (CSE) program into the government primary and secondary school curriculum. The CSE, which is delivered in the Khmer language, provides Cambodian youth with an avenue to access accurate SRH information that will aid their SRH decision-making. However, indigenous girls face numerous social, cultural, economic and language barriers that restrict or prevent their access to formal education. Therefore, additional SRH materials and resources that are culturally and linguistically appropriate need to be developed for indigenous students attending primary and secondary schools in Ratanak Kiri Province and for young people who have ceased formal education. Educating village chiefs to deliver non-formal, community-based education programs is proposed as a means of increasing SRH knowledge and reducing health inequalities faced by this population group while ensuring that accurate information is delivered in a culturally appropriate manner.