Perspectives of Mothers and Healthcare Workers on the Implementation of Routine Chlorhexidine Gluconate Cleansing for Sepsis Prevention in a Neonatal Unit in Botswana

Perspectives of Mothers and Healthcare Workers on the Implementation of Routine Chlorhexidine Gluconate Cleansing for Sepsis Prevention in a Neonatal Unit in Botswana | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Perspectives of Mothers and Healthcare Workers on the Implementation of Routine Chlorhexidine Gluconate Cleansing for Sepsis Prevention in a Neonatal Unit in Botswana Jonathan Strysko, Carolyn McGann, Phemelo Minja, Chimwemwe Viola Tembo, and 3 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8123714/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 7 You are reading this latest preprint version Abstract Background Neonatal sepsis remains a major cause of mortality globally, especially in low- and middle-income countries (LMICs), where overcrowding, understaffing, and limited infection prevention and control (IPC) capacity heighten the risk of healthcare-associated infections (HAIs). Routine whole-body chlorhexidine gluconate (CHG) cleansing is an increasingly used, low-cost strategy to reduce skin colonization and prevent sepsis in LMIC neonatal units. While safety and feasibility data for this practice are accumulating, little is known about how caregivers and healthcare workers (HCWs) understand and implement this practice. Methods We conducted a qualitative study in a 33-bed neonatal ward at a tertiary hospital in Botswana (March 2024–March 2025), where twice-weekly CHG cleansing for eligible infants (>24 hours old and >1 kg) had been implemented one year earlier. Semi-structured interviews were completed with mothers and HCWs to explore perceptions of HAIs, routine cleansing, and CHG use. Interviews were conducted in English or Setswana, transcribed, translated when necessary, and analyzed using a team-based rapid qualitative approach to identify themes across respondent groups. Results Twenty interviews were completed (10 mothers, 10 HCWs). Both mothers and HCWs described HAIs as frequent and severe. Mothers explained they had been taught how to prevent infection by HCWs and attributed transmission to not following IPC practices. HCWs highlighted persistent structural barriers to IPC—including staffing shortages, overcrowding, and shared equipment. CHG cleansing was widely perceived as beneficial; HCWs viewed CHG cleansing as addressing a prior “practice gap,” but expressed concern that CHG cleansing was withheld from those most vulnerable to HAIs (i.e. <1kg preterm neonates) due to exclusion criteria. Task-shifting of cleansing to mothers was acceptable given staff shortages, Mothers reported enhanced confidence, infant comfort, and meaningful participation in IPC through CHG cleansing. Some mothers expressed concerns about long-term safety, and desired clearer communication about the intervention from staff. Conclusions HCWs perceived CHG cleansing as valuable within a resource-constrained neonatal unit and mothers viewed cleansing as a meaningful caregiving role, supporting family-centered IPC. Strengthening caregiver education, supply reliability, and guidance for fragile infants will be essential to optimize implementation. Further research should evaluate fidelity and clinical impact of caregiver-performed CHG cleansing. Neonatal sepsis chlorhexidine cleansing infection prevention qualitative methods Background Neonatal sepsis is the third most common cause of neonatal deaths globally, and this burden is disproportionately high in low- and middle-income countries (LMICs). 1 , 2 For resource-limited neonatal intensive care units (NICUs) in LMICs, structural challenges—including overcrowded facilities, understaffing, and inadequate infection prevention and control (IPC) infrastructure—contribute to both a higher incidence of sepsis and greater sepsis-associated mortality. 3 Therefore, low-cost, feasible interventions that can reduce the risk of healthcare-associated infections (HAI) are urgently needed to improve neonatal outcomes. Pathogen colonization of skin often precedes bloodstream infection in hospitalized neonates and thus skin decolonization with an antiseptic has been used as a strategy to help interrupt transmission and translocation of neonatal pathogens. Chlorhexidine gluconate (CHG) is a widely used broad-spectrum antiseptic with a long history of use in NICUs, primarily for pre-procedural skin disinfection. 4 More recently, many units in LMICs have adopted routine whole-body CHG cleansing with reports from sub-Saharan Africa (e.g. Zambia, 5 South Africa, 6 ), and south Asia (e.g. Bangladesh 7 , India 8 ) demonstrating reductions in pathogen colonization and mixed success in reducing sepsis and mortality. Importantly, adverse events have not been identified from published reports which have cumulatively studied > 10,000 newborns, 6,7,9 and available data suggest that dilute aqueous CHG is generally well-tolerated in hospitalized infants > 1 kg despite concerns about dermal absorption and irritation. 7 The effectiveness of CHG skin cleansing depends not only on its biological efficacy, but also on effective implementation—a process often challenged by supply constraints and workforce shortages in resource-limited settings. In many LMIC NICUs, routine cleansing responsibilities are task-shifted to family caregivers, especially mothers, who are central to day-to-day infant care. Understanding how healthcare workers and caregivers perceive this intervention—including its purpose, safety, and the practical logistics of implementation—is critical to its success. Although perspectives on CHG use have been studied among adult and pediatric patient populations, 10,11 there is little evidence on how family and neonatal staff view routine CHG use for hospitalized newborns. One study from Zambia demonstrated that CHG cleansing of hospitalized neonates was perceived to be feasible among healthcare workers, but did not explore caregiver acceptability or experience. 12 In this qualitative study, our objective was to identify the perceptions of mothers of neonates admitted to a busy public-sector neonatal unit in Botswana and of healthcare workers responsible for IPC in the same setting. We examine how these stakeholders understand infection risks, the utility and safety of CHG, and the day-to-day logistics of its implementation—including staff and family capacity, task distribution, and material availability. These insights provide a critical lens for designing sustainable, caregiver-inclusive IPC interventions for neonatal sepsis prevention in LMIC settings. Methods Study Design, Setting, and Participants We conducted a qualitative study involving semi-structured interviews with family caregivers and healthcare workers in a 33-bed neonatal ward within a 530-bed public tertiary referral hospital in Botswana between March 2024 and March 2025. This facility manages approximately 6,000–8,000 births each year and serves as a national referral center. The neonatal unit admits infants with conditions commonly linked to neonatal mortality worldwide, including prematurity and its complications, perinatal hypoxic injury, and sepsis. Infants typically remain hospitalized for an average of three weeks. Nurse-to-patient ratios are low, often between 1:6 and 1:12, resulting in reliance on family members to support basic caregiving tasks such as feeding, cleaning, changing, and at times assisting with medication administration. The hospital maintains a structured IPC program with two dedicated full-time IPC nurses. While hand hygiene resources (soap, running water, and alcohol-based hand rub) were consistently available in the neonatal unit during this study period, shortages of personal protective equipment—including gloves and gowns—are frequent. Fourteen months prior to the start of data collection, the unit introduced twice-weekly CHG skin cleansing for infants more than 24 hours old, weighing more than 1 kg, and without hypothermia or skin breakdown, in response to a rising number of cases of infections due to multidrug-resistant organisms. 13 The study was conducted by an international interdisciplinary investigator group with expertise in neonatology, infectious diseases, IPC in the LMIC context, healthcare epidemiology, sociology, implementation science, and qualitative methodology. Interviews were conducted in the context of a United States Centers for Disease Control and Prevention (CDC) funded project to implement a CHG cleansing intervention in the neonatal ward and adult medical intensive care unit at the hospital. The protocol was approved by the Institutional Review Boards at University of Pennsylvania (Protocol # 855362) and by the Botswana Ministry of Health, (HPRD6/14/1), University of Botswana (UB/RES/IRB/BIO/375), and the institution where the study was carried out. Interviews were conducted with family caregivers of babies who were currently receiving care in the neonatal ward and healthcare workers including physicians, matrons and nursing staff. Respondents were recruited in person by a Botswana-based research assistant (PM). During recruitment, we explained to potential participants that this study was designed to better understand the barriers and facilitators to routine cleansing of babies admitted to the neonatal ward. Caregivers were made aware that participation was entirely voluntary and their decision to participate would not influence the care their child received while in the neonatal unit. Data Collection A trained research assistant (PM) conducted all interviews in person under the supervision of an investigator with extensive experience in semi-structured interview methods (JES). Separate interview guides were created for caregivers and healthcare workers (see Supplementary Information). The guides were created based on a review of the literature on the implementation of IPC interventions in neonatal intensive care units in LMIC contexts and our prior work in this setting. 12 , 14 Each guide included the same key domains with wording tailored to the respondent. Domains included perceptions of HAI and IPC generally, patient cleansing as an IPC strategy, and CHG. Interviews were conducted in either English or Setswana, at the request of the respondent. All interviews were audio-recorded with the permission of the respondent and informed consent was obtained prior to beginning. Interviews were conducted until thematic saturation was reached in the key domains of the guide. Saturation was monitored concurrently with data collection via a saturation memo in which the research assistant and an investigator (JES) reviewed transcripts soon after the interview was completed and recorded key recurrent themes by domains. Data Analysis Interviews were transcribed and, if conducted in Setswana, translated by the research assistant. Given that this qualitative study was intended to inform the development and implementation of a CHG cleansing intervention, we utilized a team-based rapid qualitative analysis technique to summarize key findings characterizing each domain, comparing across family caregivers and healthcare workers. 