Improving hand hygiene to lower the neonatal mortality rate

Although infant mortality is dropping in Cambodia, neonatal mortality is still high due to infections that happen during childbirth and immediately afterwards. LSHTM, in partnership with WaterAid, identified that improving the hand hygiene practices of everyone who makes contact with the newborn during its first critical days of life would decrease the risk of these sorts of infections. As part of the Changing Hygiene Around Maternal Priorities (CHAMP) project, LSHTM and WaterAid engaged 17 Triggers as a collaborative partner to design and test innovative solutions that could motivate healthcare workers, family members, and visitors to follow the correct hygiene protocols.

Based on research conducted by the National Institute of Public Health (NIPH), LSHTM, and WaterAid, 17 Triggers hosted a week-long workshop to ideate and prototype potential solutions. The team spent two weeks in healthcare facilities across Kampong Chhnang testing and iterating on prototypes with mothers, family members, midwives, and hospital management teams.

To kick off the project, the team analysed barriers and motivators to improve hand hygiene.

Nudge Kit in the Labor & Delivery Room

Despite being keen learners and feeling proud of their practice, healthcare workers were unaware of all the key moments during childbirth which require handwashing with soap and a full glove change. In response, we developed a “Behavioral Nudge Kit” for use in the labor and delivery rooms. Through interactive digital training sessions, healthcare workers learned about the key moments for hand hygiene and co-created their Labor & Delivery space with color-coded nudge stickers. 

Testing showed that a token counting game, introduced to healthcare workers, encouraged them to ask each other about handwashing and reflect daily on their own practice. This helped to break through the social hierarchies that had previously made it difficult for colleagues to check that everyone was following the correct hygiene protocols. Augmenting this were video pledges and badges, which supported health worker’s motivation and commitment.

A nurse shows the design research team the current hospital set-up and processes.

A “Clean Hand Zone” in Postnatal Care Units

Postnatal care (PNC) units lacked the handwashing infrastructure to allow moms and their visitors to clean their hands during the first few critical days of the baby’s life, which was corrected with the installation of sinks at the PNC entrance and hand sanitizer stations at each bed.

Hand sanitizer stations like these were one of the many nudges tested.

17 Triggers used color and messaging to turn each postnatal care ward into a “Clean Hand Zone” where moms and visitors were asked to practice hand hygiene every time before touching the baby. The midwife created a hand hygiene moment with mom just after the delivery. This was done by returning the new baby in a “clean hands first” beanie and providing mom with her very own hand sanitizer kit.

The 2021 evaluation of the CHAMP project interventions showed statistically significant improvements in handwashing by midwives in labor and delivery rooms, and by mothers and caregivers in PNC units, giving Cambodian babies a healthier start in life.