Strengthening Neonatal Care through Ward Assistants: A Kenyan Case Study in Enhancing Infection Prevention and Control Practices

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Neonates, especially preterm and low birth-weight infants, are at higher risk for infections, including healthcare-associated infections. In Kenya, neonatal units struggle with limited resources, understaffing, and shortages of essential supplies, significantly impeding effective IPC practices. Methods: This study employed a mixed methods approach in four public neonatal units in Kenya to assess the impact of deploying ward assistants on IPC practices. Data collection included structured and unstructured observations, in-depth interviews, and focus group discussions with healthcare workers and caregivers. The intervention aimed to address gaps in routine cleanliness, waste management, and adherence to IPC protocols. Results: The introduction of ward assistants led to noticeable improvements in overall ward cleanliness and waste disposal, highlighting the potential for enhanced infection control. Mothers’ hand hygiene practices improved, driven by targeted sensitization efforts. Despite these gains, significant challenges remained. Hand hygiene adherence among healthcare providers was inconsistent, and equipment cleaning and decontamination were frequently compromised by insufficient supplies and overwhelming patient demand. The findings underscored the critical role of resources and the need for consistent supervision and training to support sustainable IPC improvements. Conclusion: Deploying ward assistants in neonatal units can positively influence IPC practices, particularly in addressing environmental cleanliness and waste management. However, these benefits alone are insufficient to address systemic barriers to IPC, including resource constraints and variability in adherence among staff. To sustain these gains, robust training, consistent supervision, and adequate resourcing are imperative. Future research should explore the long-term impact of such interventions and design context-specific strategies to overcome persistent barriers, ensuring safer neonatal care in resource-limited settings. Infection Prevention Ward assistants Neonatal care Health workforce Quality of care Figures Figure 1 Figure 2 Background It is estimated that 2.4 million newborns die each year, with a substantial proportion due to infections [ 1 ]. Mortality within neonatal units is also high; in Kenya, for example, a crude mortality rate of 10% was noted among inborn neonates admitted to the neonatal units (NBU) [ 2 ]. Neonates who are admitted into these units and require longer hospital stays, especially preterm and low birth-weight infants, whose immature immune systems make them highly susceptible to infections, are at higher risk of healthcare-associated infections (HCAI) [ 2 , 3 ]. Infection prevention and control (IPC) therefore forms a critical component of healthcare provision in these neonatal units. The neonatal units in many low- and middle-income countries (LMICs) face specific challenges that make it difficult to comply with the required IPC standards. These include shortages of water, infrastructure, and supplies [ 4 ]. To improve care, there have been global efforts to equip neonatal units with essential technologies. One such program is the Neonatal Essential Technologies (NEST 360) program which has added equipment including radiant warmers, incubators, phototherapy devices, and respiratory support systems to 13 NBUs in Kenyan public hospitals [ 5 ]. However, technologies themselves pose IPC challenges and can contribute to HCAI. The introduction of such life-saving equipment therefore needs a correspondingly robust IPC program [ 6 , 7 ]. Many neonatal units in Kenya, especially those within public hospitals, still face the challenge of extreme patient-nurse ratios, with some as low as one nurse to 40 babies and often generally poor infrastructure [ 8 ]. These low staffing ratios see some crucial tasks, including IPC-related tasks, being missed or left undone. This may affect patient safety and lead to poor outcomes[ 8 , 9 ]. IPC in many neonatal units is thus undermined by poor infrastructure, poor staffing, and by deployment of technologies in settings where maintenance of these technologies is poorly supported. At the same time, the patient population is increasingly made up of preterm / very low birth weight babies with heightened vulnerability. From the health worker perspective, it has been estimated that nurses in NBUs spend almost a quarter of their nursing time on non-direct care activities including environmental cleaning and decontamination, waste disposal and supervision of mothers and caregivers on essential IPC tasks [ 10 ]. By delegating these responsibilities to trained non-clinical staff, nurses can dedicate more time to direct patient care activities [ 11 ]. These models have been shown to streamline workflows and increase efficiency with improved patient outcomes [ 12 ]. Here we examine IPC practices in four neonatal units in Kenyan public hospitals that were recipients of NEST 360 technologies using a mixed methods approach. Additionally, we explore the potential value of ward assistants to promote and improve IPC in these clinical contexts. Methods This study was embedded in a larger pre-post study that examined the changes in the quality of care after the introduction of additional nurses and ward assistants in facilities [ 13 ]. In summary, the study was conducted in four public neonatal units in Kenya. The four facilities are part of 13 hospitals that received a bundle of medical technologies in 2021 that included radiant warmers, Continuous Positive Airway Pressure machines (CPAP), phototherapy machines and oxygen concentrators under the NEST 360 programme [ 5 ]. These units aim to provide intermediate-level neonatal care led by one to two paediatricians, with medical officers, non-physician clinicians and nurses (see Table 3 ). These facilities are also training centres for diploma-level nurses and internship centres for doctors and clinicians. Data collection Facility assessment using checklists. The first category of data was collected using a facility assessment of key IPC infrastructure and status. These assessments were conducted by two research assistants (VK and OO) who are trained nurses with knowledge and experience of care procedures and standards in Kenyan hospitals. The assessments were carried out over a total of 27 randomly selected 12-hour shifts across the facilities covering both weekdays and weekends (including night shifts). These data collection tools were piloted before the study commenced and any necessary improvements were made to promote reliability. The tools captured IPC-related activities that were carried out in the unit across 4 domains (Table 1 , appendix 1). For the hand hygiene domains, the research assistants observed instances where mothers, nurses, clinicians, and students practised hand hygiene. For the clinicians, nurses, and students, hand hygiene was evaluated against the World Health Organization (WHO) five moments of hand hygiene[ 14 ]. There was no set minimum number of observations for the hand hygiene events but based on their observation notes the assessor assigned an overall shift-level aggregate score at the end of the shift for hand hygiene practices (Table 1 ). In the same way, the observers kept notes on other IPC practices within the shift, and at the end of the shift assigned an overall shift-level aggregate score against each criterion defined in Table 1 . Table 1 IPC Domains, indicators assessment metric Domain Indicators/Practices assessed Assessment Metric Hand hygiene practices and supplies Mothers/Caregivers practice hand hygiene. (Hand hygiene assessed before holding the baby, breastfeeding, changing diapers or touching the hospital surfaces) Likert scale: Never, rarely, occasionally, often, always Clinicians, nurses, and students practice the WHO five moments of hand hygiene. Likert scale: Never, rarely, occasionally, often, always There is a continuous supply of water, soap, hand towels, and alcohol hand rubs. No, yes Sinks for handwashing are available, clean, and functional No, yes There are posters/charts on handwashing in the ward or hand washing stations No, yes General ward cleanliness The surfaces, walls and floors are kept clean with no visible marks or dirt. No, yes Equipment cleaning and decontamination Nasal prongs, incubators, oxygen concentrators, pulse oximeters, radiant warmers, phototherapy, and feeding cups are consistently kept clean and routinely decontaminated No, yes Cleaning rotas and equipment cleaning instructions are available in the unit No, yes Waste management Colour-coded waste disposal bins with liners and sharps disposal containers are available and functional No, yes Waste is correctly segregated into appropriately coloured bins. No, yes Pictures/posters of waste segregation are available next to the waste collection bins No, yes Non-structured observations, interviews and Focus group Discussions (FGDs) In addition to the structured assessments conducted by the research assistants, non-participant observations were conducted by two non-clinician observers (NO, CW), social scientists with no previous experience working in a hospital setting. They employed an ethnographic approach and were stationed in the neonatal units over extended periods to generate data to examine neonatal care quality more broadly. As part of this, they documented in ‘field notes’ ward sanitation and hygiene practices, interactions among mothers, clinicians, and ward assistants, and IPC counselling practices. Additionally, they conducted interviews with nurses and FGDs with groups of six to nine mothers. The semi-structured interview guide, which was for the larger project but included specific questions on IPC, was developed through informal discussions with stakeholders and clinicians and then refined iteratively based on observations and initial interview findings. Interviews were expected to last between 30 and 90 minutes and were audio-recorded in quiet hospital areas. FGDs provided insights into mothers’ experiences and IPC-related practices. Data Analysis Facility assessment Data For facility assessment data, binary outcome (yes or no) assessments were made for the structural and supplies indicators and given a numeric score of 1 or 0 respectively. Observed behaviours and practices were scored using a 5-point Likert scale (Table 1 ) and converted to numeric scores (0 -Never, 0.25 -Rarely, 0.5- Occasionally, 0.75 -Often, 1 -Always). Aggregate scores were calculated by summing the numeric scores as a proportion of the total possible score for each of the domains assessed in each of the facilities during the two rounds of assessment. Later, descriptive statistics were generated, presented, and reported using simple histograms/bar charts. The analysis was conducted in R statistical software[ 15 ]. Qualitative Data The field notes were entered into NVIVO 14 software for inductive coding and thematic analysis with a focus on examining IPC and hand hygiene activities, behaviours, communications, and relationships. For the audio-recorded interview and FGD data, the audio files were kept on an encrypted laptop. These were transcribed and uploaded into NVivo 14 software [ 16 ]. NO, and CW coded the transcripts independently before discussing the codes with DO and EM and agreeing on combined, axial codes that highlight key information about the IPC arrangements in the four hospitals. The findings from the interviews are presented as quotes to illustrate some of the insights gained. Data Integration For this mixed methods approach, the analysis of data from the facility assessment and the qualitative data were done separately. The results were brought together with the qualitative data explaining some of the facility assessment data. Ward Assistants intervention As part of the parent study each of the four study hospitals received an additional three ward assistants for seven months in the study period [ 13 ]. The ward assistants were recruited and trained for 1 week in different non-clinical tasks including IPC tasks like ward cleaning, waste management device cleaning and effective communication. They were supervised by the ward managers and were provided with a clear job description (Appendix 2). Table 2 below shows the number of ward assistants before and after the intervention, their allocation across shifts and IPC duties covered in the wards. Table 2 Ward assistant distribution and roles within the facilities Hospital H1 H2 H3 H4 Study Phase Pre intervention Post intervention Pre intervention Post intervention Pre intervention