15 , 16 Analysis was completed by three investigators (JS, CM, JES) in a multi-stage process. First, the analysts familiarized themselves with the interview guide and a subset of transcripts from family caregivers and healthcare personnel by reading through them. Second, we created summary templates for each interview respondent. To achieve reliability in this approach we began by each summarizing the same five transcripts and evaluated the summaries for consistency across key domains. Then, we split the remaining transcripts up amongst two of the investigators (JS, CM). Once the summary transcripts were completed we created an analytic matrix to summarize key findings across domains and evaluate variation across respondent types. Results Semi-structured interviews were conducted with 10 family caregivers (all mothers) of infants admitted to the neonatal unit and 10 healthcare workers, including nurses, medical officers, and one head matron (nurse manager). Three domains were explored during interviews across all respondents: (1) perception of HAIs and IPC measures in the neonatal ward, (2) cleansing as an IPC measure and (3) CHG cleansing. We summarize parent and healthcare worker perspectives under each domain. Healthcare Associated Infections Family Caregiver Perspectives All mothers were aware of the risk of infection to hospitalized neonates with few stating that this was general knowledge but most reporting that they learned about this risk from hospital staff. Most mothers felt that infections could be prevented through measures such as adherence to hand hygiene, general hygiene, and use of personal protective equipment (such as shoe and hair covers). These measures were communicated to mothers from hospital staff, and many expressed a belief that it is important for mothers to adhere to them: "Yes germs are there on the babies but I think if one follows the instructions we have been given by the health workers to wash our hands frequently, cleansing your child on Mondays and Thursdays as we have been told, one should do that and adhere to the rules without thinking that no one is monitoring it so they can get away with it, no. As a mother you will be cheating yourself." Only one mother reported that the risk of infection remains despite the preventive measures. Mothers identified the following barriers to IPC: lack of healthcare worker adherence to hand hygiene or other hygiene measures, ward overcrowding, and lack of adherence on the part of other mothers to the training that nurses provided. As one mother said: Though we are being taught, it’s not everyone who listens. It’s not everyone who practices what we are being taught. I don’t know how, maybe it will help to repeat those lessons often. Like we have these bags here, sterilizing bags…I was coming from my room, there is somewhere we keep them and we are not allowed to take them to the rooms. So you come here and you try to get your bag, you find that it is missing. That means that another mother who has a baby in NNU [Neonatal Unit] just came and grabbed the nearest one which goes to show that it’s not all of us who listen when we are taught. Maybe if these lessons were repeated it would help. The majority of our family caregiver respondents acknowledged that HAI were a risk, understood the importance of infection prevention measures, and saw an important role for mothers in preventing infection by following the recommendations carefully. Healthcare Worker Perspectives All clinicians identified nosocomial infections as a major issue in the neonatal unit, and key contributor to mortality. As one physician respondent said: I think it’s a major problem if you look at the fact that most of the cases of fatality are secondary to sepsis which is caused by the infections. It’s a major thing. It’s a very big thing in NNU. Many staff members recounted scenarios that they had encountered such as outbreaks of Klebsiella pneumoniae , relayed statistics or the number of infections in the unit in the last month, or described times that infection prevention measures had been tried to contain an outbreak. In discussing infection prevention in the neonatal ward, all clinicians identified hygiene measures, including hand hygiene, proper attire/personal protective equipment, and equipment cleaning as key strategies. When discussing these strategies, respondents would often talk about barriers to infection prevention in the neonatal ward. As one physician said: So we can do basic things just washing hands upon arrival to our NNU, sanitizing, ensuring that we put on face masks when we are seeing patients. Spacing which is a big issue in our NNU because we don’t have enough space to isolate babies who are at risk of infection from babies who are infected. Also just to make sure that we practice hand hygiene from one patient to another just to make sure you are not touching the patient without doing hand hygiene, spacing which is something that is really big and is beyond our control right now. Another thing is to try and give staff gowns or clothes that they can only use when they are in NNU. Once they leave NNU, they take off those to clothes to avoid coming with clothes from home or outside to avoid bringing infection in the NNU and that is something that can also be considered but the main thing is hand hygiene. When asked about the role that clinicians and parents can play in infection prevention, most mentioned that infection prevention and control is a shared responsibility among all people who enter the neonatal ward. Nurses recognized the importance of educating family caregivers. As one matron respondent explained: We teach them how to prevent infections. Each mother is given sterilizing equipment. We also take them to the breastfeeding café where they are taught on the importance of taking care of the baby, infection control measures, those who have been isolated the mothers are being taught and told why the babies are being isolated and also teaching them that they are not supposed to be sharing equipment even including the pen because some of them come without a pen and they end up sharing. Clinicians identified areas where things were going well including availability of hand sanitizer, and a sense that there is a shared perception amongst clinicians and family caregivers that it is an important priority to try to prevent infection. As one medical officer respondent said: For the doctors and nurses who take care of the baby, maybe every time before they touch the babies they should sanitize before and after. Also make sure that when they are actually interchanging between the babies they do sanitize, they always sanitize. They should have sanitizer everywhere which is something that they are doing. I can praise them for that. Barriers to infection prevention were noted to interact and compound one another for example all clinicians noted that staff shortage and overcrowding were key contributors to the burden of infection. Several pointed out that overcrowding and staff shortages also contribute to the need for shared equipment and contribute to staff forgetting to use hand sanitizer between patients who are close together or when there are so many patient care tasks to be done for each provider. All healthcare workers had ideas for how to prevent infections however many relayed a sense of futility given the perceived barriers to infection prevention that are out of their control including staffing shortages, ward overcrowding and shared equipment. As one nurse respondent explained: I would say it’s impossible honestly. Right now we are working there as nurses and we know the infection control issues. We understand them and how we can avoid them but it’s just a matter of availing those prevention matters and availing all the necessary things that are needed for and trying to uptake it example, monitors; we wish each child could have their own monitor or at least sharing between very few where you know you can control say between three children as opposed to when more are sharing. Like this nurse, many other healthcare worker respondents relayed that staff have knowledge about infections and infection prevention but are limited in what they can do in the face of structural barriers. Cleansing as an Infection Prevention Intervention Family Caregiver Perspectives Most mothers reported that they felt cleansing of babies while they are receiving care in the neonatal ward is an important part of infection prevention. When asked who should be responsible for cleansing, the majority thought that mothers should take on that role. Mothers explained that if they did their child’s cleansing they could be sure it was done well. As one respondent explained: Honestly it gives me satisfaction, like I have said there is how we were taught. If somebody else is doing it you won’t be sure if they are doing it well. Maybe there is a lot of babies and they have to do all of them so maybe they will not do it thoroughly and skip some parts that are important and need to be cleansed. So I leave satisfied knowing that my baby is okay and he is protected. A few respondents noted that they can tell the difference stating that their child appeared more comfortable, slept for longer after being bathed, or had noticeably improved skin after receiving a bath. As one mother explained: “They [baths] prevent germs. The baby also should bathe in order for their health to improve. What I have observed is that sometimes after cleansing the baby is able to sleep longer which shows that she was, just like an adult won’t feel good if they are not cleansing. Your body just feels heavy and uncomfortable.” Most mothers felt that participating in the cleansing of their child while they were admitted to the hospital gave them a sense of satisfaction and participation in the team. As one mother explained: As for me I’m taking part, I am taking part because I am in the team that is ensuring that my baby is doing well. I try to prevent germs from causing infections to my child. I really take part. Only one mother thought that cleansing should be the job of clinicians. However, she also acknowledged that because nurses are often very busy and short-staffed, that it was acceptable for family caregivers to help with cleansing. Clinician Perspectives Most clinicians felt that cleansing was an important and effective part of infection prevention. It was also seen as a feasible and currently adoptable practice. As one nurse said about cleansing – I like it because I think it’s the only available option that is working for us. Some respondents believed that it made procedures safer by reducing bacterial colonization. As a medical officer explained: I think it would be quite effective or it is effective because I’m thinking about mostly in terms of either cases of venipuncture or when you doing lumbar puncture, inserting urinary catheters because the major risk of infection with these procedures is you introducing bacteria that you would find on the baby’s skin into the blood stream or into the urethra. So then I feel like if you ensure that the skin is actually disinfected and there is a low chance of you actually, there is a lower chance of you essentially transmitting or moving that bacteria. Some felt that there had been fewer resuscitations or sepsis cases since the introduction of cleansing, while others were unsure of the impact of the practice on outcomes. As one medical officer said: “Yeah, eish! It’s hard to tell because despite us or the mothers using that [CHG] we still are having higher numbers of sepsis in the ward. So it’s hard to tell." Across clinician respondents there was an appreciation for the benefits of cleansing and a sense that