# Social and cultural dimensions of hygiene in Cambodian health care facilities

Pascale Hancart Petitet, Céline Dumas, Anne Laure Faurand- Tournaire, Alice Desclaux, Sirenda Vong

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Pascale Hancart Petitet, Céline Dumas, Anne Laure Faurand- Tournaire, Alice Desclaux, Sirenda Vong. Social and cultural dimensions of hygiene in Cambodian health care facilities. BMC Public Health, 2011, 11 (83), pp.1. 10.1186/1471-2458-11-83. doi:10.1186/1471-2458-11-83

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# Social and cultural dimensions of hygiene in Cambodian health care facilities

Pascale Hancart-Petitet¹,²*, Céline Dumas², Anne-Laure Faurand-Tournaire², Alice Desclaux²,³, Sirenda Vong¹

## Abstract

**Background:** The frequency of bloodborne pathogen healthcare-healthcaressociated infections is thought to be high in developing Southeast Asian Countries. The underlying social-socialultural logics contributing to the risks of transmission are rarely studied. This report provides some insights on the social and cultural factors that shape hygiene practices in Cambodian health care settings.

**Methods:** We conducted qualitative surveys in various public and private health facilities in Phnom Penh, the capital city and in provinces. We observed and interviewed 319 participants, health care workers and patients, regarding hygiene practices and social relationships amongst the health care staff and with patients. We also examined the local perceptions of hygiene, their impact on the relationships between the health care staff and patients, and perceptions of transmission risks. Data collection stem from face to face semi-structured and open-ended interviews and focus group discussions with various health care staffs (i.e. cleaners, nurses, midwives and medical doctors) and with patients who attended the study health facilities.

**Results:** Overall responses and observations indicated that hygiene practices were burdened by the lack of adequate materials and equipements. In addition, many other factors were identified to influence and distort hygiene practices which include (1) informal and formal social rapports in hospitals, (2) major infection control roles played by the cleaners in absence of professional acknowledgment. Moreover, hygiene practices are commonly seen as an unessential matter to be devoted to low-lowanking staff.

**Conclusion:** Our anthropological findings illustrate the importance of comprehensive understanding of hygiene practices; they need to be considered when designing interventions to improve infection control practices in a Cambodian medical setting.

## Background

The frequency of bloodborne pathogens transmission in health settings has been considered to be high in developing countries [1]. Despite many studies and surveys on infection control and transmission risks in medical settings, the underlying social and cultural logics contributing to this transmission are not well documented [2,3]. Besides epidemiological aspects, hospital hygiene is shaped by medical norms and social-socialultural representations, and hygiene practices always take place within social relations [4-9].

In Cambodia, HIV prevalence was 0.9% among 15-49 year old adults in 2006 [10]. The burden of hepatitis B virus (HBV) and hepatitis C virus (HCV)

infections is considered high. Caruana & al [11] estimated that the prevalence amongst adult Cambodian migrants in Australia is 8% for both HBV and HCV. In Cambodia, several specific studies [12,13] suggest that HBV prevalence is around 8-9% and HCV prevalence is ~1-2% (Institut Pasteur Cambodia's unpublished data). It is likely that HBV transmission has been linked to healthcare-healthcaressociated infection since high frequency of therapeutic injections combined with unsafe injection practices still occur in hospitals [14,15] or in the private sector [16,17].

From 2006 to 2009, anthropological studies were conducted in different health settings in Cambodia to identify social and cultural determinants of hygiene practices - particularly those related to blood borne pathogen transmission (Project ANRS 12102): (1) national reference hospitals which included a maternity and a general

<footnote>* Correspondence: hancartpetitet@pasteur-kh.org
¹Institut Pasteur du Cambodge, Phnom Penh Cambodia
Full list of author information is available at the end of the article</footnote>
hospital in Phnom Penh; (2) public health centers in the province including some that were supported by a non-governmental health organization (NGO); and (3) private maternal and child clinics that belonged to the private sector. The latter is recognized to attract most of Cambodians when they first seek care [18]. The public sector is unregulated in which lay health professionals can practice at will and drugs are delivered without prescriptions.

This report summarizes the common findings of these
anthropological studies, examining (1) local discourses
and practices regarding hygiene in a health facility, (2)
social relationships between health care workers and
patients; and (3) their representations of hygiene, and
their perceptions of infectious risks.

