ARTICLE IN PRESS

American Journal of Infection Control 000 (2018) 1−8

Contents lists available at ScienceDirect

American Journal of Infection Control

journal homepage: www.ajicjournal.org

Major Article

Hand washing glove use, and avoiding recontamination before aseptic

procedures at birth: A multicenter time-and-motion study conducted
in Zanzibar
l de Barra D6X XPhD c, D7X XSaid M. Ali D8X XMSc d,
D1X XGiorgia Gon D2X XMSc a,*, D3X XMarijn de Bruin D4X XPhD b, D5X XMíchea
D9X XOona M. Campbell D10X XPhD , D1X XWendy J. Graham D12X XDPhil (Oxon) a, D13X XMohammed Juma D14X XPGD d, D15X XStephen Nash D16X XMSc a,
a

D17X XClaire Kilpatrick D18X XMSc e, D19X XLoveday Penn-Kekana D20X XMA a, D21X XSandra Virgo D2X XPhD a, D23X XSusannah Woodd D24X XMSc a
a
London School of Hygiene and Tropical Medicine, Faculty of Epidemiology and Population Health, London, United Kingdom
b
University of Aberdeen, Institute of Applied Health Sciences, Aberdeen, United Kingdom
c
Brunel University London, Department of Life Sciences, Uxbridge, United Kingdom
d
Public Health Laboratory-Ivo de Carneri, Chake Chake, Pemba, Zanzibar, Tanzania
e
Consultant, World Health Organization IPC Global Unit, Service Delivery and Safety Department, Geneva, Switzerland

Key Words: Background: Our primary objective was to assess hand hygiene (HH) compliance before aseptic procedures
Maternal health among birth attendants in the 10 highest-volume facilities in Zanzibar. We also examined the extent to
Newborn health which recontamination contributes to poor HH. Recording exact recontamination occurrences is not possible
Behavioral medicine using the existing World Health Organization HH audit tool.
Labor ward
Methods: In this time-and-motion study, 3 trained coders used WOMBATv2 software to record the hand
Tanzania
actions of all birth attendants present in the study sites. The percentage compliance and 95% confidence
Hand hygiene
intervals (CIs) for individual behaviors (hand washing/rubbing, avoiding recontamination and glove use) and
for behavioral sequences during labor and delivery were calculated.
Results: We observed 104 birth attendants and 781 HH opportunities before aseptic procedures. Compliance
with hand rubbing/washing was 24.6% (95% CI, 21.6-27.8). Only 9.6% (95% CI, 7.6-11.9) of birth attendants
also donned gloves and avoided recontamination. Half of the time when rubbing/washing or glove donning
was performed, hands were recontaminated prior to the aseptic procedure.
Conclusions: In this study, HH compliance by birth attendants before aseptic procedures was poor. To our
knowledge, this is the first study in a low- to middle-income country to show the large contribution to poor
HH compliance from hand and glove recontamination before the procedure. Recontamination is an impor-
tant driver of infection risk from poor HH. It should be understood for the purposes of improvement and
therefore included in HH monitoring and interventions.
© 2018 Published by Elsevier Inc. on behalf of Association for Professionals in Infection Control and
Epidemiology, Inc.

Health care−associated infections (HAIs) in low- and middle-income

* Address correspondence to Giorgia Gon, MSc, London School of Hygiene and Tropi- countries (LMICs) affect an estimated 15% of patients, 5 times more
cal Medicine, Faculty of Epidemiology and Population Health, Keppel St, WC1E 7HT, than in Europe.1 For mothers and newborns in LMICs, where infection
London, United Kingdom. is already a leading cause of death,2,3 the risk of HAIs could escalate
E-mail address: giorgia.gon@lshtm.ac.uk (G. Gon).
Funding/support: Funded by the Medical Research Council−PHIND scheme, award
with increasing health care facility newborn deliveries as well as sub-
number MR/N015975/1. The Soapbox Collaborative also contributed by funding staff standard infection prevention standards.4
involved in this project. The writing of this paper provided part of the background Hand hygiene (HH) is deemed the single most important behavior
needed for the CLEAN Study, funded by the United Kingdom Joint Global Health Trials for preventing HAIs.5 Historical evidence suggests the importance of
(Wellcome, MRC, DFID, and DOH), award number MR/R019274/1. SN is supported by
HH in reducing maternal infections in European hospitals, and recent
an award jointly funded by the UK Medical Research Council (MRC) and the UK Depart-
ment for International Development (DFID) under the MRC/DFID Concordat agreement studies support its value for newborns in LMICs.6 The World Health
which is also part of the EDCTP2 programme supported by the European Union. Grant Organization (WHO) recommends Five Moments for Hand Hygiene
Reference MR/K012126/1. (5MHH) during patient care.7 Among these, Moment 2—HH before
Conflicts of interest: None to report.

