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RESEARCH ARTICLE

Infection prevention and control in neonatal

units: An ethnographic study of social and

clinical interactions among healthcare

providers and mothers in Ghana

Gifty Sunkwa-MillsID 1,2*, Kodjo Senah3, Britt Pinkowski Tersbøl2

1 Ghana Health Service, Central Region, Kasoa, Ghana, 2 Global Health Section, Department of Public

Health, University of Copenhagen, Copenhagen, Denmark, 3 Department of Sociology, University of Ghana,

Accra, Ghana

* [email protected]

Abstract

Introduction

Healthcare-associated infections (HAIs) are a global health challenge, particularly in low-

and middle-income countries (LMICs). Infection prevention and control (IPC) remains an

important strategy for preventing HAIs and improving the quality of care in hospital wards.

The social environment and interactions in hospital wards are important in the quest to

improve IPC. This study explored care practices and the interactions between healthcare

providers and mothers in the neonatal intensive care units (NICU) in two Ghanaian hospitals

and discusses the relevance for IPC.

Methodology

This study draws on data from an ethnographic study using in-depth interviews, focus group

discussions involving 43 healthcare providers and 72 mothers, and participant observations

in the wards between September 2017 and June 2019. The qualitative data were analysed

thematically using NVivo 12 to facilitate coding.

Findings

Mothers of hospitalized babies faced various challenges in coping with the hospital environ-

ment. Mothers received sparse information about their babies’ medical conditions and felt

intimidated in the contact with providers. Mothers strategically positioned themselves as

learners, guardians, and peers to enable them to navigate the clinical and social environ-

ment of the wards. Mothers feared that persistent requests for information might result in

their being labelled “difficult mothers” or might impact the care provided to their babies.

Healthcare providers also shifted between various positionings as professionals, caregivers,

and gatekeepers, with the tendency to exercise power and maintain control over activities

on the ward.

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OPEN ACCESS

Citation: Sunkwa-Mills G, Senah K, Tersbøl BP

(2023) Infection prevention and control in neonatal

units: An ethnographic study of social and clinical

interactions among healthcare providers and

mothers in Ghana. PLoS ONE 18(7): e0283647.

https://doi.org/10.1371/journal.pone.0283647

Editor: Kahabi Ganka Isangula, Agha Khan

University, UNITED REPUBLIC OF TANZANIA

Received: July 28, 2021

Accepted: March 14, 2023

Published: July 7, 2023

Copyright: © 2023 Sunkwa-Mills et al. This is an

open access article distributed under the terms of

the Creative Commons Attribution License, which

permits unrestricted use, distribution, and

reproduction in any medium, provided the original

author and source are credited.

Data Availability Statement: All relevant data are

within the manuscript and its Supporting

Information files.

Funding: This study was supported by the Danish

Ministry of Foreign Affairs as part of the HAI-Ghana

project (DANIDA grant number 16-PO1-GHA). The

funders played no direct role in the study design or

preparation of the manuscript.

Competing interests: The authors have declared

that no competing interests exist.

Conclusion

The socio-cultural environment of the wards, with the patterns of interaction and power,

reduces priority to IPC as a form of care. Effective promotion and maintenance of hygiene

practices require cooperation, and that healthcare providers and mothers find common

grounds from which to leverage mutual support and respect, and through this enhance care

for mothers and babies, and develop stronger motivation for promoting IPC.

Introduction

Healthcare-associated infections (HAIs) remain a global health challenge [1, 2], with associ-

ated direct and indirect costs to health institutions, families, and individuals [3, 4]. Neonatal

intensive care units (NICUs), with neonates receiving complex medical therapy in a highly

technical environment, are challenging environments in which to maintain patient safety [5].

HAIs are responsible for more than a quarter of the estimated neonatal deaths in hospitals in

LMICs [6]. In Ghana, the overall HAI prevalence rate is 8.2% among hospitalized patients [7].

In the NICU, mothers of babies on admission are important stakeholders, and their

involvement is critical in improving the quality of care [8, 9]. Although mothers are not solely

responsible for the care of their babies, their constant presence in the therapeutic space renders

them important stakeholders in care, whose concerns and roles need to be considered [8, 9].

This also requires that the underlying social relations of power are recognized and considered

[10]. The medical encounter has been portrayed as a place where patients are subordinated to

physicians’ domination. The unequal power relationships between healthcare providers (HPs)

and clients (including patients, caretakers, and mothers) are a central factor at the core of

addressing quality of care [11–15]. The differences in provider and client access to power and

decision-making are further accentuated by the different statuses of providers and clients [16].

In Ghana, research has shown how power relationships affect the quality of care women

receive during childbirth [17, 18]. HPs play a key role in involving and empowering mothers.