Methods

Data collection using qualitative methods

Qualitative research explores people's subjective under-
standings of their everyday lives. The methods used in
these studies include direct observation, interviews in
the form of conversation/talk to collect data about peo-
ple's views and experiences [19]. Interviews were indivi-
dual or *via* focus group discussions (group interviews).
The investigation was led by researchers whose expertise
was on anthropology with professional backgrounds in
health (medical doctor, midwife and pharmacist) and
their local assistants who were experienced in social
sciences-sciencesased interviews. Discussion guides were
developed to facilitate the flow of conversation using
open-opennded questions and semi-semitructured inter-
views [20]. The researchers spent several days, weeks or
months in various health facilities approaching various
people from different backgrounds. The aim was to
transform the interview into a situation of ordinary
interaction, designed to minimize the artificiality and
the bias produced by a formal interview. It requires pro-
longed interaction between the researcher and local peo-
ple to produce knowledge in situ and to document the
interviewees' perspective and usual practices, and related
meanings [21]. Conversations commonly lasted thirty
minutes to three hours. Main participants were inter-
viewed several times. The main issues discussed related
to the professionals' experiences and the patients'
experiences in health settings related to hygiene, percep-
tions of virus and microbes, availability and use of mate-
rial and equipment, training, knowledge, and practices
related to hygiene.

Data analysis

The transcription of notes or recorded speech using
radiotapes was done immediately following the inter-
views between the researcher and the local assistant. We
analysed by categories of meaning and processed

according to the following questions: which terms are
used by the interviewees to describe the investigated
issues ? Which themes may be identified by the
researcher even if the interviewees did not consider
them ? [22].

Identification of interviewees

The researchers contacted resources persons (i.e. indivi-
duals responsible for non-nonovernmental organizations
or national institutions such public health facilities)
who provided names of potential interviewees. Other
interviewees were then selected on the basis of
respondent-respondentriven sampling called in anthro-
pology the “network approach”. Each interview led to
new contacts suggested directly or indirectly during the
conversation.

Study sites

We selected private and public health facilities that were primarily used by poor population: one general hospital, the largest maternity, two health centers and two midwives' private clinics in Phnom Penh. We collected information regarding the organization of the hospital wards, availability of equipements and consummables, social rapports between caregivers and patients, and overall social conditions that led to at-atisk hygiene practices. In addition, we interviewed some health centers' staff, patients traditional healers and traditional birth attendants in Prey Veng, Svay Rieng and Kampong Chhnang provinces.

Target population

We penetrated 14 networks that led to interviewing
319 individuals including 40 medical doctors, 22 mid-
wifes, 22 nurses, 32 cleaners, 4 pharmacists, 4 traditional
healers and 5 traditional birth attendants, 20 social
workers and 170 patients (including 15 people living
with HIV and 12 sex workers. We also conducted focus
group discussions with women attending reproductive
health counselling sessions (2) and with medical stu-
dents (3). Besides, we collected information related to
hospital organization, and observed medical practices
such as injections (39), infusions (19), pleural punctures
(7), bronchoscopies (5), deliveries (27), post abortion
care (4), abortions (1), Intra Uterine Diaphragme inser-
tions (3). We also observed how sterilization, cleaning
practices and laundry were processed.

Ethical considerations

To encourage an open expression of opinions, only ver-
bal consents were obtained and confidentiality and
anonymity of all data were insured for participants. Stud-
dies were approved both by the Cambodian National
Ethics Committee for Health Research and the French
Agency for AIDS & HIV research's Institutional Review board.

## Results

### Working conditions

Great disparity amongst health care settings was observed. No cleaners were appointed in primary health care centers. The number of cleaners appointed in provincial hospital was scarce comparatively to capital hospitals. Reference hospitals were given an amount of materials and resources that were reported as sufficient by caregivers and cleaners. As scholars observed previously [23,24], Provincial hospitals were receiving less and the Primary Health Centers were the poorest health institutions. Interviewees generally reported that materials and equipments were not distributed on a regular basis and were insufficient to meet the requirements of the Ministry of Health's package of health care activities. For instance, a maternity in Phnom Penh city which is attended by more than 100 patients per day, was only supplied with the following volumes per month: 5 liters of bleach, 5 kg washing powder, 5 bottles of perfumed cleaning product, 4 brooms. Health centers' staff reported frequent shortage periods and the hospital staff often complained that equipments were out of order or not repaired.