https://doi.org/10.1016/j.ajic.2018.07.021
0196-6553/© 2018 Published by Elsevier Inc. on behalf of Association for Professionals in Infection Control and Epidemiology, Inc.
 ARTICLE IN PRESS
2 G. Gon et al. / American Journal of Infection Control 00 (2018) 1−8

clean/aseptic tasks when there is potential contact with patient’s Epidemiology guidelines.11 All observers were trained midwives.
mucous membranes or nonintact skin—is considered the most signif- Birth attendants were all staff involved in assisting deliveries, irre-
icant for preventing bacterial transmission to patients, including the spective of cadre, including midwives and orderlies. Details of the
bloodstream, that could result in infection. During birth, this primar- tool, training, and data collection protocols can be requested from the
ily occurs before and during a vaginal examination or delivery and authors.
related procedures. To estimate an HH compliance of 10% with an absolute precision
Before these aseptic procedures, WHO guidelines require attendants of §3%, 768 HH opportunities were required. For the sample size cal-
to hand rub or wash, avoid recontaminating their hands, don gloves, culation, we used the formula for estimating a proportion from a
and avoid recontaminating those gloves before starting the procedure.7 cross-sectional survey, with a = 0.05 and a design effect of 2, based on
The current WHO HH audit tool does not distinguish whether the fail- a survey in Benin of facility quality indicators.12 Using the reported
ure to comply with the 5MHH stems from not hand rubbing/washing number of deliveries in the 10 study facilities overall, we calculated
or from, for example, subsequently touching potentially unclean surfa- the length of observation required to achieve this sample size.
ces,7 thus negating the initial hand washing/rubbing action. Although Data were collected via tablets, precoded using WOMBATv2 soft-
successful multimodal interventions exist to improve HH, they require ware (Centre for Health Systems and Safety Research, Macquarie Uni-
in-depth understanding of the context and achieve only variable long- versity, Sydney, New South Wales).13,14 An observation session began
term success.5,7-9 Determining whether birth attendants comply with when an attendant started assisting a woman in labor. All observed
any of the steps in the prescribed behavioral sequence and, more spe- hand actions were recorded as they occurred, and the time of each
cifically, within the workflow in our context—Zanzibar, a region was automatically logged. A set of mutually exclusive actions was
of Tanzania—is important to inform successful improvement precoded and used specifically in this study. One attendant was
interventions. observed per observation session, but multiple patients or procedures
Therefore, our study aimed to examine the complex workflow in could be included. Multiple observation sessions were usually cap-
relation to hand hygiene and glove use undertaken by birth attend- tured in 1 shift. To minimize the Hawthorne effect, attendants in all
ants in multiple high-volume labor wards in Zanzibar. Our specific facilities but the one where the pilot occurred were told that the
research questions were: observation was about overall quality of care, not specifically HH.15
We trained on and piloted the observation tool over 2 weeks, follow-
1. What is the compliance with hand rubbing/washing (and then ing WHO guidelines.7,16 During the first month of data collection, we
avoiding hand recontamination) and donning gloves (and then also assessed interobserver agreement between pairs of data collectors
avoiding glove recontamination)? (on 49 or 50 behaviors for each pair) and calculated kappa statistics. We
2. Is variability of these behaviors primarily greater between birth provided tailored feedback to the data collectors based on these results.
attendants or within birth attendants across different HH
opportunities? Ethics
3. To what extent does failure to avoid recontamination (as opposed
to not hand rubbing/washing before a procedure) contribute to This project was approved by the Zanzibar Medical Research and
poor HH? Ethics Committee and the London School of Hygiene and Tropical Medi-
4. What behavior sequences do birth attendants undertake most cine Research Ethics Committee. Consent was obtained from women
often before aseptic procedures compared with the behavior (patients) either in writing in the antenatal ward prior to observation
sequence prescribed by WHO guidelines? or verbally in the labor ward, with written consent obtained before dis-
charge. Women were informed that the person being observed was the
birth attendant and that no information would be collected on them.
Consent to observe the birth attendants was granted by the Ministry of
METHODS Health Zanzibar and obtained verbally from the birth attendants when
the data collectors first visited the facility. All observed health care
Context worker information was anonymized.

