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Cleaners must be viewed as a key part of the health system to reduce infections and antimicrobial resistance among staff and patients, according to a report by experts from the CLEAN research group.

This is one of the recommendations in their briefing paper, which highlights the challenges facing resource-limited settings and factors that need to be considered to support the implementation of tailored and effective hospital cleaning practices. These factors include, for example, ensuring capacity strengthening of cleaners and the need for financial support to cement cleaning in the healthcare system.

The CLEAN group, convened as part of a UK-PHRST research project, sets out key research questions in the paper that must be addressed to improve hospital cleaning and help prevent infections and antimicrobial resistance in resource-limited settings.

The current picture of environmental cleaning

The current environmental cleaning research and implementation picture has many gaps; a sparse body of research with only small-scale studies, limited country-level monitoring, poor financing and a lack of formal staff training and cleaning protocols.

In real terms, this results in ineffective cleaning practices in healthcare settings with limited resources. According to the World Health Organization (WHO) and UNICEF’s joint report examining the progress on WASH in healthcare facilities 2000-2021, in 2021 alone only 45% of rural health care facilities in Sub-Saharan Africa had cleaning protocols while 32% had staff trained on environment cleaning. Importantly, most countries do not have data to report on these indicators. The lack of consistency in hospital cleaning practices can have serious impacts on patient and staff safety - increasing the risk of exposure to healthcare associated infections and enabling the spread of antimicrobial resistance.

Setting the focus for future implementation research in healthcare cleaning

To address the knowledge gap, the CLEAN Group reviewed the existing landscape. Their review highlighted four priority themes and research questions to address:

• Cleaning Standards: What are the human resource requirements to achieve microbiological cleanliness in different types of healthcare settings?

• System strengthening: What are the health system-level factors that can support the professionalisation of cleaning staff?

• Behaviour change: What are cost-effective strategies to maintain the required frequency and quality of cleaning in a healthcare setting?

• Innovation: Are locally produced disinfectants more cost-effective compared to existing commercially available disinfectants?

From theory to practice

The researchers also consulted with on-the ground specialists and experts in the resource-limited settings to understand how to effectively translate research findings into real-world change. This highlighted considerations such as:

• Accountability and shared responsibility are required at all levels of the health system to ensure improving cleaning practices remains feasible

• The background of cleaning staff needs to be considered when implementing cleaning programmes. Cleaners are often neglected in the health system hierarchy as they are typically women of low socio-economic status. The intersection of these identities needs to be considered and staff must be included in the design of new cleaning programmes

• The role of cleaners in ensuring patient and health worker safety needs to be recognised to ultimately allow them to perform their duties with dignity

• Cleanliness standards and benchmarks specific for resource-limited healthcare settings are needed

• Adequate financial support backed by business cases and cost-effective evaluation is needed to cement cleaning as a key part of the healthcare system

• Cleaning practices must align with wider policies and strategy in the field to maximise their effectiveness

Driving change

The ultimate aim of the research priorities is to implement low-resource tailored and effective cleaning practices and, as recommended by the WHO’s guidelines for Infection Prevention and Control, lead to a reduction in healthcare associated infections in patients and staff and reduce the spread of anti-microbial resistance in resource-limited settings.

Giorgia Gon, Assistant Professor of Epidemiology at the London School of Hygiene & Tropical Medicine and author on the briefing paper, said: “Cleaners have too long been invisible in the healthcare system. Only by supporting their essential role in patient and health worker safety, we can allow them to work effectively and with dignity.

“Their role is not only pivotal for safety including being better prepared for potential disease outbreaks; indeed, a clean environment is also a key element of respectful care in the healthcare setting.”

The Group is now calling on funders, policymakers and advocates to drive forward implementation research into cleaning practices in hospitals with limited resources.

The CLEAN Group was first convened in mid-2022 within a UK-Public Health Rapid Support Team (UK-PHRST) project to identify the most urgent research questions to inform or enhance the implementation of best practices in surface and non-critical equipment cleaning in healthcare facilities in resource-limited settings. It includes individuals from Africa, Europe, Asia, Australia, North and South America, with expertise in infection prevention and control, hospital cleaning and disinfection, water, sanitation and hygiene (WASH), health policy, implementation science and clinical research in resource-limited settings.

The UK Public Health Rapid Support Team is funded by UK Aid from the Department of Health and Social Care and is jointly run by UK Health Security Agency and the London School of Hygiene & Tropical Medicine. The views expressed in this publication are those of the author(s) and not necessarily those of the Department of Health and Social Care.

Read the CLEAN Briefing Paper – Research priorities for healthcare cleaning in resource-limited settings