JMIR Publications

ABSTRACT

Background:

Hand hygiene is crucial in health care and schools to avoid disease transmission. Up to this point, little is known about hand hygiene in such facilities in protracted conflict settings.

Objective:

We aim to assess the effectiveness of a multi-component hand hygiene intervention on handwashing behavior, underlying behavioral factors and well-being of health care workers and students.

Methods:

This study is a cluster randomized controlled trial with two parallel arms taking place in four countries for one year. In Burkina Faso and Mali, we worked in 24 primary health care centers per country, whereas in Nigeria and Palestine, we focused on 26 primary schools per country. Facilities were eligible if they were not connected to a functioning water source but were accessible. Additionally, health care centers were eligible if they had a maternity ward and had ≥ 5 employees, and schools if they had ≤ 7000 students visiting the fifth to seventh grade. We used covariate-constrained randomization to assign intervention facilities, which received a multi-component hand hygiene intervention including hardware, behavior change and management, and monitoring support. Control facilities will receive the same or an improved intervention after endline data collection. To evaluate the intervention, we used a self-reported survey, structured handwashing observations and hand-rinse samples at baseline, follow-up and endline. Starting from the intervention implementation, we additionally collected longitudinal data on hygiene-related health conditions and absenteeism. We also collected qualitative data with focus group discussions and interviews. Data was analyzed descriptively or with random effect regression models with the random effect on a cluster level. The primary outcome for health centers is the handwashing rate, defined as the number of times health care workers performed good handwashing practice with soap or alcoholic hand rub at one of the WHO five moments of hand hygiene, divided by the number of moments of hand hygiene present during the patient interaction. For schools, the primary outcome is the number of students who washed their hands before eating.

Results:

The baseline data collection across all countries lasted from February to June 2023. We collected data from 99 and 111 health care workers in Burkina Faso and Mali, respectively. In Nigeria, we collected data from 1300 students and in Palestine from 1,127 students. We expect the start of the endline data collection in April 2024.

Conclusions:

This is one of the first studies investigating hand hygiene in primary health care and schools in protracted conflict settings. With our innovative and strong study design, developed with a data-driven approach in inter- and trans-disciplinary teams, we expect to support the local policy makers and humanitarian organizations in developing sustainable agendas to promote hygiene in health care and schools settings. Clinical Trial: ClinicalTrials.gov NCT05946980 and NCT05964478