An invisible workforce: the neglected role of cleaners in patient safety on maternity units

ABSTRACT

Hospital cleaning has been shown to impact on rates of healthcare-associated infections (HCAIs) and good environmental hygiene is critical to quality care, yet those tasked with the role of ensuring a safe and clean environment often go unrecognised as members of the healthcare workforce. Sepsis is a leading cause of maternal and newborn death, a significant proportion of these cases are estimated to be due to HCAIs. Deliveries in health institutions have now reached 75% globally, and in low and middle income countries the corresponding increased pressure on facilities  has impacted both quality of care provided and quality of the birth environment in terms of infection prevention and control (IPC) and HCAIs. The paper discusses the neglected role of health facility cleaners, providing evidence from the literature and from needs assessments conducted by The Soapbox Collaborative and partners in Bangladesh, India, The Gambia and Zanzibar. While not the primary focus of the assessments, common themes emerged consistently pointing to institutional neglect of cleaning and cleaners. The paper argues that low status within facilities, wider societal marginalisation, lack of training, and poor pay and working conditions contribute to the lack of prioritisation placed on health facility environmental hygiene. With increased international attention focused towards health facility water, sanitation and hygiene and a growing focus on IPC, now is the time to address the neglect of this frontline healthcare workforce. We propose that provision of and improved training can enable the recognition of the valuable role cleaning staff play, as well as equipping these staff with the tools required to perform their job to the highest standard. In addition to training, wider systems changes are necessary to establish improvements in environmental hygiene and the role of cleaning staff, including addressing resource availability, supportive supervision, and an increased emphasis on preventative healthcare.

KEYWORDS:

• Infection prevention
• cleaners
• healthcare associated infections
• low and middle income countries
• environmental hygiene

Responsible Editor Nawi Ng, Umeå University, Sweden

Responsible Editor Nawi Ng, Umeå University, Sweden

Acknowledgments

The data included in the paper originated from studies conducted by The Soapbox Collaborative in partnership with BRAC (Bangladesh), the Indian Institute of Public Health, Gandhinagar (India), Pemba Public Health Laboratory Ivo de Carneri (Zanzibar), WaterAid Tanzania, The Ministry of Health & Social Welfare (The Gambia), and Horizons Trust Gambia (The Gambia). We would like to acknowledge the contribution of all those involved in the needs assessments in each country, in particular the cleaning staff who gave their time to be interviewed. We would also like to acknowledge the contributions of Natalie Gibson and Joanna MacQueen for the production of Figure 1.

Disclosure statement

The authors report no conflicts of interest.

Ethics and consent

Ethics approval was obtained at each respective site from study partners, health facility management and relevant ethical bodies – College Ethics Review Board, University of Aberdeen, UK; the Institutional Ethics Committee of IIPHG; the Government of Gujarat; the Ministry of Health & Social Welfare, The Gambia; Ethical Review Committee of the James P Grant School of Public Health (ERC ref: 31) at BRAC University, Bangladesh; the Zanzibar Medical Research and Ethics Committee; the Observational/Interventions Research Ethics Committee at the London School of Hygiene and Tropical Medicine. Informed consent was obtained from all participants.

Paper context

Marked increases in institutional deliveries across low- and middle- income countries over the last 5–10 years have resulted in significant pressure on facilities, impacting quality of care and infection prevention and control. Hospital cleaning contributes to the prevention of healthcare-associated infections, yet cleaners are often a marginalised cadre, with poor working conditions and recognition. A missed opportunity for improvement of environmental hygiene, as a key component of quality care, lies in cleaners’ training and empowerment.

Additional information

Funding

The study in India was funded by UK aid from the Department for International Development (DFID) as part of the SHARE Research Programme and the Water Supply and Sanitation Collaborative Council (WSSCC); in Bangladesh the study was funded by The Soapbox Collaborative; in Zanzibar by WaterAid, the SHARE Research Programme and The Soapbox Collaborative; and in The Gambia by The Soapbox Collaborative and Horizons Trust Gambia (HTG). The views expressed do not necessarily reflect those of DFID, WSSCC, WaterAid or HTG official policies. Neither DFID nor WSSCC had any role in study design, data collection, data analysis, data interpretation or writing of the paper. WaterAid had a role in data collection and data analysis. HTG had a role in data collection and writing of the paper. The Soapbox Collaborative had a role in study design, data analysis, data interpretation and writing of the paper. The work reported in this paper provides the foundation for the CLEAN Study funded by the UK Joint Global Health Trials (Wellcome, MRC, DFID and DOH) (grant number MR/R019274/1) currently being conducted in Tanzania as the basis for a robust evaluation of a cleaners’ training package.

Notes on contributors

Suzanne Cross

SC, GG, SA, AR, DS, KV contributed to study design and tool design, data collection and data analysis in respective sites. WJG, KA and EM contributed to study and tool design. TM and LA contributed to data collection. SC prepared the first draft of the paper. All authors commented on the drafts and approved the final version, with key revisions from WJG and GG.