Environmental cleaning is an essential part of infection prevention and control (IPC). Assessing whether an area is considered “clean” is very  subjective,  and  visibly  clean  is  very  different  from microbiologically safe.

In 2013 and 2014, Soapbox collaborated with colleagues in the UK, India  and  Bangladesh  to  develop  and  implement  novel  research methods for capturing evidence on cleanliness and the relationship to water, sanitation and hygiene (WASH) conditions and IPC in health facilities as part of the WASH & CLEAN Study. The aim was to improve understanding  of  the  determinants  of  cleaning  practices  and  so inform  improvements  in  the  state  of  cleanliness  and  safety  in maternity units.

A suite of data collection tools were developed to capture levels of cleanliness  and  the  determinants,  processes  and  outcomes  of cleaning on the maternity unit. The study also sought to understand the knowledge, attitudes and practices of stakeholders involved in maintaining cleanliness and their interrelationships. In addition, the satisfaction of women and healthcare providers was also explored. The tools combine to allow medical facilities to perform a robust ‘situational analysis’ of the state of WASH and IPC on their maternity units.

WASH & CLEAN toolkit

The WASH & CLEAN Toolkit was then piloted in two maternity units in Gujarat, India and two in Dhaka, Bangladesh. The suite of tools was then applied to a further seven maternity units in Gurujat and eight maternity units in Dhaka. To  ensure a   representative   sample,   maternity   units were  purposively  selected  to  include  public  and  private facilities,  high  and  low  caseloads  and  facilities  offering   either   Comprehensive   Emergency   Obstetric   Care (CEmOC) or Basic Emergency Obstetric Care (BEmOC).

The study found no clear relationship between visually assessed cleanliness and the presence of pathogens, indicating that visual assessment alone is an inadequate marker for ‘safety’ in terms of the presence of potential pathogens and the associated risk of infection. Routine environmental screening of high-risk touch sites using simple surface microbiology could  improve  detection  and  control  of pathogens. 

Findings  from  qualitative  interviews  and  the  facility  questionnaire  found  inadequacies  in  IPC  training  for healthcare providers and no formal training at all for ward cleaners.

Lack of written policies and protocols, and poor monitoring and supervision also contributed to suboptimal IPC standards. IPC  training  for  both  healthcare  providers  and  ward  cleaners  represents  an  important  opportunity  for  quality improvement. This should occur in conjunction with broader systems changes, including the establishment of functioning IPC  committees, implementing  standard  policies  and  protocols,  and  improving  health  management  information systems to capture evidence on maternal and newborn healthcare associated infections.

For more information on the WASH & CLEAN study, see Cross et al (2016) Hygiene on maternity units: lessons from a needs assessment in Bangladesh and India.

Download the WASH & CLEAN toolkit

The WASH & CLEAN Toolkit is a free set of tools developed as part of the SHARE Research Consortium and Water Supply and Sanitation Collaborative Council funded study, WASH & CLEAN on the Labour Ward: A situation analysis in India and Bangladesh.

The tools are to be used to perform a situation analysis of the state of hygiene (outcomes) on the maternity unit, as measured by visual cleanliness and the presence of potential pathogens, and individual and contextual/systems level determinants. The tools can be used as part of an internal audit process, as part of a continuous improvement cycle, or as part of a wider research study.

Application of the tools is to be undertaken by health facility Infection Prevention and Control Committees (or equivalent), researchers, or external agencies as commissioned for the purpose.

The data gathered by the tools is for use by health facility senior management, district and regional health management teams, policy makers, and research institute(s). The data can be used to identify priority areas and inform intervention, provide indicators to support performance, and information to inform policy.

Download the WASH & CLEAN toolkit and instruction files

Elements of the WASH & CLEAN toolkit

1 - Facility Needs Assessment Tool

Tool 1 consists of eleven sections gathering information on utilities, training, resource availability, IPC policies and routine practices, to develop a better understanding of the maternity unit and health facility context. The results of tool application are used to provide guidance for improving IPC protocols and practices by identifying WASH & IPC weaknesses and gaps. 

2 - Document Availability Checklist

Tool 2 contains a checklist of key documents relevant to WASH & IPC, for example, policy documents on staff training in IPC, waste disposal and contracting of cleaning services, to help to identify gaps in key documents relevant to WASH & IPC. 

3 - Walkthrough Checklist

Tool 3 involves capturing data through observation, the collection of swab samples and taking of photographs at specific moments and locations, during a walkthrough of the maternity unit. The checklist assesses hygiene, general cleanliness, the state of repair of infrastructure and equipment, and aspects of WASH and IPC, and composite scores as summary measures are created regarding the state of visual cleanliness and the determinants of hygiene. 

4-7 - Semi-Structured Interviews

Tools 4–7 contain a series of semi-structured interview questions for health facility managers, healthcare providers, cleaning staff and recently delivered women and use photo-prompts to generate discussion. 

A series of questions are asked of facility staff to explore their views and perceptions regarding the determinants of hygiene and the state of hygiene on the maternity unit at an individual and systems level. A series of questions for recently delivered women explore their understanding of IPC and their impression of the state of hygiene on the maternity unit in which they delivered.