Post intervention Pre intervention Post intervention Total Ward Assistants 3 6 3 6 1 4 2 5 Distribution of ward assistants per shift Day 1 3 2 3 1 1 1 1 Night 1 1 1 1 0 1 1 1 IPC-specific Ward Assistant Roles Routine newborn care : Linen and diaper change, baby cleaning and assisting mothers with cord care. Device and Equipment cleaning : Cleaning and preparing feeding utensils, equipment cleaning (including decontamination General cleaning and Waste management : cleaning floors, surfaces, and waste management (lining bins, emptying bins, setting up sharps boxes Mother orientation : Orienting new mothers on ward set up including hand hygiene and waste stations Results Here we first describe the facilities and IPC practices generally and then proceed to describe the effects of the ward assistants on IPC. The four included NBU facilities are in urban and semi-urban regions with an average of about 34 babies and 2–3 nurses per shift over the study period. The first round of the hospital assessments (pre-intervention) was conducted between March and April 2022 and the second round was conducted in June and July 2023. This was six months after the ward assistants' introduction. Non-structured observations, FGDs and interviews were conducted between March 2022 and July 2023. We observed a total of 27, 12-hour shifts (18 pre-intervention and 9 post-intervention with Ward Assistants), a mix of 10 night and 17 day shifts. A total of seven FGDs were conducted with a total of 40 mothers participating. Additionally, 20 interviews were conducted with the nurses and clinicians. The non-structured observations, (which included aspects of IPC), for the larger study were carried out over 1800 hours, carried out in 260 shifts, (150 pre-intervention and 110 post-intervention). Table 3 below provides a summary of the hospital characteristics and staffing during the study period. Table 3 Hospital Characteristics and Data Collection Characteristic H1 H2 H3 H4 Overall Location of the Hospital Urban Urban Semi-urban Semi-urban NBU Capacity 50 53 47 38 Babies in the ward* 59 [53–64] 43 [39–47] 27 [24–31] 19 [ 16 – 21 ] 34 [23–51] Staffing Numbers Number of nurses on the Shift* Day 2 [ 2 – 3 ] 2 [ 2 – 3 ] 1 [ 1 – 2 ] 2 [ 1 – 2 ] 2 [ 1 – 2 ] Night 2 [ 2 – 2 ] 3 1 [ 1 – 2 ] 1 [ 1 – 2 ] 2 [ 1 – 3 ] Number of medical officers on the shifts* 1 [0–1] 0 [0–1] 0 [0–0] 0 [0–0] 0 [0–1] Number of interns on the ward** 1 [ 1 – 1 ] 1 [ 1 – 1 ] 1 [ 1 – 1 ] 1 [ 1 – 1 ] 1[ 1 – 1 ] Number of nursing students on the shifts* 2 [ 1 – 5 ] 7 [ 4 – 13 ] 8 [4 -14.5] 5 [ 3 – 11 ] 5 [ 3 – 11 ] Data Collection Hospital Assessments by the research assistants 8 7 7 5 27 Interviews with nurses 4 3 6 7 20 IPC Focus Group Discussions # 2 2 2 1 7 Number of observation shifts 74 56 54 76 260 Overall, Hours of non-participant observations*** 534 390 342 530 1796 * Median [IQR] *Medical/clinical/nursing officer interns; Median [IQR] # FGDs were conducted in the post-intervention period *** Overall hours observation included the IPC observations General Ward cleanliness From our assessments and observations across the two data collection rounds, we found the wards across the four hospitals were reported to be visibly clean. This was visible from the clean floors, walls, and surfaces, and how often we observed the wards were cleaned. From the FGDs, the mothers also reported noticing the wards were clean. “...sanitation is all right; we can't complain about cleanliness. Even if you look around the whole place is clean, even the toilets, and other places we can't complain. Hygiene is okay, according to the time I have been here, and it's been almost a month.” (Hospital 3 Mother) Hand Hygiene Practices and supplies Mothers Hand Hygiene Mothers' hand hygiene practices were observed and reported from the structured assessments. Based on the number of babies in the ward per shift, these observer scores were based on observing an average of 30 mothers per shift per hospital during the pre-and post-intervention periods. Overall performance ranged between 45–58% in the first round and was slightly higher in the post-intervention cycle at 60–65% across all the hospitals. Hand hygiene was noted to be poorest (< 40% score) after the mothers touched hospital surfaces (Fig. 1 ). The findings on hand hygiene reported above are further corroborated by findings from the non-structured observation data which show that some mothers were compliant with observing hand hygiene practices upon their arrival to the newborn units during the designated feeding hours. Some mothers wash their hands before coming in, but others just walk past the sink without washing. (Hospital 1 Observer- Field Notes) However, compliance with hand hygiene practices was not uniform for all mothers across the facilities. Observation data captured some instances where mothers did not wash their hands on their arrival at the NBU and after completion of scheduled tasks during the feeding hours. This is despite having running water and the mothers receiving the necessary training on hand hygiene from the ward staff. However, these instances were uncommon. As mothers are coming in at noon, I[observer] hear a mother saying she has been told that they need to wash their hands before they come in... Mothers don’t wash their hands inside the changing area yet there is running water. (Hospital 3 Observer- Field notes) To improve compliance with hand hygiene practices, the supportive role provided to mothers by healthcare providers including the ward assistants was also noted. This was shown through the orientation of mothers on hand hygiene. Aspects covered during the orientation process included showing them where the sinks for handwashing were located and providing them with information on the need to wash hands using soap and water. “So, we keep on reminding them of course these mothers you have to remind them all the time because maybe they came from an environment where hand washing is not a must but, in the hospital, you know now like NBU you have to tell them.” (Hospital 2 Nurse) Further, the observation data below provides the context of a healthcare provider supporting a mother visiting the newborn unit for the first time. This support included communication on hand hygiene. A new mother stands next to the nurse’s desk. She is stranded and the nurse is busy with the students. She talks to a nurse about her baby. She tells her, "I have come from ward xxx and the nurse told me my baby is here.” The nurse asks, "When did you deliver and what is your name?” After the mother responds, the nurse then leads her to the preterm room and shows her the baby. Before entering the room, the nurse shows her the handwashing sink and tells her to wash her hands with the liquid soap placed next to the sink. She also tells her to dry her hands in the acute room using the heaters. (Hospital 4 Observer Field notes) Nurses, clinicians, and students' hand hygiene Part of the structured assessments included observing the clinicians' and students' hand hygiene practices using the five moments of hand hygiene [ 14 ]. Overall, nurses had better hand hygiene practices compared to other clinicians. There was poor performance among students, with most facilities scoring less than 50% across the two rounds of data collection for student hand hygiene practices (Fig. 2 , in the post-intervention period, no medical officers were observed in H2). While healthcare providers tried their best to observe IPC, there were instances where handwashing was not preferred as it was inconvenient. “Well, we try to maintain the cleanliness by making sure we clean our hands often with soap and water, we have sanitisers [alcohol hand rub] around, but I think, we don't do a good job about that because for example, if you're giving medication on this side on the preterm side, we rarely go clean our hands. We just use the sanitiser, which I think is not okay to use it so many times. But I think at some point we fail, but we try at least to sanitize. Yeah. Although I think the frequency of washing our hands should be improved.” (Hospital 1 Nurse) Further, from the FGDs the findings reveal lapses in the student nurses' observing hand hygiene practices. The mothers reported differences in hand hygiene practices between the qualified nurses and those in training. “On the nurses’ side, it’s alright, but for students [student nurses], not all, others, you find she’s attending to you, she doesn't have gloves, and when she’s called, she won’t wash her hands, she’ll just go there without gloves. Also, you find some have gloves and after attending to the child, when she’s called, she won’t remove the gloves, she’ll use the same gloves, and she won’t sanitize.” (Hospital 2 Mother) Other than the student nurses, from the interviews, due to the three-monthly rotations of medical interns, there was a general impression of the need to orient clinicians rotating in the units on hand hygiene to enhance IPC. “I can say because in NBU we keep having new students, nurses and even the MO and clinical officer intern who keep rotating. I would...suggest, every time we have a new team, if it's from the nursing side, let there be an orientation before, especially on infection prevention, because for us who are already there, we know how to prevent infection... [Nurse Hospital 3] Equipment and supplies for IPC For this domain, all four facilities had hand hygiene stations (some were dysfunctional) and posters. However, water supply availability varied across the facilities and none of the facilities had hand towels next to the sinks. The non-participant observations and interviews also reported data on the availability of hand hygiene equipment and supplies. Interruptions in water supply and sporadic shortages in hand hygiene supplies prompted adaptation measures (“workarounds”) among healthcare providers. Such measures included using methylated spirit which is inappropriate for hand hygiene. “Hand washing is not followed satisfactorily and for this, it’s quite complex because sometimes you will want to but there is no water, other times people will[clean their hands], because if you endeavour to clean your hands you find no water, your next resort will be a sanitiser which is not always there, so we use methylated spirit which is not so good.” (Hospital 3 Medical Officer) Waste Management From the observations and assessments, the sharps box, and the colour-coded bins were present in the hospitals. Waste was also segregated into the appropriate bins. However, waste disposal pictures with segregation instructions were not available at all the waste disposal sites within the units. This brought the score for this indicator to 40–70% across the facilities. Cleaning of Hospital equipment The structured assessments observed the cleaning and decontamination of selected hospital equipment. In these facilities, none of the devices had cleaning rotas or cleaning instructions available. This brought the overall performance for this domain to less than 30% for all the hospitals in the two rounds of observation. Across the hospitals, we noted different compounds were used to clean the equipment. These included a common chlorine-based household cleaner and disinfectant “Jik®”, for cleaning equipment like incubators. “We have the incubator; you don’t use spirit. That one has its special cleaning agent, so that one I must use it. If maybe it's out of stock, I use plain water or chlorinated water, maybe this portion of Jik and this portion of water, then I clean. That is for the incubator. Yeah.” (Hospital 4 Nurse) High demand for the limited equipment affected their cleaning and decontamination. For instance, since there was a high demand for incubators, we observed inadequate cleaning where some of them were cleaned on the outside and the inside was left uncleaned. “We always use Jik, as our major cleaning…sometimes we don’t have the Jik, you know that but what is expected of us especially if we have students [student nurses], if the incubators have no babies, we are supposed to dismantle [disassemble] it. We are supposed to remove it from the room bring it to this side so that we dismantle [disassemble] it and then we clean with Jik, leave it to air dry and then we return it but, in most cases, when we have so many babies, we may not dismantle[disassemble] it. You’ll clean it on the side. You just put some Jik with some clean cloth or cotton wool, just decontaminate it, air dry it and put another baby.” (Hospital 3 Nurse) Equipment sharing of some equipment like incubators and phototherapy machines affected how the equipment was cleaned. “Again, it is another challenge because like the new phototherapies we have, ideally, they are supposed to be used for one baby, but we get so many