This study is part of the larger Hand-hygiene of Attendants for DEFINITIONS

Newborn Deliveries and Survival (HANDS) project: a mixed-methods
study investigating drivers of birth attendant HH. HANDS ran HH opportunity
between November 2015 and April 2017 in the 10 highest-volume
labor wards in Zanzibar, with average monthly delivery volumes HH compliance was calculated as the number of times HH was
ranging from 75 to 930 (Appendix A, available from https://doi.org/ performed divided by the number of opportunities when HH ought
10.17037/DATA.00000778). The project was a partnership of the Lon- to occur. The opportunities in this study were procedures at birth
don School of Hygiene and Tropical Medicine, the University of Aber- that ought to be aseptic (Table 1). We termed a “delivery flow” as any
deen, and the Public Health Laboratory of Pemba. Previous work in 8 sequence of these procedures occurring one after the other without a
of these maternity wards found that most had policies and basic break and considered as 1 opportunity for HH. We defined these
infrastructure to perform HH, but only 50% received HH training in opportunities using available guidelines,16-18 unstructured observa-
the previous year.10 tions in 4 of the study wards, and expert consultation. This aimed to
capture realistic workflows within our setting and accurately observe
Study design and data collection HH according to WHO recommendations.
During a delivery flow, a birth attendant was permitted to under-
Within HANDS, we conducted a time-and-motion study wherein 3 take hand actions within the patient zone, defined for this study as
observers recorded the hand actions (eg, procedures and hand the woman’s perineal area and thighs, any clean or sterile equipment
touches on surfaces) of birth attendants 24 hours per day (1 data col- being used, and the newborn as it was caught and wiped (Table 2).
lector per 8-hour shift−morning, evening, and night), for a mode of The patient zone included the patient and some surfaces and items
6 days (range, 5-14 days) per labor ward. Results are reported using that were temporarily and exclusively dedicated to her, limiting the
the Strengthening the Reporting of Observational Studies in risk of transmitting pathogenic organisms.17 We excluded the
 ARTICLE IN PRESS
G. Gon et al. / American Journal of Infection Control 00 (2018) 1−8 3