However, mothers’ reliance on the perceived expertise of HPs enforces unequal power rela-

tions [12, 19].

The joint endeavour of meaningful collaboration between HPs and mothers in managing

the risk of infection in this context is complex and compounded with challenges [20–22]. In

this context, HPs are often more focused on the provision of clinical care and are uncertain

about how to engage parents and relatives in care delivery [8, 9]. Although IPC as a form of

care may seem less of a priority to HPs, management of the risk of infection constitutes a cru-

cial aspect of care.

Limited research exists on the social environments of NICUs in low- and middle-income

settings including the interaction between HPs and mothers [23–26]. Using Positioning The-

ory, this ethnographic study explores care practices in two NICU wards in Ghana, to identify

challenges and opportunities for improved IPC.

Conceptual framework

Positioning Theory is a psycho-sociological concept of how people position themselves and

others within society and in institutions [27–29]. It is concerned with revealing the patterns of

reasoning that underlie how people behave toward one another [28]. This theory has been

applied to workplace interactions in fields ranging from public relations [30, 31] to

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Abbreviations: FA, Facility A (Tertiary Hospital; FB,

Facility B (Secondary Hospital; FGD, Focus Group

Discussions; GHS, Ghana Health Service; HAIs,

Healthcare-Associated Infections; HPs, Healthcare

providers; IDIs, In-depth interviews; IPC, Infection

Prevention and Control; LMICS, Low-and middle-

income countries; MOH, Ministry of Health; NICU,

Neonatal Intensive Care Unit; WHO, World Health

Organization.

interprofessional relations in healthcare, including how HPs see themselves in relation to

other colleagues, patients and their relatives [32, 33]. Harré and colleagues explain that "posi-

tioning theory studies refer to cognitive processes that are instrumental in supporting the

actions people undertake, particularly by fixing for this moment and this situation what these

actions mean" [28].

HPs orient themselves to the hierarchies and duties attached to their professional functions

in the hospital setting. Communication and negotiations about hygiene and IPC compliance

also take place in this context [32]. Among HPs, collaboration across organisational bound-

aries remains challenging, and power dynamics affect the strategic choices about how and with

whom to collaborate [13]. Positioning theory [28, 30, 34] is employed to shed light on the

necessity and functionality of positions in this context.

Positioning theory has been used to examine how people produce and explain their behav-

iour and that of others, and how positions are invoked and negotiated [29, 34–37]. Positioning

and other-positioning may result in marginalization, decreased opportunities, and exclusion

[38]. HPs are continuously engaged with mothers in the NICU context, with its characteristic

structural and socio-cultural working conditions. Focusing on the positionings of HPs and

mothers, the relevant factors and the framework within which care is delivered are explored.

From the Foucauldian perspective, the hospital ward can be described as a ‘heterotopia’, a

relatively segregated place in which several spatial arrangements and rules co-exist, practices

and power structures interconnect, and various lines of interest, identity, authority, and activ-

ity intersect [39]. Doctors, nurses, administrators, patients, and families, who are involved in

this space subscribe to a set of cultural norms and base their expectations and decisions on

professional information, knowledge, and background [40–42].

Power shapes social inequalities experienced by individuals and communities as well as

health collaboration, participation, and ownership [43]. In hospital settings, where there is an

asymmetrical power difference between clients and HPs [11, 44], any form of collaboration

toward improving the quality of care is associated with complexities. Continuous attention

should be focused on the care practices in such contexts [45]. Using positioning theory, we

explore the potential to attend to and strengthen care practices in hospital wards.

Methodology

Study setting

Ghana is a West African country with a population of about 30.3 million and is divided into 16

regions, constituting the northern, middle, and southern zones [46]. Ghana has 10 regional-

level hospitals which form secondary-level referral points from primary care centres, and 5

teaching hospitals providing tertiary-level care in the public sector [47]. This study occurred in

two purposively selected hospitals in southern Ghana: the Greater Accra region and the East-

ern region. The Greater Accra region was selected because it is the national capital and has

some of the largest health facilities in the country. The Eastern region was selected due to logis-

tical reasons, with its proximity to the national capital. This study was conducted in the NICU

of a tertiary-level hospital and a secondary-level hospital, which were purposively selected as

part of a larger field study on HAIs in Ghana [7, 47]. The two hospitals selected for this study

have an average HAI prevalence rate of 10.2%, which is above the overall HAI prevalence rate

of 8.2% among hospitalized patients in Ghana [7].

The tertiary-level hospital (hereafter referred to as Facility A or FA) is a 2,000-bed hospital

in Accra in the Greater Accra region and serves as a referral centre for most hospitals in the

southern zone and beyond. FA has a 55-bed NICU and a 261-bed maternity unit. The NICU

admits approximately 2400 neonates yearly. The secondary-level hospital (hereafter, FB) is in

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Koforidua in the Eastern region and has a 356-bed capacity that serves the population of the

Eastern and other nearby regions. FB has a 30-bed NICU and a 54-bed maternity unit. The

NICU admits about 1000 neonates yearly.

