14 April 2020

“It is difficult to change people but it is worth giving it a shot”


Gifty Sunkwa-Mills is a public health researcher from Ghana especially passionate about one thing: making sure that patients do not leave the hospital with more infections than they arrived with.

Nurses receive feedback from Gifty on their hand hygiene practices in the neonatal intensive care unit.
Nurses receive feedback from Gifty on their hand hygiene practices in the neonatal intensive care unit.

Text: Morten Mechlenborg Nørulf / Pictures: Gifty Sunkwa-Mills

Gifty recently located to Copenhagen for the finalisation of her PhD thesis on healthcare-associated infections in Ghana, just days before Denmark shut down due to the corona pandemic. Like many others, she is working from home these days so we met her online for a talk about her research and the importance of good hygiene – something so relevant and ever-present in the times we live in right now.

Coming in with one disease and leaving with another

As the name implies healthcare-associated infections are infections which patients acquire during healthcare. It is measured as any infection that comes 48 hours after hospital admission. Globally it affects millions of patients and in Ghana a recent study done in ten hospitals, representing 32.9% of all acute care beds in government hospitals, showed that 8,2% of hospitalised patients experience healthcare-associated infections [1].

Healthcare-associated infections have severe consequences: patients spend more time being hospitalised, it increases morbidity and mortality and the financial burden on the healthcare systems grows.

“In low-income countries having a healthcare-associated infection can cost a patient a lot of money. Coming in with one disease and leaving with another means that you often need to spend more time being hospitalised or having to pay for more medicine if it is not provided for free by the healthcare system, which is often not the case” Gifty explains.

For some people this will pose challenges on making a living. Traders, for example, have to work every day and if they get sick they will lose money. All patients deserve good quality care but the question is: are we really achieving that if they leave the hospitals with more infections than when they arrived.

A major undocumented health burden

One of the big problems of healthcare-associated infections is the lack of data. The surveillance systems that are in place does not capture the reality and the severity of problem. Compared to other major diseases like malaria, hypertension and cardiovascular diseases, healthcare-associated infections are under-documented. As Gifty puts it: “You simply have too few staff producing reliable data.

And she is right. 66% of the world’s countries do not have data on healthcare-associated infections or they are underreporting. In high-income countries, healthcare-associated infections can be as low as 3-5% of the hospitalised patients. In low-income countries, good quality studies have shown a prevalence as high as 15,5% [2]. The prevalence study done by Gifty and her colleagues showed a 8,2% prevalence in Ghana in 2019. It varied from hospital to hospital with the highest prevalence being 14,4% and the lowest 3,5%. She further explains:

“Healthcare-associated infections might be one of the top ten burden of diseases in the world for all I know but we don’t know because there is no data on it. If we do not know how serious it is, then it is also hard to alert hospital managers and staff and make them take it seriously.”

Picture of prevalence of healthcare-associated infections in ten hospitals across Ghana
Prevalence of healthcare-associated infections in ten hospitals across Ghana [3].

Including both patients and healthcare workers in interventions

Although Gifty is a medical doctor, her PhD study is mainly based on ethnographic research of healthcare-associated infections in selected health facilities in Ghana.

If you want to design and implement effective interventions, you need to look at the social and cultural aspects surrounding the infections happening in hospitals. In my research, I look at the interactions among the healthcare workers, their cultural background, their perception of hygiene, as well as the interactions among patients and the healthcare workers. We tend to look at the workers and ignore the patients but patients need to be included to make interventions effective” she explains.

Global efforts to reduce healthcare-associated infections focus on infection prevention and control practices such as hand hygiene promotion efforts among healthcare workers. But healthcare workers do not always appreciate the gravity of the situation. Patients are an important resource for improving hygiene in hospitals. If they are more knowledgeable and educated about good hygiene they also know how to keep themselves away from infection.

The unveiling of a hygiene banner in a neonatal ward in Korle-Bu hospital.
 The unveiling of a hygiene banner in a neonatal ward in Korle-Bu Hospital.

Improving infection control in neonatal wards

A part of Gifty’s PhD focus on social and clinical interactions between healthcare workers and mothers in two neonatal wards. After a six months long standardised multimodal hand hygiene intervention, Gifty and her colleagues saw a decrease in healthcare-associated infections at the neonatal intensive incubation units. Hand hygiene compliance also increased after the intervention.

“This study was particular interesting”, she explains. “My main focus was to find out what mothers know about healthcare-associated infections and infection control. But I quickly realised that I had to understand the fundamental needs and concerns of the mothers before I could talk to them about healthcare-associated infections and thus include them in the study.”

After conducting 62 interviews, Gifty found that the healthcare workers and the mothers had varying perceptions of each other. Healthcare workers perceived themselves as clean and at risk of getting infections from the mothers. They had concerns about inadequate resources, heavy work load and lack of trained staff. The mothers on the other hand felt ill-informed and struggled to define their roles and share their concerns. They often felt marginalised, vulnerable and disempowered and the environment was stressful for them.

However, Gifty also discovered that experienced mothers spontaneously provided peer guidance to new mothers. They know how frustrating it can be when the healthcare workers do not have the time to talk to you so when a new mother is confused about something and feels too intimidated to approach a doctor or a nurse, they can turn to the experienced mothers.

Gifty explains: “If this peer-to-peer system can be institutionalised and you can recruit and train mothers, it would improve not only the experience for first-time mothers but also hygiene in the neonatal intensive care units, which in the end will decrease healthcare associated infections.”

A nurse in Korle- Bu Teaching hospital is practicing her hand hygiene
A nurse in Korle-Bu Teaching Hospital is practicing her hand hygiene.

How do you stop healthcare-associated infections?

If you ask Gifty, the answer is clear:

“Supportive leadership and resources are important. Once we provide supportive leadership and resources to the health institutions, there is more commitment to keeping up better hygiene. Secondly, make sure that the healthcare workers are trained in a way that enables them to have a good dialogue with patients about perceptions of infection control. Thirdly, keep reminding people to pay attention to hygiene. Rewards and telling people that they are doing a good job is also effective.

Gifty ends the interview by making a connection to the corona pandemic we currently find ourselves in:

“We are doing things now that we should have done ages ago. We are washing our hands, we don’t touch our faces, we practice social distancing. All these things will be with us for a long time after the pandemic and I hope this will help decrease healthcare-associated infections."

To Gifty it is quite simple: “We need to take infection control more seriously, be more careful and pay more attention to washing our hands. It is difficult to change people but it is worth giving it a shot.”

Picture of Gifty and her colleagues.
Gifty and her colleagues. Gifty’s PhD is part of a larger research project on healthcare-associated infections in Ghana supported by DANIDA.


1: Labi A-K, Obeng-Nkrumah N, Owusu E, Bjerrum S, Bediako-Bowan A, Sunkwa-Mills G, et al. Multi-centre point prevalence survey of hospital-acquired infections in Ghana, Journal of Hospital Infection (2018), doi: 10.1016/j.jhin.2018.04.019.)

2: Pooled prevalence of overall health-care-associated infection was 15·5 per 100 patients in high-quality studies and 8·5 in low-quality studies (Allegranzi et al. 2011).

3: Labi A-K, Obeng-Nkrumah N, Owusu E, Bjerrum S, Bediako-Bowan A, Sunkwa-Mills G, et al. Multi-centre point prevalence survey of hospital-acquired infections in Ghana, Journal of Hospital Infection (2018), doi: 10.1016/j.jhin.2018.04.019.