the new cleansing protocol was an improvement in care delivery that filled a gap in practice. When asked about who was best to perform this task, most clinicians thought that it should be healthcare workers, but noted that staff shortages often made this impossible. As one medical officer explained: “So I mean ideally it would be best if it was health care workers [who performed the cleansing] because then it would be easier to just teach that set group and then they would ensure that every time it’s done to a certain standard. So since there are limitations it’s easier to just teach the mom." Given the current staffing shortages, most clinician respondents felt that it was safe for this task to be shifted to family caregivers as long as there was enough education. Barriers identified to cleansing included product shortages, lack of clear instruction, and being unable to perform cleansing for patients < 1kg as stated in the current protocol. As one physician explained: The other ones are the [babies] less than one kilogram, I was told they are not cleansed and I didn’t get a reason why but I think those are really the ones that need to be cleansed except if, because the small ones sometimes their skin is very fragile so it can easily break and they can have a bit of sores on the skin. I think those are the only ones that cannot be cleansed but the rest of them if the skin is intact; even if they are less than one kg to me I feel like we can still do the cleansing. Clinicians expressed disappointment in being unable to perform this for the most fragile or small patients because those are the same patients at the highest risk for sepsis. Chlorhexidine gluconate Family Caregiver Perspectives When asked about CHG specifically, the mothers in our sample generally expressed positive opinions of cleansing with CHG and confidence in the practice. As one mother explained: "I think it will do its job and will kill the germs from the baby's skin; I think it’s good. It is also good for the baby’s skin. I have not heard any reports about the baby’s skin reacting to the CHG after we used it." When asked about any barriers to cleansing, our respondents did not identify any barriers and explained that the prepared wipes made it easy. Most parents felt that CHG cleansing was a good thing and that the wipes were better than regular baby wipes. A few parents expressed concerns about the safety of CHG as a chemical. As one mother explained: “It’s a good thing but then I worry because I have never fully been explained to, I was told that the chemical in it kills germs, yes but what are the consequences? How does it affect the child? What if the child is unable to comprehend the chemical and it affects him somewhere somehow? Who is going to be accountable for that?” They voiced concerns about long term outcomes, absorption of the chemical and the feeling that they did not have a forum to voice their concerns. Clinician Perspectives Generally, clinicians expressed positive opinions about CHG cleansing. A few respondents reported anecdotally that the rate of infections seemed to be decreasing since the introduction of this practice. As one nurse stated: "It should be like antibiotics and should be made as part of a way of preventing infection in NNU because those numbers are less, the spread of infection is less from my own observation compared to the past.” Some respondents felt favorably towards the CHG cleansing intervention because it is something that can be feasibly implemented immediately. As one nurse explained: Structure is something that can’t be changed this year, even next year the structure will still be this one. It would be a plan for many years. When you talk about staffing, that’s not something that can change in a short time. We talk of equipment, we cannot find it in a short period of time especially that I mentioned if you do equipment and leave structure it’s still useless. Compared to CHG, we can do it in this small space; at least that can continue to prevent infections on the skin. Overall, clinicians felt positively towards CHG, although two clinicians expressed hesitancy about lack of understanding of how the chemical works. However, none shared the same concerns about long term outcomes that mothers expressed. Discussion Despite growing evidence supporting CHG use in LMIC neonatal units, little attention has been given to how caregivers and clinical staff understand, value, or operationalize this intervention. This qualitative study addresses that gap and demonstrates that both mothers and healthcare workers generally view CHG cleansing as a feasible, meaningful, and acceptable practice—even in the context of substantial structural IPC constraints. To date, only one other qualitative exploration of neonatal CHG skin cleansing has been reported, embedded within an evaluation of a CHG-containing infection-prevention bundle in a Zambian neonatal unit. 12 That study—limited to healthcare worker interviews—identified practical implementation concerns, including consent processes, the need to train non-nursing staff, and uncertainty about long-term sustainability. In contrast, our study expands this evidence base by incorporating caregiver perspectives. We document how mothers understand their role in cleansing, describe the active task-shifting of this activity from staff to caregivers, and report the sense of participation, responsibility, and engagement that cleansing provides. Other work examining patient experiences with CHG cleansing has focused on non-neonatal and high-resource settings and thus likely has limited relevance for LMIC neonatal units. In a U.S. study of non-neonatal inpatients, patients frequently reported low perceived susceptibility to HAI and low self-efficacy in preventing HAIs. 11 By contrast, both mothers and healthcare workers in our setting expressed strong motivation to prevent HAIs, emphasizing the vulnerability of hospitalized newborns. Mothers viewed CHG cleansing as a meaningful caregiving task that both protected their infants and strengthened their bond. Consistent with another U.S. study of adult inpatients, our findings reinforce that structured education is critical to support consistent and correct CHG use. 10 However, unlike that work, which conceptualized patient involvement largely as an adherence and documentation challenge, our findings highlight caregiver-delivered cleansing as both a pragmatic adaptation to staffing shortages and a mechanism to advance family-centered IPC. Notably, concerns about chemical exposure or long-term safety were not reported in other U.S.-based studies among adults; in our setting, however, some mothers expressed apprehension about skin absorption and long-term effects, underscoring the need for clear communication about known safety profiles. Healthcare workers in our study also highlighted neonatal-specific implementation complexities—including infant size and clinical instability—that complicate decisions about eligibility and technique. These contextual nuances emphasize that CHG cleansing in neonatal units requires not only appropriate education and caregiver support, but also explicit guidance on how best to adapt the practice for the smallest and most clinically fragile infants. Limitations This study has several limitations. First, it was conducted at a single public-sector neonatal unit in Botswana, which may limit transferability of findings to other settings. However, the unit shares key characteristics with many LMIC neonatal wards—including high patient acuity, caregiver involvement in routine care, staff shortages, and constrained IPC resources—supporting the relevance of these findings to similar contexts. This study did not assess clinical outcomes or directly observe cleansing practices; therefore, we cannot draw conclusions about the fidelity of implementation or the relationship between cleansing perceptions and infection-related outcomes. Additionally, as with all qualitative work, responses were based on participants’ perceptions and may not fully reflect actual practices. Social desirability bias may have influenced both caregiver and healthcare worker responses, particularly given that CHG cleansing had recently been implemented and was perceived as a clinically endorsed practice. Caregivers were interviewed while their infants were still hospitalized, which may have influenced their willingness to express negative views. To mitigate this, interviews were conducted by a trained research assistant with no clinical role in the neonatal unit, and participants were explicitly reassured that their responses would not affect their infant’s care. Conclusions In this qualitative study from a resource-constrained neonatal unit in Botswana, both mothers and healthcare workers described routine CHG cleansing as an acceptable, feasible, and meaningful component of IPC. Mothers viewed cleansing as an opportunity to participate directly in their infants’ care and as a practical way to protect vulnerable newborns from HAIs. For healthcare workers, CHG cleansing filled a perceived practice gap and offered an immediately implementable intervention in the face of persistent structural challenges, including overcrowding and staffing shortages. While CHG is unlikely to overcome entrenched systemic IPC barriers on its own, it represents a pragmatic and scalable adjunct to broader efforts aimed at improving hygiene, environmental cleaning, and staffing adequacy. Effective scale-up will require reliable product supply; clear operational guidance—particularly for small or clinically unstable infants; and structured education for both caregivers and staff to address knowledge needs and safety concerns. More broadly, this work underscores that the success of IPC interventions in neonatal units depends not only on clinical efficacy, but also on how families and health workers understand and integrate these practices into daily care. Future studies should assess implementation fidelity and clinical outcomes associated with caregiver-performed CHG cleansing and evaluate strategies to optimize family-centered delivery within strengthened IPC systems. Declarations Ethics approval and consent to participate Ethical approval for this study was obtained from the Institutional Review Boards at University of Pennsylvania (Protocol # 855362) and by the Botswana Ministry of Health, (HPRD6/14/1), University of Botswana (UB/RES/IRB/BIO/375), and the institution where the study was carried out. Before each interview, an informed consent document was reviewed with respondents and they had ample time to ask questions and make a decision about participation. Verbal consent was obtained prior to the interview. All interviews were audio-recorded with the permission of the respondent. Consent for publication Not applicable. Availability of data and materials The data generated and analyzed during this study are not publicly available due to the sensitive nature of the data and ethics restrictions on data sharing. Respondents did not consent to have their data publicly shared. A de-identified dataset may be available from the corresponding author on reasonable request. Competing interests The authors declare that they have no competing interests. Funding This work was supported by the CDC Broad Agency Announcement (BAA) Contract# 75D30122F0001 (to E.L.). This work was also supported by a CDC Cooperative Agreement FOA#CK-20-004-Epicenters for the