babies who require that phototherapy, so they end up sharing., After you remove one, you find you already having another baby who requires that. So, you use the alcohol. We swab and we use it again.” (Nurse Hospital 3) From the FGDs mothers expressed discomfort with their babies’ sharing incubators and, in some instances, the mothers cleaned the incubators themselves. “The cleaning of the incubator, I have a problem with that, because like now the baby in our incubator has been vomiting for the last three days. And you can see the stains of the vomit, and we've been the ones [mothers] doing the cleaning [wiping]ourselves, so, I just wipe where my baby is, and when I ask her to clean, she is a bit apprehensive, she perceives as if I'm instructing her on what she should do. (Hospital 1 Mother) Cleaning of single-use equipment Across the facilities, healthcare providers experienced challenges with consumable items such as nasal prongs, and CPAP connection tubes. Due to their low supply and high demand, these items were reprocessed using soap, chlorine and water and reused. These tasks were shared between the nurses and the ward assistants. “Let’s say for example a baby comes and needs NRM [nonrebreather mask]. I’m supposed to wash it before inserting. The tubes are being washed by our casual [ward assistant] with Jik there is a drum there for that. They are trying to wash. We have instructed them, once they have soaked in that Jik, let them rinse in the water.” (Hospital 2 Nurse) Effects of Ward Assistants As described above the mothers from the FGDs reported the wards were generally clean, much of which can be attributed to the ward assistants. The effects of the ward assistants on IPC were however noted in two major domains (ward cleanliness and waste management). Here we present data from our interviews on the effects of ward assistants on IPC. General cleanliness From the interviews, improvements were reported following the introduction of ward assistants this included the number of times the wards were cleaned. “...we have seen a great improvement on it, working condition, the environment is clean, that’s one...before the ward assistants came in, the wards could have not been clean as compared today. I think we have seen some great improvements.” (Hospital 1 Nurse) Waste management From the interviews, the improvements in waste management were reported to have resulted from the increase in the number of ward assistants in the newborn units (after the intervention). Waste management was one of the tasks that had been assigned to the ward assistants in the units. “Yes, there is a change. Because before [ward assistants’ intervention] you might find maybe these bins you could find some are full. They have not been emptied and maybe when you inquired the ward assistant who was there, she was only one and she had a lot of work and has not had enough time to be able to clear them out. But since the introduction [ward assistants] I haven’t seen such a scenario again. I think they have been able to deal with the waste properly.” (Hospital 1 Nurse) Discussion Improving IPC is critical in improving the quality of neonatal care. The WHO Maternal and Newborn Care quality standards speak to the importance of reliable and functional water, energy, sanitation, hand hygiene and waste disposal facilities[ 17 ]. It was against these standards we describe our findings in this report. Poor IPC structures not only increase the length of hospital stay, due to hospital-acquired infections but also increase the costs of providing care and end up increasing the workload for an already stretched workforce [ 6 ]. In addition to the provision of equipment in these hospitals, the NEST 360 programme provided training and instructions on care and maintenance, including the cleaning and decontamination of the equipment [ 5 ]. During the study, these instructions and device cleaning rotas were missing, and some equipment was visibly soiled. Due to the high patient loads, device cleaning and decontamination were reported to be a challenge. High patient loads and device sharing including incubators and radiant warmers have been described as key drivers for healthcare-associated infections in neonatal units [ 18 ]. The reuse of single-use, semi-critical devices (contact with mucous membranes); and non-critical devices (contact with unbroken skin) such as nasal prongs and face masks is common in many hospitals in resource-limited settings and was also witnessed in this study. Single use may not be feasible due to resource constraints and therefore items tend to be disinfected and reused against the manufacturer's recommendation. Manufacturers should consider items that can be used multiple times and provide clear reprocessing instructions and procedures. The number of times a device can be reprocessed should also be documented [ 19 ]. Erratic supplies of IPC-related materials and equipment have a profound effect on IPC [ 20 ]. The hospitals reported frequent water shortages, the absence of alcohol hand rubs, paper towels and materials for cleaning equipment like incubators. This makes it difficult to reinforce good practices among the healthcare workers, students, and mothers. As a result, adaptive improvisations such as using methylated spirit for hand hygiene and chlorine-based solutions to clean equipment were observed. However, these improvisations are both ineffective and damaging to medical equipment. Staff shortages and workload are also a key constraint for practicing infection prevention and hand hygiene. In units where these staff members have numerous competing tasks, these IPC related tasks may not be prioritised in the face of other more pressing (immediate) tasks, such as are needed to tend to the immediate care needs of very sick neonates [ 21 , 22 ]. After the introduction of the ward assistants, we noted an improvement in key IPC areas, notably ward cleanliness and waste management. Some of these tasks like cleaning and waste management were directly included in their job descriptions and hence we expected notable improvement in these domains. Other key tasks that the ward assistants carried out under the supervision of nurses included cleaning (medical) equipment in the neonatal units. The introduction of ward assistants was meant to free up the time for nurses and provide enhanced support, allowing nurses to focus more on patient care including monitoring, treatment, and counselling and enhancing family-centred care [ 23 , 24 ]. We argue that investing in extra workforce to assist nurses in these facilities improves the IPC status of the facility. Our data show that sometimes the facilities we observed were lacking essential IPC resources such as consistent running water, hand soap and sanitisers, and equipment disinfectant. However, we also found instances where the resident clinicians and nurses were not observing current IPC procedures despite having the requisite training and resources. Healthcare worker behaviours and lack of patient safety cultures in the neonatal units in resource-limited settings have contributed to poor IPC practices in these hospitals. Enhancing this culture, which encompasses individual and collective actions and attitudes in a setting where the individuals are knowledgeable and competent on IPC matters is critical to improving IPC [ 25 ]. In summary, improving IPC and hand hygiene in neonatal units low-resource settings requires a multifaceted approach that encompasses more consistent and adequate supplies, more professional nursing staff in general and additional human resources like ward assistants to support, promote and take on less technical roles including educating/reinforcing behaviours of mothers [ 26 , 27 ]. We acknowledge this study has some limitations; structured assessments using checklists, and our rating system, were subjective. This was however mitigated by training our observers and piloting the tools before data collection. Additionally, our observational findings were corroborated with data from our interviews and focus group discussions; we saw congruence across our measures, which increases robustness of our findings. We acknowledge that project staff conducting the interviews were linked to the implementing team and had the potential to introduce bias in interviews. However, this was minimized by non-participant observations in the NBUs and FGDs with mothers to triangulate interview data. Conclusion The addition of ward assistants into neonatal units was noted to provide an improvement in key IPC domains including general cleanliness, waste handling and hand hygiene for the carers. These positive effects were however marred by the erratic supply of crucial IPC materials. To realise a sustained improvement in IPC, the improvement of human resources and supplies needs to be accompanied by a change in patient safety attitude/culture by the health workers. Abbreviations CPAP - Continuous Positive Airway Pressure machines FGD – Focus Group Discussion HCAI- Healthcare-Associated infections IPC- Infection Prevention and Control LMIC -Low- and middle-income countries NBU Newborn Unit WHO- World Health Organization Declarations Ethics Approval and Consent to Participate This study was part of a larger project that evaluated the effects of technology and workforce enhancement to support neonatal hospital care in Kenya. This study was conducted in accordance with the ethical standards of the 1964 Helsinki Declaration. It received approvals from the Institution Review Boards (IRB); Kenya Medical Research Institute Scientific and Ethics Review Unit (KEMRI/SERU/CGMR-C/229/4203) and the Oxford Tropical Research Ethics Committee (Reference- 26-21). Additionally, we received approvals from the individual counties and health facilities where the research was conducted. Informed consent was obtained prior to data collection (observations, interviews and focus group discussions) from all the target participants. To maintain confidentiality, no personal identifiers were collected and, in the data presented here, all the study hospitals are de-identified. Consent to Publish All the authors reviewed and approved this manuscript for publication. This work is published with the permission of the director of KEMRI. Availability of Data and Materials The data used for this report is available upon request. Applications for access can be made through the Data Governance Committee on email to [email protected] . Competing Interests The authors declare that they have no competing interests Funding Information This research was funded by the NIHR (project reference: NIHR130812) using UK international development funding from the UK Government to support global health research. The views expressed in this publication are those of the authors and not necessarily those of the NIHR or the UK government. The authors received additional support from a Wellcome Trust Senior Research Fellowship (# 207522) awarded to ME. A Wellcome Trust core award to the KEMRI-Wellcome Trust Research Programme (#092654) also enabled this research. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript. Authors contribution MM together with EM, VK, DO, and ME conceptualised the idea for this manuscript. ME, DG, and MM obtained the grant funding. All authors contributed to the methods for the paper. MM, GN, CW, NO, VK and OO oversaw data collection. All authors participated in project administration from the start to finish of this research. MM analysed the data with support from VK, CW, SF, NO, and EM. MM drafted the manuscript with significant contributions from all authors. All the authors reviewed all manuscript versions and agreed on a final version for submission. Acknowledgements The authors would like to acknowledge the HIGH-Q author group comprising Peter Mwangi, Loise Mwangi, Penina Musyoka, Lucy Kinyua, Lydia Thuranira, Virginia Njoroge, Ngina Mwangi, and Zainab Kioni References UNICEF. Neonatal mortality. 2024; Available from: https://data.unicef.org/topic/child-survival/neonatal-mortality/ Irimu G, et al. Neonatal mortality in Kenyan hospitals: a multisite, retrospective, cohort study. BMJ Global Health. 2021;6(5):e004475. Tsafaras GP, Ntontsi P, Xanthou G. Advantages and Limitations of the Neonatal Immune System. Front Pediatr. 2020;8:5. Maina M, et al. Evaluating the foundations that help avert antimicrobial resistance: Performance of essential water sanitation and hygiene functions in hospitals and requirements for action in Kenya. PLoS ONE. 2019;14(10):e0222922. NEST360. NEST360. 2021 9th July 2024]; Available from: https://nest360.org/ World Health Organization. Guidelines on Core Components of Infection Prevention and Control Programmes at the National and Acute Health Care Facility Level. 