Healthcare Associated infections (HAIs) persist as a major problem in healthcare systems worldwide, and the associated morbidity and mortality is often higher in developing countries. There is dearth of reliable data on HCAIs in developing countries, and many cases go unrecorded. Strategies to combat HCAIs are largely focused on increased prevention of transmission through promotion of infection prevention and control(IPC) practices. IPC promotion requires an approach that considers personal factors affecting attitudes, as well as institutional culture and leadership.
Aim: To assess practices, perceptions and conditions that influence the occurrence of HCAIs, and the uptake of infection control interventions by health care workers, patients and their caregivers in selected health facilities in Ghana using ethnographic research approaches.
Methods: Ethnographic methods will be employed to explore perceptions of ’dirt’ and ’cleanliness’; perspectives and practices of health workers, patients and caregivers on hygiene-related issues.
This study is part of a larger project on Healthcare-associated infections in Ghana and will cover a 19-month period comprising 3 phases: a baseline phase to study existing behavior patterns, practices and perceptions; an interventional phase where a multimodal IPC intervention will be implemented; a post interventional phase to study conditions that influence the normalization of the interventions. The study will be carried out at the Neonatal, Surgical and Maternity units of the Korle-Bu Teaching Hospital and the Eastern Regional Hospital, Koforidua.
Expected Outcome: This ethnographic study will explore the perceptions of healthcare workers, patients and caregivers on hygiene management in relation to HCAIs and observe compliance and techniques of IPC practices among healthcare workers before and after the implementation of a multimodal intervention program. Findings will guide the successful implementation and integration of future research interventions, and contribute to existing policies on infection control.
The practice of poor hand hygiene is a preventable cause of death and illness in hospitals across the world. Infection prevention and control practices, including hand hygiene, have been shown to be poor among healthcare workers in Ghana. Limited access to hand hygiene facilities is a source of frustration, and is one of the primary recognized causes of low compliance with IPC measures. Correct implementation of hand hygiene practices, contact precautions and wearing of appropriate protective gowns are important in the reduction of HCAIs.
Understanding why healthcare workers, patients and their relatives behave the way they do and how behaviours can be improved demands methods that go beyond questionnaires and surveys. Ethnography can provide a deeper insight into healthcare systems and allow comparison between what people say and what they do. It can help to identify how a hospital’s formal structure is influenced by an informal system created by individuals or groups within the hospital.
An ethnographic approach will bring insight that will help to better integrate interventions into health systems. It will also guide policy makers to develop IPC guidelines and interventions based on local evidence and will help in the design and implementation of future IPC interventions.
This study seeks to identify the socio-cultural factors informing the IPC preferences and practices in hospitals and how this has influenced the occurrence of HCAIs in the selected hospitals in Ghana, and will use an ethnographic approach to assess IPC practices, perceptions and conditions that influence HCAIs, and the uptake of infection control interventions by health care providers.
To assess practices, perceptions and conditions that influence the occurrence of HCAIs, and the uptake of infection control interventions of health care workers, patients and their caregivers in selected health facilities in Ghana using ethnographic research approaches.
In furtherance of the major objective, the study will be guided by the following specific issues:
To explore the socio-cultural, institutional and material dimensions of hygiene management in selected health facilities in Ghana
To identify and describe contextual features of the working environment that may influence the uptake of a multifaceted intervention in the Neonatal Intensive Care Unit of the Korle-Bu Teaching Hospital
To identify, discuss and contextualize factors that promote or inhibit the normalisation of IPC practices in a post-intervention phase in the Neonatal Intensive Care Unit.
To identify challenging areas of IPC compliance and describe contextual features of the working environment that may explain inconsistencies in IPC practices.
To study health workers perceptions and practices of IPC in relation to HCAIs, and to identify how healthcare workers rationalize their own behaviour
To explore patients’ and caregivers’ perceptions and practices of IPC and hygiene management at the health facility and household level and its implication for HCAIs
To explore the practices and perceptions of cleaning staff in relation to hygiene and health care associated infections at the Korle-Bu Teaching hospital and the Eastern Regional hospital
UPDATES January 2018
Roles and perceptions on HAI Ghanaian Hospitals
Report from field work in the Eastern Regional Hospital and Korle-Bu Teaching Hospital
In the last quarter of 2017, the HAI-Ghana Ethnography team conducted field work in Korle-Bu and Koforidua. Koforidua is the capital of the Eastern region of Ghana, with the Eastern regional hospital (ERH) as the main referral point. Korle-Bu Teaching Hospital (KBTH) in one of the major tertiary referral centres in Ghana, located in the Greater Accra region. The team included the Principal Investigator, Gifty Sunkwa-Mills, a Public Health physician and PhD Student, and Mette Breinholdt, a Masters student of Anthropology from Denmark, whose main area of study involves the orderlies.