Prevention of Healthcare Associated Infections (to E.L.). Authors' contributions JS participated in the conceptualization and design of the study, secured access to study subjects, participated in data analysis and wrote the initial draft of the manuscript. CM participated in data analysis and wrote the initial draft of the manuscript. PM recruited all interview respondents, conducted all interviews and critically reviewed and revised the manuscript. VT participated in gaining access to the study site, assisted in the recruitment of interview respondents, and critically reviewed and revised the manuscript. EL obtained funding, participated in critically refining the conceptualization and design of the study, and critically reviewed and revised the manuscript. SC participated in critically refining the conceptualization and design of the study, assisted in gaining access to study sites, and critically reviewed and revised the manuscript. JES led the conceptualization and design of the study, obtained funding, led the qualitative data analysis, wrote and substantially revised the initial draft of the manuscript. All authors have read and approved the manuscript. References Seale AC, Blencowe H, Manu AA, et al. Estimates of possible severe bacterial infection in neonates in sub-Saharan Africa, south Asia, and Latin America for 2012: a systematic review and meta-analysis. Lancet Infect Dis . Aug 2014;14(8):731-741. doi:10.1016/S1473-3099(14)70804-7 Dramowski A, Bolton L, Fitzgerald F, Bekker A, Neo NETAP. Neonatal Sepsis in Low- and Middle-income Countries: Where Are We Now? Pediatr Infect Dis J . Jun 1 2025;44(6):e207-e210. doi:10.1097/INF.0000000000004815 Dramowski A, Bekker A, Anugulruengkitt S, et al. Keeping It Real: Infection Prevention and Control Problems and Solutions in Low- and Middle-income Countries. Pediatr Infect Dis J . Mar 1 2022;41(3S):S36-S39. doi:10.1097/INF.0000000000003319 Kwon JA, Cho MJ. Effectiveness and safety of chlorhexidine gluconate double-cleansing for surgical site infection prevention in neonatal intensive care unit surgical patients. Ann Surg Treat Res . Nov 2024;107(5):291-299. doi:10.4174/astr.2024.107.5.291 Westling T, Cowden C, Mwananyanda L, et al. Impact of chlorhexidine baths on suspected sepsis and bloodstream infections in hospitalized neonates in Zambia. Int J Infect Dis . Jul 2020;96:54-60. doi:10.1016/j.ijid.2020.03.043 Dramowski A, Pillay S, Bekker A, et al. Impact of 1% chlorhexidine gluconate bathing and emollient application on bacterial pathogen colonization dynamics in hospitalized preterm neonates - A pilot clinical trial. EClinicalMedicine . Jul 2021;37:100946. doi:10.1016/j.eclinm.2021.100946 Russell N, Clements MN, Azmery KS, et al. Safety and efficacy of whole-body chlorhexidine gluconate cleansing with or without emollient in hospitalised neonates (NeoCHG): a multicentre, randomised, open-label, factorial pilot trial. EClinicalMedicine . Mar 2024;69:102463. doi:10.1016/j.eclinm.2024.102463 Sharma A, Kulkarni S, Thukral A, et al. Aqueous chlorhexidine 1% versus 2% for neonatal skin antisepsis: a randomised non-inferiority trial. Arch Dis Child Fetal Neonatal Ed . Nov 2021;106(6):643-648. doi:10.1136/archdischild-2020-321174 Johnson J, Suwantarat N, Colantuoni E, et al. The impact of chlorhexidine gluconate bathing on skin bacterial burden of neonates admitted to the Neonatal Intensive Care Unit. J Perinatol . Jan 2019;39(1):63-71. doi:10.1038/s41372-018-0231-7 Vanhoozer G, Lovern Bs I, Masroor N, et al. Chlorhexidine gluconate bathing: Patient perceptions, practices, and barriers at a tertiary care center. Am J Infect Control . Mar 2019;47(3):349-350. doi:10.1016/j.ajic.2018.08.002 Caya T, Knobloch MJ, Musuuza J, Wilhelmson E, Safdar N. Patient perceptions of chlorhexidine bathing: A pilot study using the health belief model. Am J Infect Control . Jan 2019;47(1):18-22. doi:10.1016/j.ajic.2018.07.010 Cowden C, Mwananyanda L, Hamer DH, et al. Healthcare worker perceptions of the implementation context surrounding an infection prevention intervention in a Zambian neonatal intensive care unit. BMC Pediatr . Sep 10 2020;20(1):432. doi:10.1186/s12887-020-02323-2 Strysko J, Machiya T, Lechiile K, et al. Carbapenem-resistant Acinetobacter baumannii at a tertiary-care hospital in Botswana: Focus on perinatal environmental exposures. (2022). Antimicrobial Stewardship & Healthcare Epidemiology, 2(S1), S79-S79. doi:10.1017/ash.2022.206. Triantafillou V, Kopsidas I, Kyriakousi A, Zaoutis TE, Szymczak JE. Influence of national culture and context on healthcare workers' perceptions of infection prevention in Greek neonatal intensive care units. J Hosp Infect . Apr 2020;104(4):552-559. doi:10.1016/j.jhin.2019.11.020 Kowalski CP, Nevedal AL, Finley EP, et al. Planning for and Assessing Rigor in Rapid Qualitative Analysis (PARRQA): a consensus-based framework for designing, conducting, and reporting. Implement Sci . Oct 11 2024;19(1):71. doi:10.1186/s13012-024-01397-1 Vindrola-Padros C, Johnson GA. Rapid Techniques in Qualitative Research: A Critical Review of the Literature. Qual Health Res . Aug 2020;30(10):1596-1604. doi:10.1177/1049732320921835 Additional Declarations No competing interests reported. Cite Share Download PDF Status: Under Review Version 1 posted Reviewers agreed at journal 30 Mar, 2026 Reviews received at journal 28 Feb, 2026 Reviewers agreed at journal 17 Feb, 2026 Reviewers invited by journal 16 Feb, 2026 Editor assigned by journal 26 Nov, 2025 Submission checks completed at journal 17 Nov, 2025 First submitted to journal 15 Nov, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-8123714","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":594831970,"identity":"91e0e118-ad2f-4955-8d9f-e9c5c0f83088","order_by":0,"name":"Jonathan Strysko","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAAz0lEQVRIie3OsQrCMBCA4SuRdAl0TSmlrxAJdLH0XaTQSaSjoyDopHOdfAUfoVKIS9zrXHDu2E1rdBRON4f8w3HDfXAANtvfVgHxgJnVWaLX9E385a8ERPUtiQ7bm9/rxJXny6ktIAmPFUKEcuOANTmJ9TyTJeQSJ5TSALqaxA0bLNRTlERrSv1+ILI05I4TUJRy1tREcEMqnAiVkwnTOeF6JmUpMrlHH1sp59qrJPM2etwWizTcoY8BjPgwsudGQODn5rAbRvoiNpvNZvvQAxNjPQ2TAr7lAAAAAElFTkSuQmCC","orcid":"","institution":"Botswana University of Pennsylvania Partnership","correspondingAuthor":true,"prefix":"","firstName":"Jonathan","middleName":"","lastName":"Strysko","suffix":""},{"id":594831972,"identity":"10d72bde-8545-458a-b09c-c4511a5cf1f7","order_by":1,"name":"Carolyn McGann","email":"","orcid":"","institution":"The University of Pennsylvania","correspondingAuthor":false,"prefix":"","firstName":"Carolyn","middleName":"","lastName":"McGann","suffix":""},{"id":594831974,"identity":"b5e3351c-598d-4104-9427-69d3e5d94d48","order_by":2,"name":"Phemelo Minja","email":"","orcid":"","institution":"Botswana University of Pennsylvania Partnership","correspondingAuthor":false,"prefix":"","firstName":"Phemelo","middleName":"","lastName":"Minja","suffix":""},{"id":594831976,"identity":"9a3793a5-5ee3-4f81-9ec4-6c9ad842c365","order_by":3,"name":"Chimwemwe Viola Tembo","email":"","orcid":"","institution":"Botswana University of Pennsylvania Partnership","correspondingAuthor":false,"prefix":"","firstName":"Chimwemwe","middleName":"Viola","lastName":"Tembo","suffix":""},{"id":594831977,"identity":"cef1f636-d1c2-4c77-9038-df229f7fea84","order_by":4,"name":"Ebbing Lautenbach","email":"","orcid":"","institution":"University of Pennsylvania","correspondingAuthor":false,"prefix":"","firstName":"Ebbing","middleName":"","lastName":"Lautenbach","suffix":""},{"id":594831979,"identity":"95c320b0-26ba-4b19-b03f-767b896639b2","order_by":5,"name":"Susan Coffin","email":"","orcid":"","institution":"The University of Pennsylvania","correspondingAuthor":false,"prefix":"","firstName":"Susan","middleName":"","lastName":"Coffin","suffix":""},{"id":594831981,"identity":"347a5f8a-5fb8-4394-bc0f-b90ac020b042","order_by":6,"name":"Julia E. Szymczak","email":"","orcid":"","institution":"University of Utah School of Medicine","correspondingAuthor":false,"prefix":"","firstName":"Julia","middleName":"E.","lastName":"Szymczak","suffix":""}],"badges":[],"createdAt":"2025-11-15 18:08:16","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-8123714/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-8123714/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":103506096,"identity":"7c1181b6-7dcf-4f6b-ac5c-b054ba14e1dd","added_by":"auto","created_at":"2026-02-26 13:34:05","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":568397,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8123714/v1/138a4a5d-b5a6-4762-9560-56fbba1ff51f.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Perspectives of Mothers and Healthcare Workers on the Implementation of Routine Chlorhexidine Gluconate Cleansing for Sepsis Prevention in a Neonatal Unit in Botswana","fulltext":[{"header":"Background","content":"\u003cp\u003eNeonatal sepsis is the third most common cause of neonatal deaths globally, and this burden is disproportionately high in low- and middle-income countries (LMICs).\u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e,\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u003c/sup\u003e For resource-limited neonatal intensive care units (NICUs) in LMICs, structural challenges\u0026mdash;including overcrowded facilities, understaffing, and inadequate infection prevention and control (IPC) infrastructure\u0026mdash;contribute to both a higher incidence of sepsis and greater sepsis-associated mortality.\u003csup\u003e\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u003c/sup\u003e Therefore, low-cost, feasible interventions that can reduce the risk of healthcare-associated infections (HAI) are urgently needed to improve neonatal outcomes.\u003c/p\u003e \u003cp\u003ePathogen colonization of skin often precedes bloodstream infection in hospitalized neonates and thus skin decolonization with an antiseptic has been used as a strategy to help interrupt transmission and translocation of neonatal pathogens. Chlorhexidine gluconate (CHG) is a widely used broad-spectrum antiseptic with a long history of use in NICUs, primarily for pre-procedural skin disinfection.\u003csup\u003e\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u003c/sup\u003e More recently, many units in LMICs have adopted routine whole-body CHG cleansing with reports from sub-Saharan Africa (e.g. Zambia,\u003csup\u003e5\u003c/sup\u003e South Africa,\u003csup\u003e6\u003c/sup\u003e), and south Asia (e.g. Bangladesh\u003csup\u003e\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u003c/sup\u003e, India\u003csup\u003e\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u003c/sup\u003e) demonstrating reductions in pathogen colonization and mixed success in reducing sepsis and mortality. Importantly, adverse events have not been identified from published reports which have cumulatively studied\u0026thinsp;\u0026gt;\u0026thinsp;10,000 newborns,\u003csup\u003e6,7,9\u003c/sup\u003eand available data suggest that dilute aqueous CHG is generally well-tolerated in hospitalized infants\u0026thinsp;\u0026gt;\u0026thinsp;1 kg despite concerns about dermal absorption and irritation.