2016. Haque M et al. Health care-associated infections–an overview. Infection and drug resistance, 2018: pp. 2321–2333. Gathara D, et al. Missed nursing care in newborn units: a cross-sectional direct observational study. BMJ Qual Saf. 2020;29(1):19–30. Imam A, et al. Missed nursing care in acute care hospital settings in low-income and middle-income countries: a systematic review. Hum Resour Health. 2023;21(1):19. Squires JE, et al. To what extent do nurses use research in clinical practice? A systematic review. Implement Sci. 2011;6:21. Kagonya VA, et al. Characterising support and care assistants in formal hospital settings: a scoping review. Hum Resour Health. 2023;21(1):90. Aiken LH, et al. Effects of hospital care environment on patient mortality and nurse outcomes. J Nurs Adm. 2008;38(5):223–9. Imam A, et al. Evaluating the effects of supplementing ward nurses on quality of newborn care in Kenyan neonatal units: protocol for a prospective workforce intervention study. BMC Health Serv Res. 2022;22(1):1230. Sax H, et al. My five moments for hand hygiene’: a user-centred design approach to understand, train, monitor and report hand hygiene. J Hosp Infect. 2007;67(1):9–21. Team. RC. R: A language and environment for statistical computing. Austria: Vienna; 2020. Lumivero. NVivo . 2023. Organization WH. Standards for improving quality of maternal and newborn care in health facilities. 2016. Yee D et al. Identifying the priority infection prevention and control gaps contributing to neonatal healthcare-associated infections in low-and middle-income countries: results from a modified Delphi process. J Glob Health Rep, 2021. 5. International Society for Infectious diseases. Guide to infection control in the healthcare settingreuse of disposable devices:Reuse of disposable devices , S.P.d. León, Editor. 2018. Lowe H, et al. Challenges and opportunities for infection prevention and control in hospitals in conflict-affected settings: a qualitative study. Confl Health. 2021;15(1):94. Chang NN, et al. The impact of workload on hand hygiene compliance: Is 100% compliance achievable? Infect Control Hosp Epidemiol. 2022;43(9):1259–61. Pittet D. Infection control and quality health care in the new millennium. Am J Infect Control. 2005;33(5):258–67. Dear K, Grayson L, Nixon R. Potential methanol toxicity and the importance of using a standardised alcohol-based hand rub formulation in the era of COVID-19. Volume 9. Antimicrobial Resistance & Infection Control; 2020. p. 129. 1. journal, C.s. New research highlights corrosive potential of chlorine-based disinfectants . 2011; Available from: https://www.clinicalservicesjournal.com/story/8971/new-research-highlights-corrosive-potential-of-chlorine-based-disinfectants The Joint Commission USA. The essential role of leadership in developing a safety culture. Sentin Event Alert, 2017(57): pp. 1–8. Bagheri Nejad S, et al. Health-care-associated infection in Africa: a systematic review. Bull World Health Organ. 2011;89(10):757–65. Chimhini G, Magwenzi M, Fitzgerald FC. Infection Prevention and Control in low-resource settings: the need for the local, the contextual and the pragmatic. Infect Prev Pract. 2022;4(3):100135. Additional Declarations No competing interests reported. Supplementary Files SupplementaryMaterialIPC.docx Cite Share Download PDF Status: Published Journal Publication published 02 Jun, 2025 Read the published version in Antimicrobial Resistance & Infection Control → Version 1 posted Editorial decision: Revision requested 03 Apr, 2025 Reviews received at journal 03 Apr, 2025 Reviews received at journal 31 Mar, 2025 Reviewers agreed at journal 24 Mar, 2025 Reviewers agreed at journal 24 Mar, 2025 Reviewers invited by journal 24 Mar, 2025 Editor assigned by journal 16 Mar, 2025 Submission checks completed at journal 13 Mar, 2025 First submitted to journal 10 Mar, 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. 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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-6194020","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":433494945,"identity":"b0672799-cff1-4c15-ba7d-9664c9070487","order_by":0,"name":"Michuki 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Programme","correspondingAuthor":false,"prefix":"","firstName":"Edna","middleName":"","lastName":"Mutua","suffix":""}],"badges":[],"createdAt":"2025-03-10 09:38:16","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-6194020/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-6194020/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s13756-025-01575-w","type":"published","date":"2025-06-02T15:57:31+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":79328935,"identity":"0c58131f-2763-41f1-96e0-0717912e0bc4","added_by":"auto","created_at":"2025-03-27 06:07:21","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":20290,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cem\u003eMothers hand hygiene performance.\u003c/em\u003e\u003c/p\u003e","description":"","filename":"Onlinefloatimage1.png","url":"https://assets-eu.researchsquare.com/files/rs-6194020/v1/52883a3a1cf3ff37b968c638.png"},{"id":79327069,"identity":"e54fc847-29d7-47b8-a2a0-a5e3312af68b","added_by":"auto","created_at":"2025-03-27 05:43:21","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":16465,"visible":true,"origin":"","legend":"\u003cp\u003eHand hygiene performance among clinicians and students\u003c/p\u003e","description":"","filename":"Onlinefloatimage2.png","url":"https://assets-eu.researchsquare.com/files/rs-6194020/v1/346655ee4ee71be7bf304155.png"},{"id":84242570,"identity":"58551e5e-d830-4966-9b37-ac7bbef8a79c","added_by":"auto","created_at":"2025-06-09 16:09:42","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1172400,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6194020/v1/327c2ab8-0e90-409b-8645-69303521deec.pdf"},{"id":79327067,"identity":"a066219c-9387-42d0-9dfe-9c510c4262fd","added_by":"auto","created_at":"2025-03-27 05:43:21","extension":"docx","order_by":0,"title":"","display":"","copyAsset":false,"role":"supplement","size":61522,"visible":true,"origin":"","legend":"","description":"","filename":"SupplementaryMaterialIPC.docx","url":"https://assets-eu.researchsquare.com/files/rs-6194020/v1/e749189866f8e8be3f56cc40.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Strengthening Neonatal Care through Ward Assistants: A Kenyan Case Study in Enhancing Infection Prevention and Control Practices","fulltext":[{"header":"Background","content":"\u003cp\u003eIt is estimated that 2.4\u0026nbsp;million newborns die each year, with a substantial proportion due to infections [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. Mortality within neonatal units is also high; in Kenya, for example, a crude mortality rate of 10% was noted among inborn neonates admitted to the neonatal units (NBU) [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. Neonates who are admitted into these units and require longer hospital stays, especially preterm and low birth-weight infants, whose immature immune systems make them highly susceptible to infections, are at higher risk of healthcare-associated infections (HCAI) [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. Infection prevention and control (IPC) therefore forms a critical component of healthcare provision in these neonatal units. The neonatal units in many low- and middle-income countries (LMICs) face specific challenges that make it difficult to comply with the required IPC standards. These include shortages of water, infrastructure, and supplies [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eTo improve care, there have been global efforts to equip neonatal units with essential technologies. One such program is the Neonatal Essential Technologies (NEST 360) program which has added equipment including radiant warmers, incubators, phototherapy devices, and respiratory support systems to 13 NBUs in Kenyan public hospitals [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. However, technologies themselves pose IPC challenges and can contribute to HCAI. The introduction of such life-saving equipment therefore needs a correspondingly robust IPC program [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eMany neonatal units in Kenya, especially those within public hospitals, still face the challenge of extreme patient-nurse ratios, with some as low as one nurse to 40 babies and often generally poor infrastructure [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. These low staffing ratios see some crucial tasks, including IPC-related tasks, being missed or left undone. This may affect patient safety and lead to poor outcomes[\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. IPC in many neonatal units is thus undermined by poor infrastructure, poor staffing, and by deployment of technologies in settings where maintenance of these technologies is poorly supported. At the same time, the patient population is increasingly made up of preterm / very low birth weight babies with heightened vulnerability.\u003c/p\u003e \u003cp\u003eFrom the health worker perspective, it has been estimated that nurses in NBUs spend almost a quarter of their nursing time on non-direct care activities including environmental cleaning and decontamination, waste disposal and supervision of mothers and caregivers on essential IPC tasks [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. By delegating these responsibilities to trained non-clinical staff, nurses can dedicate more time to direct patient care activities [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. These models have been shown to streamline workflows and increase efficiency with improved patient outcomes [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eHere we examine IPC practices in four neonatal units in Kenyan public hospitals that were recipients of NEST 360 technologies using a mixed methods approach. Additionally, we explore the potential value of ward assistants to promote and improve IPC in these clinical contexts.\u003c/p\u003e "},{"header":"Methods","content":" \u003cp\u003eThis study was embedded in a larger pre-post study that examined the changes in the quality of care after the introduction of additional nurses and ward assistants in facilities [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. In summary, the study was conducted in four public neonatal units in Kenya. The four facilities are part of 13 hospitals that received a bundle of medical technologies in 2021 that included radiant warmers, Continuous Positive Airway Pressure machines (CPAP), phototherapy machines and oxygen concentrators under the NEST 360 programme [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. These units aim to provide intermediate-level neonatal care led by one to two paediatricians, with medical officers, non-physician clinicians and nurses (see Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e). These facilities are also training centres for diploma-level nurses and internship centres for doctors and clinicians.\u003c/p\u003e\n\u003ch3\u003eData collection\u003c/h3\u003e\n\u003cp\u003e \u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003eFacility assessment using checklists.\u003c/span\u003e \u003c/p\u003e \u003cp\u003eThe first category of data was collected using a facility assessment of key IPC infrastructure and status. These assessments were conducted by two research assistants (VK and OO) who are trained nurses with knowledge and experience of care procedures and standards in Kenyan hospitals. The assessments were carried out over a total of 27 randomly selected 12-hour shifts across the facilities covering both weekdays and weekends (including night shifts). These data collection tools were piloted before the study commenced and any necessary improvements were made to promote reliability. The tools captured IPC-related activities that were carried out in the unit across 4 domains (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e, appendix 1). For the hand hygiene domains, the research assistants observed instances where mothers, nurses, clinicians, and students practised hand hygiene. For the clinicians, nurses, and students, hand hygiene was evaluated against the World Health Organization (WHO) five moments of hand hygiene[\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. There was no set minimum number of observations for the hand hygiene events but based on their observation notes the assessor assigned an overall shift-level aggregate score at the end of the shift for hand hygiene practices (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). In the same way, the observers kept notes on other IPC practices within the shift, and at the end of the shift assigned an overall shift-level aggregate score against each criterion defined in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eIPC Domains, indicators assessment metric\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDomain\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eIndicators/Practices assessed\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eAssessment Metric\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"4\" rowspan=\"5\"\u003e \u003cp\u003e\u003cb\u003eHand hygiene practices and supplies\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMothers/Caregivers practice hand hygiene. (Hand hygiene assessed before holding the baby, breastfeeding, changing diapers or touching the hospital surfaces)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eLikert scale: Never, rarely, occasionally, often, always\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eClinicians, nurses, and students practice the WHO five moments of hand hygiene.