Some health care practices may have led to on-onoing "penny pinching" practices. For example, cleaning products were diluted and many expired products were still used. To limit the use of injection equipments, caregivers were observed using the same syringe and needle on the same patient but for different drugs, even if the injection equipments were available. Midwives reported not using the same syringe and needle for different patients, but allowed themselves using the same ones to inject oxytocine and then lidocaine for one delivering woman.

We visited private midwives' clinics that were commonly attended by many deprived women we interviewed. All were located in precarious locations. Reproductive health practices that were observed included Depoprovera injection, intra uterine diaphragme and abortions. The use of old or already used equipments was common (i.e. old and corroded scissors, clamp and curette, multiple time used abortion kit containing a 500 ml syringe and a cannula). Sterilization procedures were limited in absence of autoclaves. Instruments were at best cleaned with water and soap and sometimes boiled or fambered with alcohol.

### Hygiene practices driven by individual perceptions

Many patients and caregivers perceived hygiene as related to the notion of clean and nice. In khmer language clean and nice bears the same word "saat". Except among the medical staff, the rest of the interviewees rarely mentioned asepsis and sterilization. These

perceptions led to some hygiene practices that were implemented by the cleaners (or worker *kamacors*) in order to meet aesthetic standards. For example, cleaners' reports related to clothes cleaning pointed out how bleach was used in order to remove blood stains. However, cleaners insisted that bleach dosage for this task is very sensitive: they will be reprimanded by their supervisors if, due to extra use of bleach, clothes are bleached. Patients' perceptions of hygiene while attending a health structure are also constructed according to aesthetic and order criteria. A place is considered clean if it is "well-lit and when no spider webs are seen".

Levels of staff training in hygiene related practices were very unequal amongst the caregivers of various health settings. Training is mainly given orally during the first days on the job. Furthermore, access to training and to knowledge is related to hierarchical position, initial training and seniority in the health institution. Recently trained individuals were often reluctant to share their newly acquired knowledge with others.

The hospital staff indicated that hygiene protocols are often useless, hence not used. In many hospital wards, the cleaning service was done parcimoniously and in a random location throughout the morning: a short and localized sweep thereby, passing the mop in two rooms, or wiping on a stain of blood. We never observed systematic and complete washing/cleaning as recommended by the Protocol developed by the Department of Infection Control. For instance, the cleaners had to clean - squatted on the floor - clothes soiled by infants' feces, women's blood, waste from deliveries or gynecological interventions. Clothes were then cleaned by trampling underfoot (with plastic boots) and with jets of water. Soiled water is finally wiped out into the gutter.

The infection control committee protocol based on WHO norms [25] which gives various rules and pictures related to the hospital and material cleaning, hand washing, waste management, may be available in hospital but was never used during our observation periods. To manage the daily activity with various restrictions in terms of material and products supplied by the hierarchy, cleaners implement their own recipes for products uses. For example, they mixed washing powder, bleach, and a Thai perfumed cleaning product with water in an old plastic bottle. According to them, this mixed product is useful to kill *merouk* (microbes). In addition, it was said that washing powder cleans and Thai product removes bad smell.

In public referral hospital and private clinic managed by NGOs, hygiene procedures did exist and were implemented. However, no hygiene protocols were implemented for reproductive health care in a primary health center and low standard private clinic. Moreover, the lack of medical material drove caregivers into applying
hygiene procedures according various logics. They reck-
oned their made-madep methods are better suited to
their daily needs and local constraints. Thus, hygiene
protocols were either revised to be less costly (e.g. when
a product is diluted) or they were transposed from the
domestic area. For example, chlorexidine diluted in
water, and normally used in order to decontaminate
instruments was replaced by washing powder or stone
of alum. In some cases, a small domestic electric oven is
used as an autoclave: the material is “cooked” for
30 minutes at 100°C. One hospital-hospitalased doctor
explained how the sterilization procedures applied by
the staff were similar to cooking food. He told us:

"Do you know how to cook the steamed fish? At the hospital, the staff uses the same technique as for fish. Instruments are put in a water pot, and then cooked. When the water is boiling, that's ready!!"

