What is the CLEAN Briefing and why was it developed?

Giorgia Gon (G): The CLEAN Briefing Paper identifies research priorities for healthcare cleaning in resource-limited settings. About 10 years ago during our work for the Soapbox Collaborative (see Panel 1), we discovered that environmental cleaning was a neglected issue. There were no international guidelines for cleaners in low-income settings and most countries didn't have any formal training for cleaning staff. There were no expectations, no accreditation or accountability systems.

With funding from the UK Public Health Rapid Support Team we conducted a systematic review to see what interventions existed to improve environmental cleaning and train cleaners in low-resource settings. Little research was out there, with most of the studies small-scale pilots. It was clear that more and better primary research in this area was needed.

This led us to think about the research priorities that would allow us to improve environmental cleaning in low resource settings through implementation research. The CLEAN Briefing is an output of this research prioritisation process. It outlines evidence gaps and defines a purpose and agenda for future research in this area. It also calls on funders to invest in these research priorities and for policymakers to enable and support such research.

The Soapbox Collaborative was established in 2012 to inform and influence policymakers, funders, researchers and healthcare staff of the importance of hygiene as an integral part of improving quality of care and reduce healthcare associated infections, focusing on maternity units in low-resource settings. In 2016, we developed and piloted a package of training resources called TEACH CLEAN which was designed to fill this training gap. The resources we developed were the first standardized training materials for cleaners in low resource settings. They have recently been adopted by the World Health Organization (WHO) and form the basis of the Trainer’s Guide and Modules and Resources for the document Environmental cleaning and infection prevention and control in health care facilities in low- and middle-income countries.

Who developed the CLEAN Briefing?

G: The CLEAN Briefing is an output of the CLEAN Group – a group of stakeholders from across the world including representatives from the London School of Hygiene & Tropical Medicine (LSHTM), the WHO, the Africa Center for Disease Control, the US Center for Disease Control and Prevention, and experts in infection prevention and control (IPC); water, sanitation and hygiene (WASH); and antimicrobial resistance (AMR). The group have come together to push the field forward and advocate for greater investment and support in filling the research gaps we have identified.

Why is environmental cleaning important for maternal, newborn and child health?

Wendy Graham (W): A lot more women are now delivering their babies in health care facilities which is a very important strategy for reducing maternal and newborn mortality globally. In some countries there has been a doubling of the number of women getting themselves to facilities to deliver and at one level, that's great news. But maternal and newborn wellbeing, survival and morbidity depends on the quality of the care provided, not just the access to services.

Research has indicated that women are really concerned about hygiene and want a respectful environment as well as respectful care from providers. When we started this work in 2012, we were seeing environments that were very disrespectful in terms of hygiene to women, their babies, their families and to health care providers. We conducted participatory photography projects and gathered a lot of image evidence which we went on to use as part of the TEACH CLEAN package.

Through this work, the Maternal and Newborn Health Group at the London School of Hygiene & Tropical Medicine (LSHTM) began making connections to communities that we did not have strong relationships with previously, such as the Water, Sanitation & Hygiene (WASH) sector and those working in Infection Prevention and Control (IPC). In early 2013-14, WaterAid were interested in strengthening healthcare facilities from an infrastructure point of view and we felt that the maternity wing was a great place to start.

G: Our first project was in Zanzibar, Tanzania, with WaterAid and the Ministry of Health. We found that cleaning staff also had lots of other duties, indeed sometimes assisting with the delivery of babies. They had no formal training and were being stretched in many different directions with lots of responsibilities beyond their skills. They were low in the health care hierarchy, being paid differently and had different benefits compared to other staff yet they were an integral part of the health care staff providing patient care.

W: These individuals were providing a service without any protection, without the correct personal protective equipment (PPE), and without accurate knowledge of what they were doing, both to protect themselves and others. If you take vulnerable patients into an unhygienic environment, they are very likely to get a healthcare associated infection and the maternity ward is an area where that risk is very high for both mothers and newborns. Women were going to health facilities in larger numbers but there was a risk attached to this when the facilities were not prepared in terms the required standards of hygiene.

What did you do?

W: We identified a significant lack of appropriate training materials for cleaning staff, so we developed the TEACH CLEAN package which was first made available in 2018. The outbreak of COVID-19 shone a light on environmental hygiene and the physical environment became very important. We agreed for TEACH CLEAN to be used as the basis for a WHO training resource and this was released in April 2023 and now it’s a global public resource that is free to access. We are also developing an online course for trainers of trainers for cleaners with the WHO which should be available in July 2023.

Who is the CLEAN Briefing aimed at?

G: The CLEAN Briefing provides a priorities for implementation research, aimed at funders, policymakers and researchers seeking to ensure environmental cleanliness in health care facilities. It identifies 12 priority research questions that would ensure we have good information to enable countries to implement cost-effective environmental cleaning programmes in health care facilities in resource-limited settings. These are organized into four categories: standards; system strengthening; behaviour change; and innovation.

It also includes overarching key considerations for implementation research in environmental cleaning, such as ensuring accountability; cleaning benchmarks; capacity strengthening; and environmental sustainability.

W:  Environmental hygiene is multifaceted. From an antimicrobial resistance perspective, we must prevent as many health care associated infections as possible so that we can save our antibiotics for when they are really needed. From a humanitarian perspective, in fragile states and conflict situations, when the system breaks down hygiene is often the last thing thought about but it is essential to prevent harm. From a climate perspective, the climate crisis is affecting water supplies and healthcare facilities. If your water supply is interrupted due to fragility or climate change, how are you going to keep your hands and your environment clean?

G: This is an issue everywhere, not just in low-resource settings. The fact that cleaners are undervalued, and we don't have enough cleaners to do the amount of work that is needed, is a global issue.

The CLEAN Briefing identifies research priorities but what can people do now?

W: We are outlining priority research areas but that does not mean that we should not act now. Instead, we are highlighting the opportunity to strengthen the evidence base alongside taking action.

Environmental cleaning is seen as a very basic practice but there is in fact a science behind effective cleaning. That is one of the challenges we've had in raising awareness of this work – people think cleaning is obvious, you clean a hospital just as you clean your home, but that's not true. The WHO Trainer’s Guide and Modules and Resources are free to access and can be used now to implement good environmental cleaning in health care facilities anywhere in the world.

What are your hopes for the CLEAN Briefing? / What are the next steps?

G: We hope the CLEAN Briefing leverages research funding and policy change and this leads to cost-effective implementation.

We have a trial ongoing in Cambodia where we are testing the latest version of the TEACH Clean package. We will be analysing the data produced and identifying what worked, or didn’t, and why.

W: It's important that the maternal, newborn and child health (MNCH), WASH and IPC communities continue to work together on the research priorities we’ve identified in the briefing. We need sustained partnerships to emphasise and communicate the significance of environmental cleaning.

Access the CLEAN Briefing.

The UK Public Health Rapid Support Team is funded by UK Aid from the Department of Health and Social Care and is jointly run by UK Health Security Agency and the London School of Hygiene & Tropical Medicine. The views expressed in this publication are those of the author(s) and not necessarily those of the Department of Health and Social Care.