Table 1 2. Avoid hand recontamination after rubbing/washing until gloves

List of aseptic procedures during a delivery flow are donned (or until the procedure if gloves are not worn).
Wiping the vagina 3. Don at least 1 glove.
Vaginal examination 4. Avoid glove recontamination before starting the delivery flow.
Artificial rupture of membranes
Episiotomy
Catching the baby (delivering the baby) We defined recontamination of hands or gloves as any touch on
Cord cutting and clamping potentially contaminated surfaces within the workflow; this included
Cord traction
touching an unclean delivery surface (eg, a sheet that was in contact
Manual removal of placenta*
Postdelivery vaginal examination with the floor or with the woman’s feces), unclean hand-drying mate-
Suturing of the perineum* rial (eg, reusable material), the woman and newborn outside the
Wiping baby clean defined patient zone, the woman’s bed, trolley, unclean objects used
Urinary catheter insertion or removal during HH (eg, the sink tap or the bin), and other unclean surfaces,
*We allowed manual removal of the placenta or suturing to be considered within the unless classified as outside the workflow (a full list of activities outside
delivery flow when these occurred before or after a vaginal examination, during post- the workflow is shown in Appendix B, available from https://doi.org/
delivery examination, or during vaginal wiping, or when manual removal of the pla-
10.17037/DATA.00000778). These touches were distinguished from a
centa occurred after cord traction.
deliberate new activity outside the workflow that would lead to a new
HH opportunity as per the 5MHH (eg, leaving the room or measuring
blood pressure after completion of the aseptic procedure; see Appendix
B, available from https://doi.org/10.17037/DATA.00000778).
Table 2
Types of hand actions that did not indicate a new opportunity for HH When none of the 4 behaviors was implemented, we described
the suboptimal glove-related behaviors practiced instead.
Touching the patient’s thighs or perineal area and the newborn after birth
Touching her own (the attendant’s) body*
Data cleaning and analyses
Touching a cleany delivery surface−cloth or macintosh
Touching equipment contaminated only with the woman’s own body fluids during
the procedure One author cleaned and checked the data for consistency. When
Touching other sterile or clean material (eg, cotton swabs or drying material multiple actions were recorded simultaneously, we used the actions
already available in the area for patient care)z related to the hygiene behaviors and procedures of interest above other
Performing an injection (oxytocin) or supporting breastfeeding
Carrying the placenta to be disposed (ie, “dragging” the patient zone)
actions (eg, leaving the room), leading to some loss of information.
Removing or adding gloves or rinsing hands with water,x per WHO When contradictory information was reported about the same action
recommendations (eg, if observers recorded both that soap was used and that they did
HH, hand hygiene; WHO, World Health Organization. not see soap being used), we coded the data as inconsistent information.
*
Unconscious touches (eg, touching briefly her own face) are allowed by WHO guide- For software interruptions during data collection, we followed the
lines (7). During the training, we did not differentiate between this type of unconscious WOMBAT guidelines to clean time data.14 We censored opportunities
gesture and a longer behavior (eg, standing with hands on hips for minutes). This rec-
with insufficient information on hand rubbing/washing glove use, and
ommendation assumed overall cleanliness and health of the birth attendant. These
“permitted touches” did not include the birth attendant’s clothes or gown. recontamination because they occurred too close to the start of a time-
y
Usually, a delivery surface was a large rectangular sheet of cloth or plastic (also called and-motion observation session.
a macintosh) brought by the woman from her own household. The surface was pre- We estimated percentage compliance (behavior performed over
sumed to be clean, provided it was not contaminated (eg, with a woman’s feces or after number of opportunities) and 95% confidence intervals (CIs) for the
falling on the floor). When the observer could not see what happened to the sheet, it
entire recommended behavior sequence (Behaviors 1-4), for partial
was presumed to be clean.
z
If these items were collected outside the patient zone, they were also allowed as long completion of the sequence, and for each of the 4 hygiene behaviors
as the birth attendant did not touch any other surface while collecting these items. individually. Behaviors 2 and 4 (avoid hand and glove recontamina-
Any other hand touch was recorded as a separate action and would indicate a new tion) were, respectively, contingent on hand rubbing/washing
opportunity.
x (Behavior 1) and donning gloves (Behavior 3) (see Appendix C for
We allowed for the donning or removal of gloves and rinsing hands with water only
during the delivery flow (after the first procedure) without indicating a new HH oppor- numerators and denominators for each combination, available from
tunity. This is because the WHO Guidelines for Pregnancy and Childbirth suggest that https://doi.org/10.17037/DATA.00000778).
birth attendants should change their gloves before cord cutting and clamping, without We calculated frequency of adequate rubbing/washing technique
needing HH, or that they should wash their gloved hands,18 although this is not a rec- (right palm over left dorsum with interlaced fingers and vice versa (16)
ommendation of the WHO HH guidelines.
and duration ( ≥ 10 seconds, following the Zanzibar infection prevention
guidelines). We also described surfaces touched during hand/glove
delivery bed and trolley from the patient zone because previous work
recontamination. Finally, we described within- and between-individual
in Zanzibar found that these surfaces were often contaminated with
variation for the 4 behaviors using bar charts and intracluster correla-
bacteria.10 A break in the delivery flow, indicating a new HH opportu-
tion coefficients (ICCs), restricted to attendants with ≥ 5 opportunities.
nity, arose if an activity occurred that was not exclusive to the patient
The ICC is a measure of the relatedness of data. It accounts for this
zone (eg, inserting an intravenous line, touching the patient beyond
relatedness by comparing the variance within clusters with the variance
the zone, or leaving the room).
between clusters.19 The ICC was calculated on the log odds scale from
univariate logistic regression models accounting for individual-level
clustering at the birth attendant level. G.G. coded all outcomes, and S.
Hand rubbing/washing, glove use, and recontamination
W. checked the coding. Analyses were performed using STATA v14 soft-
ware (StataCorp LLC, College Station, TX).
Before a delivery flow, a birth attendant should perform 4 behav-
iors sequentially, defined in our study as follows7:
DATA SHARING
1. Rub hands with alcohol-based hand rub or wash hands with soap
and water (soap use was presumed if the observer could not see Anonymized data at the opportunity level are available in Appen-
the action). dix F, from https://doi.org/10.17037/DATA.00000778.
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4 G. Gon et al. / American Journal of Infection Control 00 (2018) 1−8