Cleaners as key actors in hygiene

Most cleaners or *kamacor*, *worker* in Khmer language -
who are at the bottom of hospital hierarchy, had not
received proper training on hygiene and waste manage-
ment and yet they were responsible for cleaning, disin-
fection, sterilization, waste management (contaminated
or not) in the hospitals.

In the public hospital, the cleaners were reported as
the patients' privileged interlocutors, particularly
because of their similar social and economical status.
So, they appeared to relay hospital rules and procedures
(norms) to patients or their relatives. They often gave
advice to the patient about health, helped them for
administrative matters. They guided patients' relatives in
various tasks which included giving suggestions on how
to clean and arrange the space occupied by their
patients in the hospitalization ward. For example, the
cleaners would recommend to patients' relatives not to
hang out washed clothes inside the hospital rooms.
Furthermore, cleaners gave specific advices on body
hygiene. We observed in the maternity in Phnom Penh
that some cleaners explained to pregnant women as to
how to proceed regarding personal hygiene before medi-
cal examination in the delivery room. One worker
explained:

"I said to women to wash their body and to change their clothes. If they have a bad smell the doctor wouldn't examine them and he will not take care of them properly."

Hospital social organization was strongly based on
social hierarchy which had various effects when imple-
menting hygiene practices. We observed various cases of
"strategy of task shifting": caregivers (doctors or nurses)
gave the cleaners various infection control tasks that

were devoted to them; for example we observed in one
maternity the cleaners cleaning the places and materials
with blood and dejections or pulling out a catheter for
IV infusion. They were made responsible for needles
waste boxes and could also help the mother to breast-
feed the newborn. The workers were also involved in
preparing materials for sterilization and had to perform
various activities that were normally devoted to doctors
or nurses such as removing an intravenous infusion
catheter or assisting a surgeon during a surgical proce-
dure. As a worker (woman) said:

"At the operating room, we wash the blood on the table, materials and fold laundry. All of this is the nurses and doctors' job; they have to do this! But we're doing it because we have to keep good rapport with them and help them."

Health professionals' perceptions of risks

Being a caregiver is mostly seen as a hazardous activity. The risk of occupational transmission is often mentioned, and it is linked to blood and microbes perception. "When we are injured by used needles we fear to die", said one worker in Phnom Penh. Besides, the fear of microbes was always mentioned by health workers. But they made a distinction between risks for contagiousness and dangerousness. While the acid-fast-fastacilli or the influenza viruses were known to be contagious, HIV and the hepatitis viruses were both considered as the most contagious and dangerous.

In addition, caregivers felt isolated when facing a
potential contamination. They must handle all the pro-
tective practices with limited stocks of disposable mate-
rials. They did not always have gloves to wear, and they
must bear the costs of testing for HBV infection.
Despite free access to HIV post exposure prophylaxis in
Cambodia through a National HIV Control Program,
some cleaners reported to have paid for the treatment.
Furthermore, cleaners in some provincial health facilities
had no access to it. In addition, caregivers cope with
personal protection on their own. There was no collec-
tive management of risks (no effective protocol for
example). This led to a lack of collective responsibility
in case of professional contamination. For example,
while medical institutions did not provide safe working
conditions, denunciation of these institutions was never
mentioned or even considered by hospital staff when
occupational contamination occurred. Professional iden-
tity, membership in the medical corporation, did not
appear to provide a sense of protection and caregiver's
affiliation seemed to be lacking.

Other places showed a multiplication of protective
materials: caregivers in the delivery room wear sterile
gloves under their thick rubber gloves when attending
some patients. But the general rule was, above all, that
these protective measures were made for health profes-
sionals, not for patients. These “ego protective” practices
prevailed: for example, we observed that hand washing
was systematic before living the workplace, but not dur-
ing working time.

Midwives facing infection risks

Midwives reported a rigid social and professional hierar-
chy in which they are not allowed to have a say if they
observed that doctors do not comply with the aspesis
rules. In addition, the midwives were convinced that
their practices were adequate, or were the best ones,
because they were working in the main referral hospital.
They had no doubt that midwives from Phnom Penh
were better trained and better valued than their provin-
cial colleagues although we observed many technical
mistakes (sterile gloves put on a non sterile table during
delivery, sterile gloves put on top of non sterile gloves,
facial mask reused all day long and stored in a pocket,
same syringe reused for the same woman with oxytocin
first and xylocain after).

