More Than Clean Hands – Designing a Culture of Hygiene

Ekta Ohri is the Head of Project Operations at CKS.

In early May, we blogged about the challenge of getting doctors to wash their hands. As it turns out, even in the best of hospitals, doctors and nurses only wash their hands in half of the situations that they’re supposed to. On the Fixes blog, Tina Rosenburg explored the reasons why:

Using alcohol rub takes only a few seconds, but many nurses should be doing this dozens of times a day — in some intensive care wards, 100 times a day for each patient.

CKS has been working on several projects aimed at improving maternal and child healthcare in rural parts of the Indian state of Bihar, and we’ve found the same difficulty around hygiene. For one, not many of healthcare workers we observed had a very strong sense of the importance of hygiene, even in their personal lives. But even those who did maintain a level of hygiene at home didn’t maintain that level of hygiene while they were working.

Divya Datta is a senior design researcher managing one of our current projects:

We’ve observed frontline health workers begin service provision without washing their hands, administer vaccines without disinfecting the injection site because they have to wait for 2 minutes for the [alcohol] to dry off, inject multiple recipients even when their hands may be dirty with recipient urine. The severity of hazards caused by such practices is not understood by health providers.

When we were last in Bihar, I assumed that this had to do with a lack of infrastructure necessary for hygiene (the workers were working on the ground, without tables, chairs or a place to wash their hands or dispose of waste) and also a lack of awareness about proper hygiene.

But after reading Rosenburg’s article, I realized that there are multiple layers to this problem. There is a lack of an infrastructure and a lack of awareness. But even in the most modern hospitals, healthcare workers still don’t wash their hands.

In her blog, Rosenburg talks about some high-tech attempts to make enforce hand-washing:

Every health care worker wears an electronic badge. When she washes her hands or uses alcohol rub, a sensor at the sink or dispenser or her own badge smells the alcohol and registers that she has washed her hands. Another sensor near the patient detects when her badge enters a room or the perimeter around a patient that the hospital sets. If that badge shows that her hands were recently washed, it displays a green light or something else the patient can see. If she hasn’t washed, her hands, the badge says so and emits a signal to remind her to do so.

Whether these systems will work remains to be seen. But in these rural, underdeveloped areas, the problem is more than just hand-washing. There are countless ways that a person could fail to maintain hygiene, and even the most high-tech solutions don’t account for workers using soiled cotton balls or disposing of needles on the ground.

So it’s more than just enforcing one behavior. It requires creating a broad cultural shift around perceptions of hygiene.

Later, we’ll be posting some thoughts from Divya about how our projects are looking to promote hygiene. More soon.

About Ekta Ohri

Ekta Ohri has a background in Architecture, Visual and Critical Studies, and Anthropology and is interested in exploring links between design, culture, and lived experience.
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