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eLikert scale: Never, rarely, occasionally, often, always\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eThere is a continuous supply of water, soap, hand towels, and alcohol hand rubs.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNo, yes\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSinks for handwashing are available, clean, and functional\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNo, yes\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eThere are posters/charts on handwashing in the ward or hand washing stations\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNo, yes\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eGeneral ward cleanliness\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eThe surfaces, walls and floors are kept clean with no visible marks or dirt.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNo, yes\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u003cb\u003eEquipment cleaning and decontamination\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNasal prongs, incubators, oxygen concentrators, pulse oximeters, radiant warmers, phototherapy, and feeding cups are consistently kept clean and routinely decontaminated\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNo, yes\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCleaning rotas and equipment cleaning instructions are available in the unit\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNo, yes\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003e\u003cb\u003eWaste management\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eColour-coded waste disposal bins with liners and sharps disposal containers are available and functional\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNo, yes\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eWaste is correctly segregated into appropriately coloured bins.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNo, yes\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePictures/posters of waste segregation are available next to the waste collection bins\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNo, yes\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eNon-structured observations, interviews and Focus group Discussions (FGDs)\u003c/h2\u003e \u003cp\u003eIn addition to the structured assessments conducted by the research assistants, non-participant observations were conducted by two non-clinician observers (NO, CW), social scientists with no previous experience working in a hospital setting. They employed an ethnographic approach and were stationed in the neonatal units over extended periods to generate data to examine neonatal care quality more broadly. As part of this, they documented in \u0026lsquo;field notes\u0026rsquo; ward sanitation and hygiene practices, interactions among mothers, clinicians, and ward assistants, and IPC counselling practices. Additionally, they conducted interviews with nurses and FGDs with groups of six to nine mothers. The semi-structured interview guide, which was for the larger project but included specific questions on IPC, was developed through informal discussions with stakeholders and clinicians and then refined iteratively based on observations and initial interview findings. Interviews were expected to last between 30 and 90 minutes and were audio-recorded in quiet hospital areas. FGDs provided insights into mothers\u0026rsquo; experiences and IPC-related practices.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003eData Analysis\u003c/h2\u003e \u003cdiv id=\"Sec5\" class=\"Section3\"\u003e \u003ch2\u003eFacility assessment Data\u003c/h2\u003e \u003cp\u003eFor facility assessment data, binary outcome (yes or no) assessments were made for the structural and supplies indicators and given a numeric score of 1 or 0 respectively. Observed behaviours and practices were scored using a 5-point Likert scale (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e) and converted to numeric scores (0 -Never, 0.25 -Rarely, 0.5- Occasionally, 0.75 -Often, 1 -Always). Aggregate scores were calculated by summing the numeric scores as a proportion of the total possible score for each of the domains assessed in each of the facilities during the two rounds of assessment. Later, descriptive statistics were generated, presented, and reported using simple histograms/bar charts. The analysis was conducted in R statistical software[\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e].\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e\n\u003ch3\u003eQualitative Data\u003c/h3\u003e\n\u003cp\u003eThe field notes were entered into NVIVO 14 software for inductive coding and thematic analysis with a focus on examining IPC and hand hygiene activities, behaviours, communications, and relationships. For the audio-recorded interview and FGD data, the audio files were kept on an encrypted laptop. These were transcribed and uploaded into NVivo 14 software [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. NO, and CW coded the transcripts independently before discussing the codes with DO and EM and agreeing on combined, axial codes that highlight key information about the IPC arrangements in the four hospitals. The findings from the interviews are presented as quotes to illustrate some of the insights gained.\u003c/p\u003e\n\u003ch3\u003eData Integration\u003c/h3\u003e\n\u003cp\u003eFor this mixed methods approach, the analysis of data from the facility assessment and the qualitative data were done separately. The results were brought together with the qualitative data explaining some of the facility assessment data.\u003c/p\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eWard Assistants intervention\u003c/h2\u003e \u003cp\u003eAs part of the parent study each of the four study hospitals received an additional three ward assistants for seven months in the study period [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. The ward assistants were recruited and trained for 1 week in different non-clinical tasks including IPC tasks like ward cleaning, waste management device cleaning and effective communication. They were supervised by the ward managers and were provided with a clear job description (Appendix 2). Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e below shows the number of ward assistants before and after the intervention, their allocation across shifts and IPC duties covered in the wards.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eWard assistant distribution and roles within the facilities\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"10\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c9\" colnum=\"9\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c10\" colnum=\"10\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eHospital\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003eH1\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e \u003cp\u003eH2\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c8\" namest=\"c7\"\u003e \u003cp\u003eH3\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c10\" namest=\"c9\"\u003e \u003cp\u003eH4\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eStudy Phase\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePre\u003c/p\u003e \u003cp\u003eintervention\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003ePost\u003c/p\u003e \u003cp\u003eintervention\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003ePre\u003c/p\u003e \u003cp\u003eintervention\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003ePost\u003c/p\u003e \u003cp\u003eintervention\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003ePre\u003c/p\u003e \u003cp\u003eintervention\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c8\"\u003e \u003cp\u003ePost\u003c/p\u003e \u003cp\u003eintervention\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c9\"\u003e \u003cp\u003ePre\u003c/p\u003e \u003cp\u003eintervention\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c10\"\u003e \u003cp\u003ePost\u003c/p\u003e \u003cp\u003eintervention\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTotal Ward Assistants\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e3\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e6\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e3\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003cb\u003e6\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u003cb\u003e1\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e\u003cb\u003e4\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e\u003cb\u003e2\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e\u003cb\u003e5\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eDistribution of ward assistants\u003c/p\u003e \u003cp\u003eper shift\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eDay\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e1\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e3\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e2\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003cb\u003e3\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u003cb\u003e1\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e\u003cb\u003e1\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e\u003cb\u003e1\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e\u003cb\u003e1\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eNight\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e1\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e1\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e1\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003cb\u003e1\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u003cb\u003e0\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e\u003cb\u003e1\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e\u003cb\u003e1\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e\u003cb\u003e1\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"10\" nameend=\"c10\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eIPC-specific Ward Assistant Roles\u003c/b\u003e\u003c/p\u003e \u003cp\u003e\u003cb\u003eRoutine newborn care\u003c/b\u003e: Linen and diaper change, baby cleaning and assisting mothers with cord care.\u003c/p\u003e \u003cp\u003e\u003cb\u003eDevice and Equipment cleaning\u003c/b\u003e:\u0026nbsp;Cleaning and preparing feeding utensils, equipment cleaning (including decontamination\u003c/p\u003e \u003cp\u003e\u003cb\u003eGeneral cleaning and Waste management\u003c/b\u003e: cleaning floors, surfaces, and waste management (lining bins, emptying bins, setting up sharps boxes\u003c/p\u003e \u003cp\u003e\u003cb\u003eMother orientation\u003c/b\u003e: Orienting new mothers on ward set up including hand hygiene and waste stations\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eHere we first describe the facilities and IPC practices generally and then proceed to describe the effects of the ward assistants on IPC.\u003c/p\u003e \u003cp\u003eThe four included NBU facilities are in urban and semi-urban regions with an average of about 34 babies and 2\u0026ndash;3 nurses per shift over the study period. The first round of the hospital assessments (pre-intervention) was conducted between March and April 2022 and the second round was conducted in June and July 2023. This was six months after the ward assistants' introduction. Non-structured observations, FGDs and interviews were conducted between March 2022 and July 2023.\u003c/p\u003e \u003cp\u003eWe observed a total of 27, 12-hour shifts (18 pre-intervention and 9 post-intervention with Ward Assistants), a mix of 10 night and 17 day shifts. A total of seven FGDs were conducted with a total of 40 mothers participating. Additionally, 20 interviews were conducted with the nurses and clinicians. The non-structured observations, (which included aspects of IPC), for the larger study were carried out over 1800 hours, carried out in 260 shifts, (150 pre-intervention and 110 post-intervention). Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e below provides a summary of the hospital characteristics and staffing during the study period.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eHospital Characteristics and Data Collection\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"7\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCharacteristic\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eH1\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eH2\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eH3\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eH4\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003eOverall\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLocation of the Hospital\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eUrban\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eUrban\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eSemi-urban\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eSemi-urban\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNBU Capacity\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e50\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e53\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e47\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e38\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBabies in the ward*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e59 [53\u0026ndash;64]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e43\u0026nbsp;[39\u0026ndash;47]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e27 [24\u0026ndash;31]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e19 [\u003cspan additionalcitationids=\"CR17 CR18 CR19 CR20\" citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e34 [23\u0026ndash;51]\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"6\" nameend=\"c6\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eStaffing Numbers\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eNumber of nurses on the Shift*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eDay\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2 [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2 [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1 [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e2 [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e2 [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNight\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2 [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1 [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1 [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e2 [\u003cspan additionalcitationids=\"CR2\" citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNumber of medical officers on the shifts*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1\u0026nbsp;[0\u0026ndash;1]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0 [0\u0026ndash;1]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0 [0\u0026ndash;0]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0 [0\u0026ndash;0]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0 [0\u0026ndash;1]\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNumber of interns on the ward**\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1\u0026nbsp;[\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1\u0026nbsp;[\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1\u0026nbsp;[\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1\u0026nbsp;[\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e1[\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNumber of nursing students on the shifts*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2\u0026nbsp;[\u003cspan additionalcitationids=\"CR2 CR3 CR4\" citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e7\u0026nbsp;[\u003cspan additionalcitationids=\"CR5 CR6 CR7 CR8 CR9 CR10 CR11 CR12\" citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e8\u0026nbsp;[4 -14.5]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e5\u0026nbsp;[\u003cspan additionalcitationids=\"CR4 CR5 CR6 CR7 CR8 CR9 CR10\" citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e5\u0026nbsp;[\u003cspan additionalcitationids=\"CR4 CR5 CR6 CR7 CR8 CR9 CR10\" citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"7\" nameend=\"c7\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eData Collection\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHospital Assessments by the research assistants\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e27\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eInterviews with nurses\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e20\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIPC Focus Group Discussions\u003csup\u003e#\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNumber of observation shifts\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e74\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e56\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e54\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e76\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e260\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOverall, Hours of non-participant observations***\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e534\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e390\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e342\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e530\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e1796\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"7\" nameend=\"c7\" namest=\"c1\"\u003e \u003cp\u003e* Median [IQR]\u003c/p\u003e \u003cp\u003e*Medical/clinical/nursing officer interns; Median [IQR]\u003c/p\u003e \u003cp\u003e# FGDs were conducted in the post-intervention period\u003c/p\u003e \u003cp\u003e*** Overall hours observation included the IPC observations\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e\n\u003ch3\u003eGeneral Ward cleanliness\u003c/h3\u003e\n\u003cp\u003eFrom our assessments and observations across the two data collection rounds, we found the wards across the four hospitals were reported to be visibly clean. This was visible from the clean floors, walls, and surfaces, and how often we observed the wards were cleaned. From the FGDs, the mothers also reported noticing the wards were clean.\u003c/p\u003e \u003cp\u003e \u003cem\u003e\u0026ldquo;...sanitation is all right; we can't complain about cleanliness. Even if you look around the whole place is clean, even the toilets, and other places we can't complain. Hygiene is okay, according to the time I have been here, and it's been almost a month.\u0026rdquo; (Hospital 3 Mother)\u003c/em\u003e \u003c/p\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003eHand Hygiene Practices and supplies\u003c/h2\u003e \u003cdiv id=\"Sec12\" class=\"Section3\"\u003e \u003ch2\u003eMothers Hand Hygiene\u003c/h2\u003e \u003cp\u003eMothers' hand hygiene practices were observed and reported from the structured assessments. Based on the number of babies in the ward per shift, these observer scores were based on observing an average of 30 mothers per shift per hospital during the pre-and post-intervention periods. Overall performance ranged between 45\u0026ndash;58% in the first round and was slightly higher in the post-intervention cycle at 60\u0026ndash;65% across all the hospitals. Hand hygiene was noted to be poorest (\u0026lt;\u0026thinsp;40% score) after the mothers touched hospital surfaces (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eThe findings on hand hygiene reported above are further corroborated by findings from the non-structured observation data which show that some mothers were compliant with observing hand hygiene practices upon their arrival to the newborn units during the designated feeding hours.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003eSome mothers wash their hands before coming in, but others just walk past the sink without washing.\u003c/em\u003e (Hospital 1 Observer- Field Notes)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eHowever, compliance with hand hygiene practices was not uniform for all mothers across the facilities. Observation data captured some instances where mothers did not wash their hands on their arrival at the NBU and after completion of scheduled tasks during the feeding hours. This is despite having running water and the mothers receiving the necessary training on hand hygiene from the ward staff. However, these instances were uncommon.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003eAs mothers are coming in at noon, I[observer] hear a mother saying she has been told that they need to wash their hands before they come in... Mothers don\u0026rsquo;t wash their hands inside the changing area yet there is running water.\u003c/em\u003e (Hospital 3 Observer- Field notes)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eTo improve compliance with hand hygiene practices, the supportive role provided to mothers by healthcare providers including the ward assistants was also noted. This was shown through the orientation of mothers on hand hygiene. Aspects covered during the orientation process included showing them where the sinks for handwashing were located and providing them with information on the need to wash hands using soap and water.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;So, we keep on reminding them of course these mothers you have to remind them all the time because maybe they came from an environment where hand washing is not a must but, in the hospital, you know now like NBU you have to tell them.\u0026rdquo;\u003c/em\u003e (Hospital 2 Nurse)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eFurther, the observation data below provides the context of a healthcare provider supporting a mother visiting the newborn unit for the first time. This support included communication on hand hygiene.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003eA new mother stands next to the nurse\u0026rsquo;s desk. She is stranded and the nurse is busy with the students. She talks to a nurse about her baby. She tells her, \"I have come from ward xxx and the nurse told me my baby is here.\u0026rdquo; The nurse asks, \"When did you deliver and what is your name?\u0026rdquo; After the mother responds, the nurse then leads her to the preterm room and shows her the baby. Before entering the room, the nurse shows her the handwashing sink and tells her to wash her hands with the liquid soap placed next to the sink. She also tells her to dry her hands in the acute room using the heaters.\u003c/em\u003e (Hospital 4 Observer Field notes)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003eNurses, clinicians, and students' hand hygiene\u003c/h2\u003e \u003cp\u003ePart of the structured assessments included observing the clinicians' and students' hand hygiene practices using the five moments of hand hygiene [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. Overall, nurses had better hand hygiene practices compared to other clinicians. There was poor performance among students, with most facilities scoring less than 50% across the two rounds of data collection for student hand hygiene practices (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e, in the post-intervention period, no medical officers were observed in H2).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eWhile healthcare providers tried their best to observe IPC, there were instances where handwashing was not preferred as it was inconvenient.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;Well, we try to maintain the cleanliness by making sure we clean our hands often with soap and water, we have sanitisers [alcohol hand rub] around, but I think, we don't do a good job about that because for example, if you're giving medication on this side on the preterm side, we rarely go clean our hands. We just use the sanitiser, which I think is not okay to use it so many times. But I think at some point we fail, but we try at least to sanitize. Yeah. Although I think the frequency of washing our hands should be improved.\u0026rdquo;\u003c/em\u003e (Hospital 1 Nurse)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eFurther, from the FGDs the findings reveal lapses in the student nurses' observing hand hygiene practices. The mothers reported differences in hand hygiene practices between the qualified nurses and those in training.