RESULTS most commonly touched surfaces were the patient outside the
defined patient zone and unclean delivery surfaces.
Dataset
Between-person and within-person variability
We observed a total of 7,893 hand actions (including procedures,
touches, and HH). After cleaning, the final results present the actions The 65 individuals with ≥ 5 HH opportunities contributed to the
of 104 birth attendants across 10 facilities, with 4-18 attendants per individual-level analyses of hand rubbing/washing (Behavior 1) and
facility. These data were collected during 336 observation sessions glove donning (Behavior 3) (Fig 1). However, recontamination could
ranging from 13 minutes to 6 hours, 45 minutes, with a median time only be examined among 11 individuals who rubbed/washed and 44
of 1 hour, 41 minutes. Each attendant was observed 1-9 times (obser- individuals who donned gloves ≥ 5 times.
vation sessions). The kappa statistic calculated for pairs of data collec- Fifteen attendants never rubbed/washed, 1 had 100% compli-
tors was good for 2 of 3 pairs at .93 and .90, but it was below the ance, and the rest ranged between 5% and 85.7% compliance. The
optimal level of .85 for 1 of the pairs, at .73.14 Tailored feedback was ICC indicates that most of the variation was within individuals
provided to data collectors based on these results. (72%; 95% CI, 0.57-0.84) rather than between individuals (28%; 95%
CI, 0.16-0.43). One attendant always avoided hand recontamina-
tion. The rest ranged between 28.6% and 83.3%. Most of the varia-
HH opportunities tion was within individuals rather than between individuals (10%;
95% CI, 0.01%-0.59%).
There were 914 HH opportunities, of which 127 (13.9%) were cen- Two individuals never added new gloves before an aseptic proce-
sored because they occurred too close to the start of the observation dure, and 5 individuals always did. The rest ranged between 10.5%
period. Six HH opportunities were dropped because they had incon- and 88.2%. Almost all of the variation was within individuals (96%;
sistent information on HH. Our final dataset contained 781 HH 95% CI, 0.86-0.99) rather than between individuals (4%; 95% CI, 0.01-
opportunities. 0.14). After glove donning, 2 individuals always avoided recontami-
nation. The rest ranged between 14.3% and 88.2%. Only 8% (95% CI,
0.03-0.22) of the variation was between individuals, and most of the
Compliance levels variation was within individuals (92%; 95% CI, 0.78-0.97). All ICC anal-
yses were also carried out with all 104 individuals and yielded
Birth attendants hand rubbed/washed in 24.6% (95% CI, 21.6-27.8; remarkably similar results.
192/781) of opportunities, and 6.3% (12/192) of these instances were
hand rubbing. Compliance with hand rubbing/washing did not vary Behavior sequences
much by observer or by shift—the CIs overlapped (Appendix D, avail-
able from https://doi.org/10.17037/DATA.00000778). Hand rubbing/ Figure 2 presents the specific behavior sequences of birth
washing was performed with adequate technique 30.7% (59/192) of the attendants. Sequence 1, the WHO recommendation, was followed
time, and 14.6% (160/192) of the time lasted ≥ 10 seconds (Appendix E, in only 9.6% (95% CI, 7.6-11.9) of opportunities. The most common
available from https://doi.org/10.17037/DATA.00000778). Birth attend- practice, Sequence 9, was to perform none of the 4 behaviors
ants avoided hand recontamination after rubbing/washing in 68.8% (35.8%; 95% CI, 32.5-39.3), followed by donning gloves without
(95% CI, 61.7-75.2; 28/192) of opportunities. hand rubbing/washing and avoiding glove recontamination (24.8%;
In 63.0% (95% CI, 59.5-66.4; 492/781) of opportunities, attendants 95% CI, 21.9-28.0) or not avoiding recontamination (14.7%; 95% CI,
added at least 1 glove before the procedure (with or without prior hand 12.3-17.4) (Appendix F, available from https://doi.org/10.17037/
washing/rubbing). Of these, 61.8% (95% CI, 57.3-66.1; 304/492) avoided DATA.00000778).
glove recontamination. Overall, birth attendants risked recontaminat- In most opportunities in Sequence 9 (55.0%; 95% CI, 49.0-61.0;
ing their hands or gloves in 45.3% (95% CI, 40.9-49.8; 227/501) of the 154/280), attendants wore gloves used in a previous delivery flow.
opportunities when rubbing/washing or glove donning occurred. Other patterns are described in Appendix G, available from https://
Consider now the actions that led to failures in avoiding glove or doi.org/10.17037/DATA.00000778.
hand recontamination (Table 3). On average, 1.3 unclean touches
occurred after hand washing/rubbing (standard deviation [SD] = 0.7; DISCUSSION
range, 1-4), and the most commonly touched surfaces were the glove
packs and unclean hand-drying material. On average, 1.5 unclean In this time-and-motion study of 104 birth attendants across the 10
touches occurred after adding gloves (SD = 0.5; range, 1-7), and the highest-volume labor wards in Zanzibar, we observed 781 HH