As part of our study, the team conducted participant observation, in-depth interviews and quantitative surveys in both hospitals. Working with doctors, nurses, cleaners and patients in the same space helped us to appreciate that infection control is indeed everybody’s business.
In Koforidua, we recruited a 3-member team from the hospital and took them through some training in the administration of survey instruments. The team involved the research coordinator, a pharmacist, and a national service personnel.
Each morning for the first two weeks of October, the team joined the hospital staff to carry out routine ward work, whilst taking keen interest in activities related to HAI. Subsequently, we paid intermittent visits to the field, to spend time doing participant observation, and to supervise data collection and other activities related to the project.
All staff groups were considered equally important for the study. The overlapping roles played by various cadres of staff places even more emphasis on this. Have you ever thought about the role a nurse plays in the hospital? Most people think that the role of a nurse is limited to taking care of patients, taking blood pressure, temperature and dressing wounds. It would interest you to know that nurses do far more than that, and their work involves a holistic approach to patient care which includes carrying out health education, health promotion and counselling sessions when required. It even includes cleaning! Yes, they spend a good amount of time cleaning babies’ incubators, patients’ bedside drawers, etc. Student nurses posted to the wards for attachment also take up some of these roles - cleaning up patient areas after discharge, tidying sinks and laying beds.
Though the laying of patient beds may sound like a straightforward task, it comes with lots of negotiation amidst the resource constraints in some hospital wards- which bedsheet is really ‘dirty’ enough, or has visible stains?; how long has it been since the sheets were changed, and how many clean sheets are really available to give out? These are some practical challenges associated with ensuring that each patient has a clean sheet every day.
Sometimes, just like some of the other staff, orderlies find themselves performing multiple roles too - wheeling patients in and out of theatre, fetching food from the kitchen, and running other errands.
It is interesting how much patients know, or do not know about HAI. Some have never heard the term; others have only heard it in passing. Much as many are aware that one could get an infection from within the hospital environment, most have not given much thought to how it could be prevented; however, they are curious to know. We interacted with some patients, to gain insight into their own perspectives of dirt and cleanliness in the hospitals. Beyond cleanliness, patients have many other concerns, which we shall explore further, in relation to healthcare associated infections.
Sometimes, we observed staff performing procedures, on some occasions with gloves on one hand and not the other- another area of negotiation- maybe, depending on how risky the task at hand is perceived to be. The term ‘hospital economy’ came up a few times when we tried to find explanations to why things were being done in a particular way. ‘Shortage of gloves’ was an equally common term used on the ward. The hospitals seem to have a system where logistics and disposables are distributed in defined quotas to various units.
The team will continue to study the management and organisational structure of the hospitals to get a better understanding of how the system works, and put all the bits and pieces of information and observations into perspective. Undoubtedly, there is an interesting ethnographic journey ahead.
UPDATES February 2018
The HAI-Ghana Ethnography team is currently conducting a baseline ethnographic research in two hospitals: Korle-Bu Teaching Hospital (KBTH), one of the major referral centres in Ghana, and Koforidua, the capital of the Eastern region of Ghana, with the Eastern regional hospital (ERH) as the main referral point. The team includes the Principal Investigator, Gifty Sunkwa-Mills, a Public Health physician and PhD Student, and Mette Breinholdt, a Masters student of Anthropology from Denmark, whose main area of study involves the orderlies. Participant observation, in-depth interviews and quantitative surveys in both hospitals are the main methods used by the team.
We observe staff performing procedures, and interact with them to gain a better understanding as to why things are being done in a particular way. We also interact with patients, to gain insight into their own perspectives of dirt and cleanliness in the hospitals. Beyond cleanliness, patients have many other concerns, which we shall explore further, in relation to healthcare associated infections.
The team will continue to study the management and organisational structure of the hospitals to understand and appreciate how the system works, and put the other ethnographic findings into perspective, while preparing toward the next phase of the research, the intervention phase.