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;On the nurses\u0026rsquo; side, it\u0026rsquo;s alright, but for students [student nurses], not all, others, you find she\u0026rsquo;s attending to you, she doesn't have gloves, and when she\u0026rsquo;s called, she won\u0026rsquo;t wash her hands, she\u0026rsquo;ll just go there without gloves. Also, you find some have gloves and after attending to the child, when she\u0026rsquo;s called, she won\u0026rsquo;t remove the gloves, she\u0026rsquo;ll use the same gloves, and she won\u0026rsquo;t sanitize.\u0026rdquo; (Hospital 2 Mother)\u003c/em\u003e \u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eOther than the student nurses, from the interviews, due to the three-monthly rotations of medical interns, there was a general impression of the need to orient clinicians rotating in the units on hand hygiene to enhance IPC.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;I can say because in NBU we keep having new students, nurses and even the MO and clinical officer intern who keep rotating. I would...suggest, every time we have a new team, if it's from the nursing side, let there be an orientation before, especially on infection prevention, because for us who are already there, we know how to prevent infection... [Nurse Hospital 3]\u003c/em\u003e \u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec14\" class=\"Section2\"\u003e \u003ch2\u003eEquipment and supplies for IPC\u003c/h2\u003e \u003cp\u003eFor this domain, all four facilities had hand hygiene stations (some were dysfunctional) and posters. However, water supply availability varied across the facilities and none of the facilities had hand towels next to the sinks. The non-participant observations and interviews also reported data on the availability of hand hygiene equipment and supplies. Interruptions in water supply and sporadic shortages in hand hygiene supplies prompted adaptation measures (\u0026ldquo;workarounds\u0026rdquo;) among healthcare providers. Such measures included using methylated spirit which is inappropriate for hand hygiene.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;Hand washing is not followed satisfactorily and for this, it\u0026rsquo;s quite complex because sometimes you will want to but there is no water, other times people will[clean their hands], because if you endeavour to clean your hands you find no water, your next resort will be a sanitiser which is not always there, so we use methylated spirit which is not so good.\u0026rdquo;\u003c/em\u003e (Hospital 3 Medical Officer)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec15\" class=\"Section2\"\u003e \u003ch2\u003eWaste Management\u003c/h2\u003e \u003cp\u003eFrom the observations and assessments, the sharps box, and the colour-coded bins were present in the hospitals. Waste was also segregated into the appropriate bins. However, waste disposal pictures with segregation instructions were not available at all the waste disposal sites within the units. This brought the score for this indicator to 40\u0026ndash;70% across the facilities.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec16\" class=\"Section2\"\u003e \u003ch2\u003eCleaning of Hospital equipment\u003c/h2\u003e \u003cp\u003eThe structured assessments observed the cleaning and decontamination of selected hospital equipment. In these facilities, none of the devices had cleaning rotas or cleaning instructions available. This brought the overall performance for this domain to less than 30% for all the hospitals in the two rounds of observation. Across the hospitals, we noted different compounds were used to clean the equipment. These included a common chlorine-based household cleaner and disinfectant \u0026ldquo;Jik\u0026reg;\u0026rdquo;, for cleaning equipment like incubators.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;We have the incubator; you don\u0026rsquo;t use spirit. That one has its special cleaning agent, so that one I must use it. If maybe it's out of stock, I use plain water or chlorinated water, maybe this portion of Jik and this portion of water, then I clean. That is for the incubator. Yeah.\u0026rdquo;\u003c/em\u003e (Hospital 4 Nurse)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eHigh demand for the limited equipment affected their cleaning and decontamination. For instance, since there was a high demand for incubators, we observed inadequate cleaning where some of them were cleaned on the outside and the inside was left uncleaned.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;We always use Jik, as our major cleaning\u0026hellip;sometimes we don\u0026rsquo;t have the Jik, you know that but what is expected of us especially if we have students [student nurses], if the incubators have no babies, we are supposed to dismantle [disassemble] it. We are supposed to remove it from the room bring it to this side so that we dismantle [disassemble] it and then we clean with Jik, leave it to air dry and then we return it but, in most cases, when we have so many babies, we may not dismantle[disassemble] it. You\u0026rsquo;ll clean it on the side. You just put some Jik with some clean cloth or cotton wool, just decontaminate it, air dry it and put another baby.\u0026rdquo;\u003c/em\u003e (Hospital 3 Nurse)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eEquipment sharing of some equipment like incubators and phototherapy machines affected how the equipment was cleaned.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;Again, it is another challenge because like the new phototherapies we have, ideally, they are supposed to be used for one baby, but we get so many babies who require that phototherapy, so they end up sharing., After you remove one, you find you already having another baby who requires that. So, you use the alcohol. We swab and we use it again.\u0026rdquo;\u003c/em\u003e (Nurse Hospital 3)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eFrom the FGDs mothers expressed discomfort with their babies\u0026rsquo; sharing incubators and, in some instances, the mothers cleaned the incubators themselves.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;The cleaning of the incubator, I have a problem with that, because like now the baby in our incubator has been vomiting for the last three days. And you can see the stains of the vomit, and we've been the ones [mothers] doing the cleaning [wiping]ourselves, so, I just wipe where my baby is, and when I ask her to clean, she is a bit apprehensive, she perceives as if I'm instructing her on what she should do.\u003c/em\u003e (Hospital 1 Mother)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec17\" class=\"Section2\"\u003e \u003ch2\u003eCleaning of single-use equipment\u003c/h2\u003e \u003cp\u003eAcross the facilities, healthcare providers experienced challenges with consumable items such as nasal prongs, and CPAP connection tubes. Due to their low supply and high demand, these items were reprocessed using soap, chlorine and water and reused. These tasks were shared between the nurses and the ward assistants.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;Let\u0026rsquo;s say for example a baby comes and needs NRM [nonrebreather mask]. I\u0026rsquo;m supposed to wash it before inserting. The tubes are being washed by our casual [ward assistant] with Jik there is a drum there for that. They are trying to wash. We have instructed them, once they have soaked in that Jik, let them rinse in the water.\u0026rdquo;\u003c/em\u003e (Hospital 2 Nurse)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec18\" class=\"Section2\"\u003e \u003ch2\u003eEffects of Ward Assistants\u003c/h2\u003e \u003cp\u003eAs described above the mothers from the FGDs reported the wards were generally clean, much of which can be attributed to the ward assistants. The effects of the ward assistants on IPC were however noted in two major domains (ward cleanliness and waste management). Here we present data from our interviews on the effects of ward assistants on IPC.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec19\" class=\"Section2\"\u003e \u003ch2\u003eGeneral cleanliness\u003c/h2\u003e \u003cp\u003eFrom the interviews, improvements were reported following the introduction of ward assistants this included the number of times the wards were cleaned.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;...we have seen a great improvement on it, working condition, the environment is clean, that\u0026rsquo;s one...before the ward assistants came in, the wards could have not been clean as compared today. I think we have seen some great improvements.\u0026rdquo;\u003c/em\u003e (Hospital 1 Nurse)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec20\" class=\"Section2\"\u003e \u003ch2\u003eWaste management\u003c/h2\u003e \u003cp\u003eFrom the interviews, the improvements in waste management were reported to have resulted from the increase in the number of ward assistants in the newborn units (after the intervention). Waste management was one of the tasks that had been assigned to the ward assistants in the units.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003e\u0026ldquo;Yes, there is a change. Because before\u003c/em\u003e \u003cspan type=\"ItalicUnderline\" class=\"ItalicUnderline\" name=\"Emphasis\"\u003e[ward assistants\u0026rsquo; intervention]\u003c/span\u003e \u003cem\u003eyou might find maybe these bins you could find some are full. They have not been emptied and maybe when you inquired the ward assistant who was there, she was only one and she had a lot of work and has not had enough time to be able to clear them out. But since the introduction [ward assistants] I haven\u0026rsquo;t seen such a scenario again. I think they have been able to deal with the waste properly.\u0026rdquo;\u003c/em\u003e (Hospital 1 Nurse)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eImproving IPC is critical in improving the quality of neonatal care. The WHO Maternal and Newborn Care quality standards speak to the importance of reliable and functional water, energy, sanitation, hand hygiene and waste disposal facilities[\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. It was against these standards we describe our findings in this report. Poor IPC structures not only increase the length of hospital stay, due to hospital-acquired infections but also increase the costs of providing care and end up increasing the workload for an already stretched workforce [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eIn addition to the provision of equipment in these hospitals, the NEST 360 programme provided training and instructions on care and maintenance, including the cleaning and decontamination of the equipment [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. During the study, these instructions and device cleaning rotas were missing, and some equipment was visibly soiled. Due to the high patient loads, device cleaning and decontamination were reported to be a challenge. High patient loads and device sharing including incubators and radiant warmers have been described as key drivers for healthcare-associated infections in neonatal units [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. The reuse of single-use, semi-critical devices (contact with mucous membranes); and non-critical devices (contact with unbroken skin) such as nasal prongs and face masks is common in many hospitals in resource-limited settings and was also witnessed in this study. Single use may not be feasible due to resource constraints and therefore items tend to be disinfected and reused against the manufacturer's recommendation. Manufacturers should consider items that can be used multiple times and provide clear reprocessing instructions and procedures. The number of times a device can be reprocessed should also be documented [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eErratic supplies of IPC-related materials and equipment have a profound effect on IPC [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. The hospitals reported frequent water shortages, the absence of alcohol hand rubs, paper towels and materials for cleaning equipment like incubators. This makes it difficult to reinforce good practices among the healthcare workers, students, and mothers. As a result, adaptive improvisations such as using methylated spirit for hand hygiene and chlorine-based solutions to clean equipment were observed. However, these improvisations are both ineffective and damaging to medical equipment. Staff shortages and workload are also a key constraint for practicing infection prevention and hand hygiene. In units where these staff members have numerous competing tasks, these IPC related tasks may not be prioritised in the face of other more pressing (immediate) tasks, such as are needed to tend to the immediate care