\u003csup\u003e\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eThe effectiveness of CHG skin cleansing depends not only on its biological efficacy, but also on effective implementation\u0026mdash;a process often challenged by supply constraints and workforce shortages in resource-limited settings. In many LMIC NICUs, routine cleansing responsibilities are task-shifted to family caregivers, especially mothers, who are central to day-to-day infant care. Understanding how healthcare workers and caregivers perceive this intervention\u0026mdash;including its purpose, safety, and the practical logistics of implementation\u0026mdash;is critical to its success. Although perspectives on CHG use have been studied among adult and pediatric patient populations,\u003csup\u003e10,11\u003c/sup\u003e there is little evidence on how family and neonatal staff view routine CHG use for hospitalized newborns. One study from Zambia demonstrated that CHG cleansing of hospitalized neonates was perceived to be feasible among healthcare workers, but did not explore caregiver acceptability or experience.\u003csup\u003e\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e\u003c/sup\u003eIn this qualitative study, our objective was to identify the perceptions of mothers of neonates admitted to a busy public-sector neonatal unit in Botswana and of healthcare workers responsible for IPC in the same setting. We examine how these stakeholders understand infection risks, the utility and safety of CHG, and the day-to-day logistics of its implementation\u0026mdash;including staff and family capacity, task distribution, and material availability. These insights provide a critical lens for designing sustainable, caregiver-inclusive IPC interventions for neonatal sepsis prevention in LMIC settings.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eStudy Design, Setting, and Participants\u003c/h2\u003e \u003cp\u003eWe conducted a qualitative study involving semi-structured interviews with family caregivers and healthcare workers in a 33-bed neonatal ward within a 530-bed public tertiary referral hospital in Botswana between March 2024 and March 2025. This facility manages approximately 6,000\u0026ndash;8,000 births each year and serves as a national referral center. The neonatal unit admits infants with conditions commonly linked to neonatal mortality worldwide, including prematurity and its complications, perinatal hypoxic injury, and sepsis. Infants typically remain hospitalized for an average of three weeks. Nurse-to-patient ratios are low, often between 1:6 and 1:12, resulting in reliance on family members to support basic caregiving tasks such as feeding, cleaning, changing, and at times assisting with medication administration.\u003c/p\u003e \u003cp\u003eThe hospital maintains a structured IPC program with two dedicated full-time IPC nurses. While hand hygiene resources (soap, running water, and alcohol-based hand rub) were consistently available in the neonatal unit during this study period, shortages of personal protective equipment\u0026mdash;including gloves and gowns\u0026mdash;are frequent. Fourteen months prior to the start of data collection, the unit introduced twice-weekly CHG skin cleansing for infants more than 24 hours old, weighing more than 1 kg, and without hypothermia or skin breakdown, in response to a rising number of cases of infections due to multidrug-resistant organisms.\u003csup\u003e\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eThe study was conducted by an international interdisciplinary investigator group with expertise in neonatology, infectious diseases, IPC in the LMIC context, healthcare epidemiology, sociology, implementation science, and qualitative methodology. Interviews were conducted in the context of a United States Centers for Disease Control and Prevention (CDC) funded project to implement a CHG cleansing intervention in the neonatal ward and adult medical intensive care unit at the hospital. The protocol was approved by the Institutional Review Boards at University of Pennsylvania (Protocol # 855362) and by the Botswana Ministry of Health, (HPRD6/14/1), University of Botswana (UB/RES/IRB/BIO/375), and the institution where the study was carried out.\u003c/p\u003e \u003cp\u003eInterviews were conducted with family caregivers of babies who were currently receiving care in the neonatal ward and healthcare workers including physicians, matrons and nursing staff. Respondents were recruited in person by a Botswana-based research assistant (PM). During recruitment, we explained to potential participants that this study was designed to better understand the barriers and facilitators to routine cleansing of babies admitted to the neonatal ward. Caregivers were made aware that participation was entirely voluntary and their decision to participate would not influence the care their child received while in the neonatal unit.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eData Collection\u003c/h3\u003e\n\u003cp\u003eA trained research assistant (PM) conducted all interviews in person under the supervision of an investigator with extensive experience in semi-structured interview methods (JES). Separate interview guides were created for caregivers and healthcare workers (see Supplementary Information). The guides were created based on a review of the literature on the implementation of IPC interventions in neonatal intensive care units in LMIC contexts and our prior work in this setting.\u003csup\u003e\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e,\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e\u003c/sup\u003e Each guide included the same key domains with wording tailored to the respondent. Domains included perceptions of HAI and IPC generally, patient cleansing as an IPC strategy, and CHG. Interviews were conducted in either English or Setswana, at the request of the respondent. All interviews were audio-recorded with the permission of the respondent and informed consent was obtained prior to beginning. Interviews were conducted until thematic saturation was reached in the key domains of the guide. Saturation was monitored concurrently with data collection via a saturation memo in which the research assistant and an investigator (JES) reviewed transcripts soon after the interview was completed and recorded key recurrent themes by domains.\u003c/p\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003eData Analysis\u003c/h2\u003e \u003cp\u003eInterviews were transcribed and, if conducted in Setswana, translated by the research assistant. Given that this qualitative study was intended to inform the development and implementation of a CHG cleansing intervention, we utilized a team-based rapid qualitative analysis technique to summarize key findings characterizing each domain, comparing across family caregivers and healthcare workers.\u003csup\u003e\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e,\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e\u003c/sup\u003e Analysis was completed by three investigators (JS, CM, JES) in a multi-stage process. First, the analysts familiarized themselves with the interview guide and a subset of transcripts from family caregivers and healthcare personnel by reading through them. Second, we created summary templates for each interview respondent. To achieve reliability in this approach we began by each summarizing the same five transcripts and evaluated the summaries for consistency across key domains. Then, we split the remaining transcripts up amongst two of the investigators (JS, CM). Once the summary transcripts were completed we created an analytic matrix to summarize key findings across domains and evaluate variation across respondent types.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eSemi-structured interviews were conducted with 10 family caregivers (all mothers) of infants admitted to the neonatal unit and 10 healthcare workers, including nurses, medical officers, and one head matron (nurse manager). Three domains were explored during interviews across all respondents: (1) perception of HAIs and IPC measures in the neonatal ward, (2) cleansing as an IPC measure and (3) CHG cleansing. We summarize parent and healthcare worker perspectives under each domain.\u003c/p\u003e\n\u003ch3\u003eHealthcare Associated Infections\u003c/h3\u003e\n\u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eFamily Caregiver Perspectives\u003c/h2\u003e \u003cp\u003eAll mothers were aware of the risk of infection to hospitalized neonates with few stating that this was general knowledge but most reporting that they learned about this risk from hospital staff. Most mothers felt that infections could be prevented through measures such as adherence to hand hygiene, general hygiene, and use of personal protective equipment (such as shoe and hair covers). These measures were communicated to mothers from hospital staff, and many expressed a belief that it is important for mothers to adhere to them:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\"Yes germs are there on the babies but I think if one follows the instructions we have been given by the health workers to wash our hands frequently, cleansing your child on Mondays and Thursdays as we have been told, one should do that and adhere to the rules without thinking that no one is monitoring it so they can get away with it, no. As a mother you will be cheating yourself.\"\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eOnly one mother reported that the risk of infection remains despite the preventive measures. Mothers identified the following barriers to IPC: lack of healthcare worker adherence to hand hygiene or other hygiene measures, ward overcrowding, and lack of adherence on the part of other mothers to the training that nurses provided. As one mother said:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eThough we are being taught, it\u0026rsquo;s not everyone who listens. It\u0026rsquo;s not everyone who practices what we are being taught. I don\u0026rsquo;t know how, maybe it will help to repeat those lessons often. Like we have these bags here, sterilizing bags\u0026hellip;I was coming from my room, there is somewhere we keep them and we are not allowed to take them to the rooms. So you come here and you try to get your bag, you find that it is missing. That means that another mother who has a baby in NNU [Neonatal Unit] just came and grabbed the nearest one which goes to show that it\u0026rsquo;s not all of us who listen when we are taught. Maybe if these lessons were repeated it would help.\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eThe majority of our family caregiver respondents acknowledged that HAI were a risk, understood the importance of infection prevention measures, and saw an important role for mothers in preventing infection by following the recommendations carefully.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eHealthcare Worker Perspectives\u003c/h3\u003e\n\u003cp\u003eAll clinicians identified nosocomial infections as a major issue in the neonatal unit, and key contributor to mortality. As one physician respondent said:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eI think it\u0026rsquo;s a major problem if you look at the fact that most of the cases of fatality are secondary to sepsis which is caused by the infections. It\u0026rsquo;s a major thing. It\u0026rsquo;s a very big thing in NNU.\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eMany staff members recounted scenarios that they had encountered such as outbreaks of \u003cem\u003eKlebsiella pneumoniae\u003c/em\u003e, relayed statistics or the number of infections in the unit in the last month, or described times that infection prevention measures had been tried to contain an outbreak.