Table 3
Surfaces touched risking recontamination after hand rubbing/washing or glove use

Type of surface touched After hand rubbing/washing, After adding gloves,

% (n) % (n)
(N* = 78) (N* = 275)

Gloves pack 47.4 (37) 0

Unclean material when drying hands 20.5 (16) 0
Other unclean touches 16.7(13) 16.4 (45)
Patient touched in areas that are not within the defined zone (ie, the pelvis and thighs or the newborn) 9.0(7) 56.0 (154)
Personal bag 5.1(4) 2.2(6)
Unclean delivery surface (cloth or macintosh) 1.3(1) 20.0 (55)
Patient bed 0 5.1(14)
Waste bin 0 0.4(1)
*Overall number of touches performed when birth attendants did not avoid hand or glove recontamination. These touches are spread across 60 opportunities when birth attendants
did not avoid hand recontamination, whereas these touches are spread across 187 opportunities when birth attendants did not avoid glove recontamination.
 ARTICLE IN PRESS
G. Gon et al. / American Journal of Infection Control 00 (2018) 1−8 5

Fig. 1. Distribution of individuals' compliance with hand rubbing/washing, glove use, and recontamination.
NOTE. Only individuals with >5 opportunities were included in each of these graphs.

opportunities before aseptic procedures. Compliance with hand rub- potentially recontaminating their hands and contributing substantially
bing/washing occurred in a quarter of opportunities, but only 9.6% of to poor HH compliance. The variation in behavior was much larger
attendants also donned gloves and avoided hand and glove recontami- within individuals than between individuals, suggesting that these
nation before the procedure, in accordance with WHO guidelines.16 behaviors are not habitual.
Half the time, attendants either rubbed/washed hands or donned Our findings of poor compliance are similar to those of other stud-
gloves that they subsequently touched unclean surfaces with, thus ies from LMICs. Low HH compliance (21%) before aseptic procedures
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6 G. Gon et al. / American Journal of Infection Control 00 (2018) 1−8

Fig. 2. Behavior sequences for 781 hand hygiene opportunities. NOTE. This figure describes the 781 opportunities available in the dataset. For each opportunity, it outlines whether
each of the 4 behaviors was performed. Percentages refer to the number of opportunities in the last column (eg, in the first sequence, 9.6% refers to 75/781). Recont., recontamina-
tion.