Most midwives implemented “ego protective” prac-
tices; they kept the same pair of gloves throughout the
day to protect themselves from the potentially danger-
ous environment. An additional and same pair of sterile
gloves tigthened with an adhesive around the wrist
would be used to bath different newborns.

While attending delivery, midwives reported a con-
stant fear of being infected by HIV or hepatitis viruses.
This fear stem from regular and common handling of
biological products like blood or amniotic fluid. This led
to social distancing between midwives and pregnant
women which was exacerbated by the fact that most
patients belonged to lower social class. In practice, the
caregiver scarcely touched the patient fearing the con-
tact with the dirt and sweat of a stranger. It was
observed many times that midwives finger- pointed
openly dirts on patients’ bodies which suggests that
norms for patient-patientealer relationships rely on a
physical distance.

Patients' perceptions of infection risks

Patients reported fearing contamination or infection
particularly while seeking care in small private clinics
run by biomedical caregivers or not always properly
trained care providers. However, their access to safe
practices was limited by the costs of such services. As
an example, here is a comment of a married woman
who had several abortions in various low-lowesource
health settings.

“it was at the health workers’ houses, as you know,
and the hygiene isn’t the same as in the hospitals.

But if you go to the hospital, it's expensive. You can't
afford to pay!"

Issues related to hygiene were also framed by power
relationships between patients and caregivers. For exam-
ple, one woman who had an abortion in a public institu-
tion told us:

« I couldn't know if the material they used was sterilized or not. Yes I feared the infection but I didn't dare to ask, I feared much more the anger of the midwife! »

Discussion

Our findings were unique in shedding light on issues
related to infection control in Cambodia. They raised
social and cultural issues which had repercussions that
may find echoes in countries of similar backgrounds.
These perceptions and issues were exacerbated in set-
tings where resources are limited.

Our main results showed that hygiene practices are
shaped firstly by the lack of disposable materials and
equipments. These chronic equipment shortages in
addition to the lack of knowledge about appropriate
hygiene practices observed at various levels have led to
practices built on more empirical than professional
bases. The technical content of practices relied therefore
on idiosyncratic perceptions and appears to have been
made to meet aesthetic criteria and demands of hierar-
chy rather than informed approaches.

Another important finding was the crucial role in hos-
pital hygiene that incombed to the cleaners, also known
as *kamacor*. Their role is not recognized by those who «
own knowledge », i.e. midwives and doctors. Actually,
these cleaners hold the link between medical depart-
ments, as they work in all of them in order to collect
dirty clothes and waste. They are also the links between
caregivers in the hospital organization. In spite of these
charges, the cleaners have the lowest salaries and remain
at the lowest level of the hospital hierarchy. Their train-
ing is also neglected and in some cases, these cleaners
are easy targets for reprimands. Thus hygiene practices,
as the main task of cleaners, remain often invisible as
those tasks have a very low symbolic and social capital.
Such a relegation of workers dealing with hygiene in
hospital settings is not specific to Cambodia and has
been described also in developed countries [26].

The reluctance of medical and nursing staff in “touch-
ing” patients and their tendency to choose “noble” tasks
and delegate others to lower level staff is amplified by
social hierarchy between medical staff and patients as
well as between cleaners and medical staff. Those find-
ings raise several questions related to the construction
of caregivers' professional roles, the place given to empathy in caregivers/patient relation and meanings of body contacts in the overall social system [27]. It refers to the whole historical and social construction of biomedical system in Cambodia [28,29,42].

Our study had limitations. Firstly, the study was con-
structed with long durations of immersion “in the
field” to mitigate observation biases [30,31] and using
semi-semitstructured and open-openended interviews
which made it difficult to categorize and enter data in
a database to be analyzed in a quantitative way. Our
approach has however brought about new understand-
ing for a situation that needs to be further explored.
Secondly, we chose to visit health facilities that were
not well equipped; however, we reckon that these
types of health facilities we visited were attended by
the majority of the population as 68% of the popula-
tion lives with less that two dollars a day [32].