\u003c/p\u003e \u003cp\u003eIn discussing infection prevention in the neonatal ward, all clinicians identified hygiene measures, including hand hygiene, proper attire/personal protective equipment, and equipment cleaning as key strategies. When discussing these strategies, respondents would often talk about barriers to infection prevention in the neonatal ward. As one physician said:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eSo we can do basic things just washing hands upon arrival to our NNU, sanitizing, ensuring that we put on face masks when we are seeing patients. Spacing which is a big issue in our NNU because we don\u0026rsquo;t have enough space to isolate babies who are at risk of infection from babies who are infected. Also just to make sure that we practice hand hygiene from one patient to another just to make sure you are not touching the patient without doing hand hygiene, spacing which is something that is really big and is beyond our control right now. Another thing is to try and give staff gowns or clothes that they can only use when they are in NNU. Once they leave NNU, they take off those to clothes to avoid coming with clothes from home or outside to avoid bringing infection in the NNU and that is something that can also be considered but the main thing is hand hygiene.\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eWhen asked about the role that clinicians and parents can play in infection prevention, most mentioned that infection prevention and control is a shared responsibility among all people who enter the neonatal ward. Nurses recognized the importance of educating family caregivers. As one matron respondent explained:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eWe teach them how to prevent infections. Each mother is given sterilizing equipment. We also take them to the breastfeeding caf\u0026eacute; where they are taught on the importance of taking care of the baby, infection control measures, those who have been isolated the mothers are being taught and told why the babies are being isolated and also teaching them that they are not supposed to be sharing equipment even including the pen because some of them come without a pen and they end up sharing.\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eClinicians identified areas where things were going well including availability of hand sanitizer, and a sense that there is a shared perception amongst clinicians and family caregivers that it is an important priority to try to prevent infection. As one medical officer respondent said:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eFor the doctors and nurses who take care of the baby, maybe every time before they touch the babies they should sanitize before and after. Also make sure that when they are actually interchanging between the babies they do sanitize, they always sanitize. They should have sanitizer everywhere which is something that they are doing. I can praise them for that.\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eBarriers to infection prevention were noted to interact and compound one another for example all clinicians noted that staff shortage and overcrowding were key contributors to the burden of infection. Several pointed out that overcrowding and staff shortages also contribute to the need for shared equipment and contribute to staff forgetting to use hand sanitizer between patients who are close together or when there are so many patient care tasks to be done for each provider.\u003c/p\u003e \u003cp\u003eAll healthcare workers had ideas for how to prevent infections however many relayed a sense of futility given the perceived barriers to infection prevention that are out of their control including staffing shortages, ward overcrowding and shared equipment. As one nurse respondent explained:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eI would say it\u0026rsquo;s impossible honestly. Right now we are working there as nurses and we know the infection control issues. We understand them and how we can avoid them but it\u0026rsquo;s just a matter of availing those prevention matters and availing all the necessary things that are needed for and trying to uptake it example, monitors; we wish each child could have their own monitor or at least sharing between very few where you know you can control say between three children as opposed to when more are sharing.\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eLike this nurse, many other healthcare worker respondents relayed that staff have knowledge about infections and infection prevention but are limited in what they can do in the face of structural barriers.\u003c/p\u003e\n\u003ch3\u003eCleansing as an Infection Prevention Intervention\u003c/h3\u003e\n\u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003eFamily Caregiver Perspectives\u003c/h2\u003e \u003cp\u003eMost mothers reported that they felt cleansing of babies while they are receiving care in the neonatal ward is an important part of infection prevention. When asked who should be responsible for cleansing, the majority thought that mothers should take on that role. Mothers explained that if they did their child\u0026rsquo;s cleansing they could be sure it was done well. As one respondent explained:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eHonestly it gives me satisfaction, like I have said there is how we were taught. If somebody else is doing it you won\u0026rsquo;t be sure if they are doing it well. Maybe there is a lot of babies and they have to do all of them so maybe they will not do it thoroughly and skip some parts that are important and need to be cleansed. So I leave satisfied knowing that my baby is okay and he is protected.\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eA few respondents noted that they can tell the difference stating that their child appeared more comfortable, slept for longer after being bathed, or had noticeably improved skin after receiving a bath. As one mother explained:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u0026ldquo;They [baths] prevent germs. The baby also should bathe in order for their health to improve. What I have observed is that sometimes after cleansing the baby is able to sleep longer which shows that she was, just like an adult won\u0026rsquo;t feel good if they are not cleansing. Your body just feels heavy and uncomfortable.\u0026rdquo;\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eMost mothers felt that participating in the cleansing of their child while they were admitted to the hospital gave them a sense of satisfaction and participation in the team. As one mother explained:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eAs for me I\u0026rsquo;m taking part, I am taking part because I am in the team that is ensuring that my baby is doing well. I try to prevent germs from causing infections to my child. I really take part.\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eOnly one mother thought that cleansing should be the job of clinicians. However, she also acknowledged that because nurses are often very busy and short-staffed, that it was acceptable for family caregivers to help with cleansing.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003eClinician Perspectives\u003c/h2\u003e \u003cp\u003eMost clinicians felt that cleansing was an important and effective part of infection prevention. It was also seen as a feasible and currently adoptable practice. As one nurse said about cleansing \u0026ndash;\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eI like it because I think it\u0026rsquo;s the only available option that is working for us.\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eSome respondents believed that it made procedures safer by reducing bacterial colonization. As a medical officer explained:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eI think it would be quite effective or it is effective because I\u0026rsquo;m thinking about mostly in terms of either cases of venipuncture or when you doing lumbar puncture, inserting urinary catheters because the major risk of infection with these procedures is you introducing bacteria that you would find on the baby\u0026rsquo;s skin into the blood stream or into the urethra. So then I feel like if you ensure that the skin is actually disinfected and there is a low chance of you actually, there is a lower chance of you essentially transmitting or moving that bacteria.\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eSome felt that there had been fewer resuscitations or sepsis cases since the introduction of cleansing, while others were unsure of the impact of the practice on outcomes. As one medical officer said:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u0026ldquo;Yeah, eish! It\u0026rsquo;s hard to tell because despite us or the mothers using that [CHG] we still are having higher numbers of sepsis in the ward. So it\u0026rsquo;s hard to tell.\"\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003e Across clinician respondents there was an appreciation for the benefits of cleansing and a sense that the new cleansing protocol was an improvement in care delivery that filled a gap in practice.\u003c/p\u003e \u003cp\u003eWhen asked about who was best to perform this task, most clinicians thought that it should be healthcare workers, but noted that staff shortages often made this impossible. As one medical officer explained:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u0026ldquo;So I mean ideally it would be best if it was health care workers [who performed the cleansing] because then it would be easier to just teach that set group and then they would ensure that every time it\u0026rsquo;s done to a certain standard. So since there are limitations it\u0026rsquo;s easier to just teach the mom.\"\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eGiven the current staffing shortages, most clinician respondents felt that it was safe for this task to be shifted to family caregivers as long as there was enough education. Barriers identified to cleansing included product shortages, lack of clear instruction, and being unable to perform cleansing for patients\u0026thinsp;\u0026lt;\u0026thinsp;1kg as stated in the current protocol. As one physician explained:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eThe other ones are the [babies] less than one kilogram, I was told they are not cleansed and I didn\u0026rsquo;t get a reason why but I think those are really the ones that need to be cleansed except if, because the small ones sometimes their skin is very fragile so it can easily break and they can have a bit of sores on the skin. I think those are the only ones that cannot be cleansed but the rest of them if the skin is intact; even if they are less than one kg to me I feel like we can still do the cleansing.\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eClinicians expressed disappointment in being unable to perform this for the most fragile or small patients because those are the same patients at the highest risk for sepsis.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003eChlorhexidine gluconate\u003c/h2\u003e \u003cdiv id=\"Sec14\" class=\"Section3\"\u003e \u003ch2\u003eFamily Caregiver Perspectives\u003c/h2\u003e \u003cp\u003eWhen asked about CHG specifically, the mothers in our sample generally expressed positive opinions of cleansing with CHG and confidence in the practice. As one mother explained:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\"I think it will do its job and will kill the germs from the baby's skin; I think it\u0026rsquo;s good. It is also good for the baby\u0026rsquo;s skin. I have not heard any reports about the baby\u0026rsquo;s skin reacting to the CHG after we used it.