needs of very sick neonates [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e, \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eAfter the introduction of the ward assistants, we noted an improvement in key IPC areas, notably ward cleanliness and waste management. Some of these tasks like cleaning and waste management were directly included in their job descriptions and hence we expected notable improvement in these domains. Other key tasks that the ward assistants carried out under the supervision of nurses included cleaning (medical) equipment in the neonatal units. The introduction of ward assistants was meant to free up the time for nurses and provide enhanced support, allowing nurses to focus more on patient care including monitoring, treatment, and counselling and enhancing family-centred care [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e, \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eWe argue that investing in extra workforce to assist nurses in these facilities improves the IPC status of the facility. Our data show that sometimes the facilities we observed were lacking essential IPC resources such as consistent running water, hand soap and sanitisers, and equipment disinfectant. However, we also found instances where the resident clinicians and nurses were not observing current IPC procedures despite having the requisite training and resources. Healthcare worker behaviours and lack of patient safety cultures in the neonatal units in resource-limited settings have contributed to poor IPC practices in these hospitals. Enhancing this culture, which encompasses individual and collective actions and attitudes in a setting where the individuals are knowledgeable and competent on IPC matters is critical to improving IPC [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eIn summary, improving IPC and hand hygiene in neonatal units low-resource settings requires a multifaceted approach that encompasses more consistent and adequate supplies, more professional nursing staff in general and additional human resources like ward assistants to support, promote and take on less technical roles including educating/reinforcing behaviours of mothers [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e, \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eWe acknowledge this study has some limitations; structured assessments using checklists, and our rating system, were subjective. This was however mitigated by training our observers and piloting the tools before data collection. Additionally, our observational findings were corroborated with data from our interviews and focus group discussions; we saw congruence across our measures, which increases robustness of our findings. We acknowledge that project staff conducting the interviews were linked to the implementing team and had the potential to introduce bias in interviews. However, this was minimized by non-participant observations in the NBUs and FGDs with mothers to triangulate interview data.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003e The addition of ward assistants into neonatal units was noted to provide an improvement in key IPC domains including general cleanliness, waste handling and hand hygiene for the carers. These positive effects were however marred by the erratic supply of crucial IPC materials. To realise a sustained improvement in IPC, the improvement of human resources and supplies needs to be accompanied by a change in patient safety attitude/culture by the health workers.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eCPAP - Continuous Positive Airway Pressure machines\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eFGD \u0026ndash; Focus Group Discussion\u003c/p\u003e\n\u003cp\u003eHCAI- Healthcare-Associated infections\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eIPC- Infection Prevention and Control\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eLMIC -Low- and middle-income countries\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eNBU Newborn Unit\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eWHO- World Health Organization\u0026nbsp;\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics Approval and Consent to Participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was part of a larger project that evaluated\u0026nbsp;the effects of technology and workforce enhancement to support neonatal hospital care in Kenya. This study was conducted in accordance with the ethical standards of the 1964 Helsinki Declaration. It received approvals from the Institution Review Boards (IRB); Kenya Medical Research Institute Scientific and Ethics Review Unit (KEMRI/SERU/CGMR-C/229/4203) and the Oxford Tropical Research Ethics Committee\u0026nbsp;(Reference- 26-21). Additionally, we received approvals from the individual counties and health facilities where the research was conducted. Informed consent was obtained prior to data collection (observations, interviews and focus group discussions) from all the target participants. To maintain confidentiality, no personal identifiers were collected and, in the data presented here, all the study hospitals are de-identified.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent to Publish\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll the authors reviewed and approved this manuscript for publication. This work is published with the permission of the director of KEMRI.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of Data and Materials\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe data used for this report is available upon request. Applications for access can be made through the Data Governance Committee on email to [email protected].\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting Interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding Information\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis research was funded by the NIHR (project reference: NIHR130812) using UK international development funding from the UK Government to support global health research. The views expressed in this publication are those of the authors and not necessarily those of the NIHR or the UK government.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe authors received additional support from a Wellcome Trust Senior Research Fellowship (# 207522) awarded to ME. A Wellcome Trust core award to the KEMRI-Wellcome Trust Research Programme (#092654) also enabled this research.\u003c/p\u003e\n\u003cp\u003eThe funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors contribution\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eMM together with EM, VK, DO, and ME conceptualised the idea for this manuscript. ME, DG, and MM obtained the grant funding. All authors contributed to the methods for the paper. MM, GN, CW, NO, VK and OO oversaw data collection. All authors participated in project administration from the start to finish of this research. MM analysed the data with support from VK, CW, SF, NO, and EM. MM drafted the manuscript with significant contributions from all authors. All the authors reviewed all manuscript versions and agreed on a final version for submission.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors would like to acknowledge the HIGH-Q author group comprising Peter Mwangi, Loise Mwangi, Penina Musyoka, Lucy Kinyua, Lydia Thuranira, Virginia Njoroge, Ngina Mwangi, and Zainab Kioni\u0026nbsp;\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eUNICEF. 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Sentin Event Alert, 2017(57): pp. 1\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBagheri Nejad S, et al. Health-care-associated infection in Africa: a systematic review. Bull World Health Organ. 2011;89(10):757\u0026ndash;65.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eChimhini G, Magwenzi M, Fitzgerald FC. Infection Prevention and Control in low-resource settings: the need for the local, the contextual and the pragmatic. Infect Prev Pract. 2022;4(3):100135.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"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":"Infection Prevention, Ward assistants, Neonatal care, Health workforce, Quality of care","lastPublishedDoi":"10.21203/rs.3.rs-6194020/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6194020/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground: \u003c/strong\u003eInfection prevention and control (IPC) is a critical component of neonatal care, particularly in low- and middle-income countries (LMICs), where healthcare settings face unique challenges. Neonates, especially preterm and low birth-weight infants, are at higher risk for infections, including healthcare-associated infections. In Kenya, neonatal units struggle with limited resources, understaffing, and shortages of essential supplies, significantly impeding effective IPC practices.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods:\u003c/strong\u003e This study employed a mixed methods approach in four public neonatal units in Kenya to assess the impact of deploying ward assistants on IPC practices. Data collection included structured and unstructured observations, in-depth interviews, and focus group discussions with healthcare workers and caregivers. The intervention aimed to address gaps in routine cleanliness, waste management, and adherence to IPC protocols.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults:\u003c/strong\u003eThe introduction of ward assistants led to noticeable improvements in overall ward cleanliness and waste disposal, highlighting the potential for enhanced infection control. Mothers’ hand hygiene practices improved, driven by targeted sensitization efforts. Despite these gains, significant challenges remained. Hand hygiene adherence among healthcare providers was inconsistent, and equipment cleaning and decontamination were frequently compromised by insufficient supplies and overwhelming patient demand. The findings underscored the critical role of resources and the need for consistent supervision and training to support sustainable IPC improvements.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion:\u003c/strong\u003eDeploying ward assistants in neonatal units can positively influence IPC practices, particularly in addressing environmental cleanliness and waste management. However, these benefits alone are insufficient to address systemic barriers to IPC, including resource constraints and variability in adherence among staff. To sustain these gains, robust training, consistent supervision, and adequate resourcing are imperative. Future research should explore the long-term impact of such interventions and design context-specific strategies to overcome persistent barriers, ensuring safer neonatal care in resource-limited settings.\u003c/p\u003e","manuscriptTitle":"Strengthening Neonatal Care through Ward Assistants: A Kenyan Case Study in Enhancing Infection Prevention and Control Practices","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-03-27 05:43:16","doi":"10.21203/rs.3.rs-6194020/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-04-03T06:32:58+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-04-03T05:23:01+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-03-31T14:57:01+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"79576898131764676132594813226105888414","date":"2025-03-25T03:40:33+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"338364195531342842572580420732578311178","date":"2025-03-25T00:55:34+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-03-24T14:37:07+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-03-16T09:20:58+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-03-13T13:50:10+00:00","index":"","fulltext":""},{"type":"submitted","content":"Antimicrobial Resistance \u0026 Infection Control","date":"2025-03-10T09:26:13+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":"f35e4f24-9e8e-4dc3-bb91-eaac0e2f2cb9","owner":[],"postedDate":"March 27th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2025-06-09T16:02:34+00:00","versionOfRecord":{"articleIdentity":"rs-6194020","link":"https://doi.org/10.1186/s13756-025-01575-w","journal":{"identity":"antimicrobial-resistance-and-infection-control","isVorOnly":false,"title":"Antimicrobial Resistance \u0026 Infection Control"},"publishedOn":"2025-06-02 15:57:31","publishedOnDateReadable":"June 2nd, 2025"},"versionCreatedAt":"2025-03-27 05:43:16","video":"","vorDoi":"10.1186/s13756-025-01575-w","vorDoiUrl":"https://doi.org/10.1186/s13756-025-01575-w","workflowStages":[]},"version":"v1","identity":"rs-6194020","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6194020","identity":"rs-6194020","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}