was recently reported in a Nigerian hospital.20 In Indian labor wards, despite high levels of self-reported HH compliance, indicating the rel-
compliance before delivery was only 10.6%.21 A study from Iran evance of recontamination in infection transmission. Recontamina-
reported similar levels during the second stage of labor.22 A study of tion may be an indication that there is a lack of understanding of the
a labor ward in Ghana reported that compliance ranged between 21% definition of the WHO 5MHH in its attempt to direct an approach to
and 27% before aseptic procedures.23 In Zimbabwe, a study found HH action at times when recontamination risk within or between
that 62% of midwives never washed their hands before procedures.24 patients has been established. Future versions of the WHO HH audit
HH definitions vary in these studies, making direct comparison with tool could add a recontamination option for the “missed” HH oppor-
our results challenging. However, all studies highlight extremely tunities (when compliance was not met), which would allow for
poor HH behavior. recontamination to be monitored for both implementation and
Although for most opportunities birth attendants did not rub/ research purposes.
wash hands, in two-thirds of opportunities they did wear at least 1 The contribution of avoiding recontamination to overall HH
new glove for the procedure. In the remaining third, birth attendants compliance in our study calls for further research, to investigate
adopted suboptimal glove-use behaviors that are not recommended7 its importance in other contexts, its drivers, and its direct contri-
but may imply an attempt at placing a barrier between the birth bution to HAIs.7 Acknowledging the avoidance of recontamination
attendant’s hands and the patient. The most common was to attend as a distinct behavior and incorporating its measurement into
different patients and procedures using the same gloves, consistent existing tools for observing compliance, such as the WHO HH
with other studies on the misuse of gloves.15,25 audit tool, would help quantify this problem and inform interven-
Although delineation between patient zones to address recontam- tions to tackle it.
ination was studied in Vietnam,26 to our knowledge, ours is the first Our analyses revealed that variation in behavior was much larger
study that sought to quantify the contribution of avoiding recontami- within individuals than between individuals, suggesting that varying
nation to HH compliance. Our findings are supported by studies in factors, such as availability of materials and workload, may be more
the United Kingdom and Australia where health care workers were important drivers than individual psychological determinants and
observed to touch privacy curtains between HH or glove donning and that behavior-change strategies need to be tailored to actual practices
patient care.15,27 In a study based in Ghana, Cronin et al. describe and contexts.30,31 It is important to note that these findings were gen-
qualitatively how birth attendants' gloved hands were observed erated in settings with limited resources; hence, in settings with
touching the patient bed before the delivery.28 Loftus et al29 demon- more stable resources, HH practices may be more habitual. Future
strated microbiological recontamination of hands at the point of care studies could further investigate this.
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G. Gon et al. / American Journal of Infection Control 00 (2018) 1−8 7

We monitored health care workers’ behavior using state-of-the- Appendix E

art time-and-motion methods that have rarely been employed in
low-resource settings.32 This allowed us to investigate compliance Duration and technique of hand rubbing/washing.
with the complete sequence prescribed by the WHO guidelines on
HH as well as each individual behavior and behavior sequence. It also
reduced the risk of observer bias, because HH opportunities were Appendix F
identified retrospectively in a standardized way rather than relying
on observer judgment. Sequence of actions preceding the first aseptic procedure in the
Our study had some potential limitations. A residual Hawthorne delivery flow.
effect may have caused overestimation of compliance, despite blind-
ing attendants to the study purpose in all but 1 facility. The 13% of Appendix G
opportunities with incomplete hand hygiene or glove information
might not be random, as they may have occurred when procedures Patterns of glove behavior under Sequence 9 (from Fig 2).
were rushed and HH more difficult, leading us to overestimate com-
pliance.33 In 5 of 336 observation sessions, we did not have data on
attendance of new patients and assumed that the same woman was References
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HH and overestimating compliance. Burden of endemic health-care−associated infection in developing countries: sys-
In conclusion, in this time-and-motion study of hand hygiene and tematic review and meta-analysis. Lancet 2011;377:228-41.
glove practices in the 10 highest-volume labor wards in Zanzibar, we 2. Kassebaum NJ, Bertozzi-Villa A, Coggeshall MS, Shackelford KA, Steiner C, Heuton
KR, et al. Global, regional, and national levels and causes of maternal mortality
found, as did previous studies, low compliance with WHO HH guide-
during 1990-2013: a systematic analysis for the Global Burden of Disease Study
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