\"\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eWhen asked about any barriers to cleansing, our respondents did not identify any barriers and explained that the prepared wipes made it easy. Most parents felt that CHG cleansing was a good thing and that the wipes were better than regular baby wipes. A few parents expressed concerns about the safety of CHG as a chemical. As one mother explained:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u0026ldquo;It\u0026rsquo;s a good thing but then I worry because I have never fully been explained to, I was told that the chemical in it kills germs, yes but what are the consequences? How does it affect the child? What if the child is unable to comprehend the chemical and it affects him somewhere somehow? Who is going to be accountable for that?\u0026rdquo;\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eThey voiced concerns about long term outcomes, absorption of the chemical and the feeling that they did not have a forum to voice their concerns.\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec15\" class=\"Section2\"\u003e \u003ch2\u003eClinician Perspectives\u003c/h2\u003e \u003cp\u003eGenerally, clinicians expressed positive opinions about CHG cleansing. A few respondents reported anecdotally that the rate of infections seemed to be decreasing since the introduction of this practice. As one nurse stated:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\"It should be like antibiotics and should be made as part of a way of preventing infection in NNU because those numbers are less, the spread of infection is less from my own observation compared to the past.\u0026rdquo;\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eSome respondents felt favorably towards the CHG cleansing intervention because it is something that can be feasibly implemented immediately. As one nurse explained:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eStructure is something that can\u0026rsquo;t be changed this year, even next year the structure will still be this one. It would be a plan for many years. When you talk about staffing, that\u0026rsquo;s not something that can change in a short time. We talk of equipment, we cannot find it in a short period of time especially that I mentioned if you do equipment and leave structure it\u0026rsquo;s still useless. Compared to CHG, we can do it in this small space; at least that can continue to prevent infections on the skin.\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eOverall, clinicians felt positively towards CHG, although two clinicians expressed hesitancy about lack of understanding of how the chemical works. However, none shared the same concerns about long term outcomes that mothers expressed.\u003c/p\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eDespite growing evidence supporting CHG use in LMIC neonatal units, little attention has been given to how caregivers and clinical staff understand, value, or operationalize this intervention. This qualitative study addresses that gap and demonstrates that both mothers and healthcare workers generally view CHG cleansing as a feasible, meaningful, and acceptable practice\u0026mdash;even in the context of substantial structural IPC constraints.\u003c/p\u003e \u003cp\u003eTo date, only one other qualitative exploration of neonatal CHG skin cleansing has been reported, embedded within an evaluation of a CHG-containing infection-prevention bundle in a Zambian neonatal unit.\u003csup\u003e\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e\u003c/sup\u003e That study\u0026mdash;limited to healthcare worker interviews\u0026mdash;identified practical implementation concerns, including consent processes, the need to train non-nursing staff, and uncertainty about long-term sustainability. In contrast, our study expands this evidence base by incorporating caregiver perspectives. We document how mothers understand their role in cleansing, describe the active task-shifting of this activity from staff to caregivers, and report the sense of participation, responsibility, and engagement that cleansing provides.\u003c/p\u003e \u003cp\u003eOther work examining patient experiences with CHG cleansing has focused on non-neonatal and high-resource settings and thus likely has limited relevance for LMIC neonatal units. In a U.S. study of non-neonatal inpatients, patients frequently reported low perceived susceptibility to HAI and low self-efficacy in preventing HAIs.\u003csup\u003e\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e\u003c/sup\u003e By contrast, both mothers and healthcare workers in our setting expressed strong motivation to prevent HAIs, emphasizing the vulnerability of hospitalized newborns. Mothers viewed CHG cleansing as a meaningful caregiving task that both protected their infants and strengthened their bond. Consistent with another U.S. study of adult inpatients, our findings reinforce that structured education is critical to support consistent and correct CHG use.\u003csup\u003e\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e\u003c/sup\u003e However, unlike that work, which conceptualized patient involvement largely as an adherence and documentation challenge, our findings highlight caregiver-delivered cleansing as both a pragmatic adaptation to staffing shortages and a mechanism to advance family-centered IPC.\u003c/p\u003e \u003cp\u003eNotably, concerns about chemical exposure or long-term safety were not reported in other U.S.-based studies among adults; in our setting, however, some mothers expressed apprehension about skin absorption and long-term effects, underscoring the need for clear communication about known safety profiles. Healthcare workers in our study also highlighted neonatal-specific implementation complexities\u0026mdash;including infant size and clinical instability\u0026mdash;that complicate decisions about eligibility and technique. These contextual nuances emphasize that CHG cleansing in neonatal units requires not only appropriate education and caregiver support, but also explicit guidance on how best to adapt the practice for the smallest and most clinically fragile infants.\u003c/p\u003e \u003cdiv id=\"Sec17\" class=\"Section2\"\u003e \u003ch2\u003eLimitations\u003c/h2\u003e \u003cp\u003eThis study has several limitations. First, it was conducted at a single public-sector neonatal unit in Botswana, which may limit transferability of findings to other settings. However, the unit shares key characteristics with many LMIC neonatal wards\u0026mdash;including high patient acuity, caregiver involvement in routine care, staff shortages, and constrained IPC resources\u0026mdash;supporting the relevance of these findings to similar contexts.\u003c/p\u003e \u003cp\u003eThis study did not assess clinical outcomes or directly observe cleansing practices; therefore, we cannot draw conclusions about the fidelity of implementation or the relationship between cleansing perceptions and infection-related outcomes. Additionally, as with all qualitative work, responses were based on participants\u0026rsquo; perceptions and may not fully reflect actual practices. Social desirability bias may have influenced both caregiver and healthcare worker responses, particularly given that CHG cleansing had recently been implemented and was perceived as a clinically endorsed practice. Caregivers were interviewed while their infants were still hospitalized, which may have influenced their willingness to express negative views. To mitigate this, interviews were conducted by a trained research assistant with no clinical role in the neonatal unit, and participants were explicitly reassured that their responses would not affect their infant\u0026rsquo;s care.\u003c/p\u003e \u003c/div\u003e"},{"header":"Conclusions","content":"\u003cp\u003eIn this qualitative study from a resource-constrained neonatal unit in Botswana, both mothers and healthcare workers described routine CHG cleansing as an acceptable, feasible, and meaningful component of IPC. Mothers viewed cleansing as an opportunity to participate directly in their infants\u0026rsquo; care and as a practical way to protect vulnerable newborns from HAIs. For healthcare workers, CHG cleansing filled a perceived practice gap and offered an immediately implementable intervention in the face of persistent structural challenges, including overcrowding and staffing shortages. While CHG is unlikely to overcome entrenched systemic IPC barriers on its own, it represents a pragmatic and scalable adjunct to broader efforts aimed at improving hygiene, environmental cleaning, and staffing adequacy. Effective scale-up will require reliable product supply; clear operational guidance\u0026mdash;particularly for small or clinically unstable infants; and structured education for both caregivers and staff to address knowledge needs and safety concerns.\u003c/p\u003e \u003cp\u003eMore broadly, this work underscores that the success of IPC interventions in neonatal units depends not only on clinical efficacy, but also on how families and health workers understand and integrate these practices into daily care. Future studies should assess implementation fidelity and clinical outcomes associated with caregiver-performed CHG cleansing and evaluate strategies to optimize family-centered delivery within strengthened IPC systems.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cu\u003eEthics approval and consent to participate\u003c/u\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eEthical approval for this study was obtained from the Institutional Review Boards at University of Pennsylvania (Protocol # 855362) and by the Botswana Ministry of Health, (HPRD6/14/1), University of Botswana (UB/RES/IRB/BIO/375), and the institution where the study was carried out. Before each interview, an informed consent document was reviewed with respondents and they had ample time to ask questions and make a decision about participation. Verbal consent was obtained prior to the interview. All interviews were audio-recorded with the permission of the respondent.\u003c/p\u003e\n\u003cp\u003e\u003cu\u003eConsent for publication\u003c/u\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cu\u003eAvailability of data and materials\u003c/u\u003e\u003c/p\u003e\n\u003cp\u003eThe data generated and analyzed during this study are not publicly available due to the sensitive nature of the data and ethics restrictions on data sharing. Respondents did not consent to have their data publicly shared. A de-identified dataset may be available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cu\u003eCompeting interests\u003c/u\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cu\u003eFunding\u003c/u\u003e\u003c/p\u003e\n\u003cp\u003eThis work was supported by the CDC Broad Agency Announcement (BAA) Contract# 75D30122F0001 (to E.L.). This work was also supported by a CDC Cooperative Agreement FOA#CK-20-004-Epicenters for the Prevention of Healthcare Associated Infections (to E.L.).