Behavioural Determinants of Hand Washing and Glove Recontamination before Aseptic Procedures at Birth: A Time-and-Motion Study and Survey in Zanzibar Labour Wards

Recent research calls for distinguishing whether the failure to comply with World Health Organisation hand hygiene guidelines is driven by omitting to rub/wash hands, or subsequently recontamination of clean hands or gloves prior to a procedure. This study examined the determinants of these two behaviours. Across the 10 highest-volume labour wards in Zanzibar, we observed 103 birth attendants across 779 hand hygiene opportunities before aseptic procedures (time-and-motion methods). They were then interviewed using a structured cross-sectional survey. We used mixed-effect multivariable logistic regressions to investigate the independent association of candidate determinants with hand rubbing/washing and avoiding glove recontamination. After controlling for confounders, we found that availability of single-use material to dry hands (OR:2.9; CI:1.58-5.14), a higher workload (OR:29.4; CI:12.9-67.0), more knowledge about hand hygiene (OR:1.89; CI:1.02-3.49), and an environment with more reminders from colleagues (OR:1.20; CI:0.98-1.46) were associated with more hand rubbing/washing. Only the length of time elapsed since donning gloves (OR:4.5; CI:2.5-8.0) was associated with avoiding glove recontamination. We identified multiple determinants of hand washing/rubbing. Only time elapsed since washing/rubbing was reliably associated with avoiding glove recontamination. In this setting, these two behaviours require different interventions. Future studies should measure them separately.