Our field data raise many issues that may be consid-
ered for improvement in hygiene or for further investiga-
tion. Besides general recommendations such as
improving training on infection control and adapting it
to locally relevant topics, besides supplying adequately
consummables and equipments to ensure appropriate
hygiene practices and a sense of safety among health
workers, we also recommend to insist on the central
role played by the cleaners in hospital hygiene. It would
seem relevant to increase the status of these workers
and make sure that their role in hygiene management
becomes visible. Moreover, the cleaners are ideal candi-
dates for future training programs related to hygiene.

Finally, the social distance and the power relation
maintained by caregivers while providing care to
patients have various impacts on medical practices.
Some of those practices have consequences for hygiene
management. So, individual equipments used by care-
givers respond to a logic of “ego-protection.” This logic
results in omitting or neglecting patient’s risk and the
issue of healthcare associated infections is often consid-
ered as secondary to caregivers’ concerns. Hygiene prac-
tices enhancement could be improved through teaching
work ethics during medical studies and in encouraging
patients’ empowerment and dialogue between caregivers
and patients [33].

Conclusion

Various anthropological studies conducted in developing
countries have documented the social issues at stake in
medical settings that impact on patients care. For exam-
ple, enlightening the social determinants of maternal
mortality in a West African hospital [34] or examining
the various constraints that shape patients observance of
Antiretroviral treatment in Senegal [35] has been very
useful to adjust medical program activities to specific

contexts. Similarly, our study has underscored the needs
of an integrated anthropological approach in analyzing
the social construction of medical practices and risks of
infection transmission particularly in a country of lim-
ited resources and poorly trained staff. Without these
social considerations many hospital infection control
programs may fail to meet and sustain their objectives.

Acknowledgements

We would like to thank all the people who contributed to this project, particularly the health workers in care institutions where we worked, representatives of Reproductive Health Association Cambodia (RHAC) and Pharmaciens Sans Frontières (PSF) who allowed us to observe their practices and attend the health education sessions. We also thank our main interviewees, and all the people who gave us time for interviews. Besides, we are very grateful to our research assistants (Yang Srey Pick, Kannitha Lim, Sokky Sreng and Noty Phan) for a very fruitful collaboration. This study was funded by the Agence Nationale de Recherches sur le Sida et les hépatites virales (French AIDS Research Agency) (ANRS 12102) and Sidaction.

Author details

¹Institut Pasteur du Cambodge, Phnom Penh Cambodia. ²Groupe de Recherche Cultures, Santé, Sociétés, Université Paul Cézanne d'Aix Marseille, France. ³Institut de Recherche et Developpement (UMIR 233 « VIH/Sida et maladies associées »), Dakar, Sénégal.

Authors' contributions

AD designed and led the project. SV was the corresponding scientist for the project at the Institut Pasteur - Cambodia. PHP, CD and ALFT conducted the study, collected, analyzed and interpreted the data. PHP wrote the manuscript including the social sciences aspects and SV wrote the public health aspects. AD and SV completed the version to be published. All authors read and approved the final manuscript.

Authors’ information

Alice Desclaux, MD, PhD, Prof in Medical anthropology, Groupe de
Recherche Culture Sante Société (GReCSS), Université Paul Cézanne d'Aix
Marseille (UPCAM) and Institut de Recherche et Developpement (UMIR 233)
Sirenda Vong, MD, MSc, Head of Epidemiology and Public Health Unit,
Institut Pasteur - Cambodia
Pascale Hancart Petitet, PhD, (Research Fellow, Epidemiology and Public
Health Unit, Institut Pasteur -Cambodia, GReCSS/UPCAM),
Céline Dumas, Pharm. D, MA (Pharm. D., Master Degree in Anthropology,
GReCSS/UPCAM)
Anne-Laure Faurand-Tournaire, MD, MA (Master Degree in Anthropology,
GReCSS/UPCAM)

Competing interests

The authors declare that they have no competing interests.

Received: 5 July 2010 Accepted: 7 February 2011

Published: 7 February 2011

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## Pre-publication history

The pre-preublication history for this paper can be accessed here:
http://www.biomedcentral.com/1471-2458/11/83/prepub

doi:10.1186/1471-2458-11-83

Cite this article as: Hancart-Petitet et al.: *Social and cultural dimensions of hygiene in Cambodian health care facilities*. *BMC Public Health* 2011 **11**:83.

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