\u0026nbsp;\u003cbr\u003e\u003cbr\u003e\u003cu\u003eAuthors\u0026apos; contributions\u003c/u\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eJS participated in the conceptualization and design of the study, secured access to study subjects, participated in data analysis and wrote the initial draft of the manuscript. CM participated in data analysis and wrote the initial draft of the manuscript. PM recruited all interview respondents, conducted all interviews and critically reviewed and revised the manuscript. VT participated in gaining access to the study site, assisted in the recruitment of interview respondents, and critically reviewed and revised the manuscript. EL obtained funding, participated in critically refining the conceptualization and design of the study, and critically reviewed and revised the manuscript. SC participated in critically refining the conceptualization and design of the study, assisted in gaining access to study sites, and critically reviewed and revised the manuscript. JES led the conceptualization and design of the study, obtained funding, led the qualitative data analysis, wrote and substantially revised the initial draft of the manuscript. All authors have read and approved the manuscript.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n \u003cli\u003eSeale AC, Blencowe H, Manu AA, et al. Estimates of possible severe bacterial infection in neonates in sub-Saharan Africa, south Asia, and Latin America for 2012: a systematic review and meta-analysis. \u003cem\u003eLancet Infect Dis\u003c/em\u003e. Aug 2014;14(8):731-741. doi:10.1016/S1473-3099(14)70804-7\u003c/li\u003e\n \u003cli\u003eDramowski A, Bolton L, Fitzgerald F, Bekker A, Neo NETAP. Neonatal Sepsis in Low- and Middle-income Countries: Where Are We Now? \u003cem\u003ePediatr Infect Dis J\u003c/em\u003e. Jun 1 2025;44(6):e207-e210. doi:10.1097/INF.0000000000004815\u003c/li\u003e\n \u003cli\u003eDramowski A, Bekker A, Anugulruengkitt S, et al. Keeping It Real: Infection Prevention and Control Problems and Solutions in Low- and Middle-income Countries. \u003cem\u003ePediatr Infect Dis J\u003c/em\u003e. Mar 1 2022;41(3S):S36-S39. doi:10.1097/INF.0000000000003319\u003c/li\u003e\n \u003cli\u003eKwon JA, Cho MJ. Effectiveness and safety of chlorhexidine gluconate double-cleansing for surgical site infection prevention in neonatal intensive care unit surgical patients. \u003cem\u003eAnn Surg Treat Res\u003c/em\u003e. Nov 2024;107(5):291-299. doi:10.4174/astr.2024.107.5.291\u003c/li\u003e\n \u003cli\u003eWestling T, Cowden C, Mwananyanda L, et al. Impact of chlorhexidine baths on suspected sepsis and bloodstream infections in hospitalized neonates in Zambia. \u003cem\u003eInt J Infect Dis\u003c/em\u003e. Jul 2020;96:54-60. doi:10.1016/j.ijid.2020.03.043\u003c/li\u003e\n \u003cli\u003eDramowski A, Pillay S, Bekker A, et al. Impact of 1% chlorhexidine gluconate bathing and emollient application on bacterial pathogen colonization dynamics in hospitalized preterm neonates - A pilot clinical trial. \u003cem\u003eEClinicalMedicine\u003c/em\u003e. Jul 2021;37:100946. doi:10.1016/j.eclinm.2021.100946\u003c/li\u003e\n \u003cli\u003eRussell N, Clements MN, Azmery KS, et al. Safety and efficacy of whole-body chlorhexidine gluconate cleansing with or without emollient in hospitalised neonates (NeoCHG): a multicentre, randomised, open-label, factorial pilot trial. \u003cem\u003eEClinicalMedicine\u003c/em\u003e. Mar 2024;69:102463. doi:10.1016/j.eclinm.2024.102463\u003c/li\u003e\n \u003cli\u003eSharma A, Kulkarni S, Thukral A, et al. Aqueous chlorhexidine 1% versus 2% for neonatal skin antisepsis: a randomised non-inferiority trial. \u003cem\u003eArch Dis Child Fetal Neonatal Ed\u003c/em\u003e. Nov 2021;106(6):643-648. doi:10.1136/archdischild-2020-321174\u003c/li\u003e\n \u003cli\u003eJohnson J, Suwantarat N, Colantuoni E, et al. The impact of chlorhexidine gluconate bathing on skin bacterial burden of neonates admitted to the Neonatal Intensive Care Unit. \u003cem\u003eJ Perinatol\u003c/em\u003e. Jan 2019;39(1):63-71. doi:10.1038/s41372-018-0231-7\u003c/li\u003e\n \u003cli\u003eVanhoozer G, Lovern Bs I, Masroor N, et al. Chlorhexidine gluconate bathing: Patient perceptions, practices, and barriers at a tertiary care center. \u003cem\u003eAm J Infect Control\u003c/em\u003e. Mar 2019;47(3):349-350. doi:10.1016/j.ajic.2018.08.002\u003c/li\u003e\n \u003cli\u003eCaya T, Knobloch MJ, Musuuza J, Wilhelmson E, Safdar N. Patient perceptions of chlorhexidine bathing: A pilot study using the health belief model. \u003cem\u003eAm J Infect Control\u003c/em\u003e. Jan 2019;47(1):18-22. doi:10.1016/j.ajic.2018.07.010\u003c/li\u003e\n \u003cli\u003eCowden C, Mwananyanda L, Hamer DH, et al. Healthcare worker perceptions of the implementation context surrounding an infection prevention intervention in a Zambian neonatal intensive care unit. \u003cem\u003eBMC Pediatr\u003c/em\u003e. Sep 10 2020;20(1):432. doi:10.1186/s12887-020-02323-2\u003c/li\u003e\n \u003cli\u003eStrysko J, Machiya T, Lechiile K, et al. Carbapenem-resistant Acinetobacter baumannii at a tertiary-care hospital in Botswana: Focus on perinatal environmental exposures. (2022). Antimicrobial Stewardship \u0026amp; Healthcare Epidemiology, 2(S1), S79-S79. doi:10.1017/ash.2022.206.\u003c/li\u003e\n \u003cli\u003eTriantafillou V, Kopsidas I, Kyriakousi A, Zaoutis TE, Szymczak JE. Influence of national culture and context on healthcare workers\u0026apos; perceptions of infection prevention in Greek neonatal intensive care units. \u003cem\u003eJ Hosp Infect\u003c/em\u003e. Apr 2020;104(4):552-559. doi:10.1016/j.jhin.2019.11.020\u003c/li\u003e\n \u003cli\u003eKowalski CP, Nevedal AL, Finley EP, et al. Planning for and Assessing Rigor in Rapid Qualitative Analysis (PARRQA): a consensus-based framework for designing, conducting, and reporting. \u003cem\u003eImplement Sci\u003c/em\u003e. Oct 11 2024;19(1):71. doi:10.1186/s13012-024-01397-1\u003c/li\u003e\n \u003cli\u003eVindrola-Padros C, Johnson GA. Rapid Techniques in Qualitative Research: A Critical Review of the Literature. \u003cem\u003eQual Health Res\u003c/em\u003e. Aug 2020;30(10):1596-1604. doi:10.1177/1049732320921835\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"antimicrobial-resistance-and-infection-control","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"aric","sideBox":"Learn more about [Antimicrobial Resistance and Infection Control](http://aricjournal.biomedcentral.com/)","snPcode":"13756","submissionUrl":"https://submission.nature.com/new-submission/13756/3","title":"Antimicrobial Resistance \u0026 Infection Control","twitterHandle":"@ARICJournal","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Neonatal sepsis, chlorhexidine cleansing, infection prevention, qualitative methods","lastPublishedDoi":"10.21203/rs.3.rs-8123714/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8123714/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNeonatal sepsis remains a major cause of mortality globally, especially in low- and middle-income countries (LMICs), where overcrowding, understaffing, and limited infection prevention and control (IPC) capacity heighten the risk of healthcare-associated infections (HAIs). Routine whole-body chlorhexidine gluconate (CHG) cleansing is an increasingly used, low-cost strategy to reduce skin colonization and prevent sepsis in LMIC neonatal units. While safety and feasibility data for this practice are accumulating, little is known about how caregivers and healthcare workers (HCWs) understand and implement this practice.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe conducted a qualitative study in a 33-bed neonatal ward at a tertiary hospital in Botswana (March 2024–March 2025), where twice-weekly CHG cleansing for eligible infants (\u0026gt;24 hours old and \u0026gt;1 kg) had been implemented one year earlier. Semi-structured interviews were completed with mothers and HCWs to explore perceptions of HAIs, routine cleansing, and CHG use. Interviews were conducted in English or Setswana, transcribed, translated when necessary, and analyzed using a team-based rapid qualitative approach to identify themes across respondent groups.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eTwenty interviews were completed (10 mothers, 10 HCWs). Both mothers and HCWs described HAIs as frequent and severe. Mothers explained they had been taught how to prevent infection by HCWs and attributed transmission to not following IPC practices. HCWs highlighted persistent structural barriers to IPC—including staffing shortages, overcrowding, and shared equipment. CHG cleansing was widely perceived as beneficial; HCWs viewed CHG cleansing as addressing a prior “practice gap,” but expressed concern that CHG cleansing was withheld from those most vulnerable to HAIs (i.e. \u0026lt;1kg preterm neonates) due to exclusion criteria. Task-shifting of cleansing to mothers was acceptable given staff shortages, Mothers reported enhanced confidence, infant comfort, and meaningful participation in IPC through CHG cleansing. Some mothers expressed concerns about long-term safety, and desired clearer communication about the intervention from staff.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eHCWs perceived CHG cleansing as valuable within a resource-constrained neonatal unit and mothers viewed cleansing as a meaningful caregiving role, supporting family-centered IPC. Strengthening caregiver education, supply reliability, and guidance for fragile infants will be essential to optimize implementation. Further research should evaluate fidelity and clinical impact of caregiver-performed CHG cleansing.\u003c/p\u003e","manuscriptTitle":"Perspectives of Mothers and Healthcare Workers on the Implementation of Routine Chlorhexidine Gluconate Cleansing for Sepsis Prevention in a Neonatal Unit in Botswana","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-02-23 06:04:14","doi":"10.21203/rs.3.rs-8123714/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"reviewerAgreed","content":"22481269106063353250660696626839783626","date":"2026-03-30T05:38:05+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-02-28T13:10:50+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"265008585605671342597782276364912136581","date":"2026-02-17T07:54:13+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-02-17T04:41:28+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-11-26T13:32:46+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-11-17T09:09:23+00:00","index":"","fulltext":""},{"type":"submitted","content":"Antimicrobial Resistance \u0026 Infection Control","date":"2025-11-15T18:03:41+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"antimicrobial-resistance-and-infection-control","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"aric","sideBox":"Learn more about [Antimicrobial Resistance and Infection Control](http://aricjournal.biomedcentral.com/)","snPcode":"13756","submissionUrl":"https://submission.nature.com/new-submission/13756/3","title":"Antimicrobial Resistance \u0026 Infection Control","twitterHandle":"@ARICJournal","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"c6ec6202-df67-41d3-8456-d27174b74549","owner":[],"postedDate":"February 23rd, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-02-23T06:04:14+00:00","versionOfRecord":[],"versionCreatedAt":"2026-02-23 06:04:14","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8123714","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8123714","identity":"rs-8123714","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}