Study design

We used an ethnographic approach involving qualitative in-depth interviews, focus group dis-

cussions (FGDs), and participant observations to collect data between September 2017 and

June 2019. Ethnographic research emphasizes "being there" and gaining an insider perspective

by observing and interacting with people in the setting, as participants become more comfort-

able with the researchers’ presence [48]. Ethnographic studies require long periods in the field

to experience the everyday lives of participants [49, 50]. This can provide a deeper insight into

social phenomena, and help in understanding the organisational and cultural aspects of patient

safety research [51].

Multiple data collection methods were employed as the hallmark of a good qualitative study

[52, 53] and to present an in-depth understanding of the topic under study. FGDs help to gain

an understanding of how individuals collectively construct meanings and provide deeper and

richer data due to group dynamics [43]. Participant observation was done to familiarize with

the care processes and appreciate the relationships and interactions between the various partic-

ipants. The first author (GSM) conducted most of the in-depth interviews and FGDs, with the

help of two trained research assistants, who have degrees in health-related fields and experi-

ence in qualitative research.

The first author (GSM) is a female medical doctor and Ph.D. researcher with a background

in anthropology and public health. GSM, under the guidance of the Ph.D. supervisors, BPT

(last author, an associate professor of public health with a background in anthropology and

qualitative research), and KS (second author, a professor of social science with decades of expe-

rience in qualitative research) trained the research assistants and also supervised them during

data collection. The researchers were not familiar with the participants before the study.

Recruitment and data collection

Purposive sampling was used to recruit HPs working in the two hospitals. We considered the

various categories of HPs on the wards during the selection, to achieve diversity in terms of

staff cadre and level of experience. HPs were approached during their break period, informed

about the research, and invited to participate. The study included doctors, nurses, auxiliary

nurses, midwives, hospital managers, IPC coordinators, and ward in-charges at the maternal

and NICU wards with more than 6 months of experience in the hospital. The study excluded

HPs working in the outpatient departments and those who were on study leave or transfer at

the time of the study. Forty-three HPs participated in in-depth interviews.

Women 15 years and older, whose babies had been admitted to the NICU for a minimum

of 48 hours were eligible to participate in the study. The mothers were selected purposively to

ensure that they had spent different periods in the NICU so they could share their varied per-

spectives on care. Mothers were recruited from the maternity and NICU wards, as some moth-

ers spent their time between the two wards. Mothers were approached, informed about the

study, and invited to participate. None of the participants who were invited refused to partici-

pate in the study. A total of 32 mothers participated in the in-depth interviews, and a conve-

nience sample of 40 eligible mothers participated in 6 FGDs, 3 in each hospital, with 6–8

women per group.

Interviews lasted 45 to 60 minutes and FGDs lasted 60 to 90 minutes. Interviews were con-

ducted face-to-face in the hospital, and in quiet side rooms on the wards, or in available

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conference rooms or meeting rooms. Demographic information was collected. A semi-struc-

tured interview guide (S1 Appendix) which had been pilot-tested was used to capture partici-

pants’ experiences with ward interactions and IPC compliance, but it was open to include

other perspectives. Some mothers’ interviews were conducted in English and others in Twi.

At the point of data saturation, no new information was generated from the interviews. We

conducted 6 FGDs with 40 mothers. We considered this sample size sufficient to fulfil the

objectives of this study, based on a predicted thematic saturation after 5 FGDs, with an allow-

ance for an extra FGD after data saturation.

Participants were provided refreshments (drinks and snacks) during the interviews.

The first author and 2 research assistants conducted participant observations intermittently

in the two hospitals. The observations were done on the wards during both the day and night

shifts, using an observation guide (S2 Appendix). This was done on 2 or more days in a week

in each hospital over the period of the research. The combination of participant observation

and interviews provided insight into how perceptions were translated into action [52–54].

During participant observations, researchers participated in activities, assisted by handing

over items during procedures, and supported HPs when they needed help to fetch items or to

arrange the wards. Informal conversations were held with HPs during work or while they were

on break. We took down observation notes and documented any interesting incidents during

the observation period. Observation notes were taken during participant observation (S3 File).

Data analysis

Interviews were audio-recorded and transcribed verbatim. Interviews conducted in Twi were

translated into the English language during transcription and then checked for accuracy. Data

were analysed thematically based on the objectives of the study [55, 56]. Relevant contextual

information from interview notes and field notes were incorporated for further ethnographic

analyses [50]. The transcripts were uploaded to QSR N Vivo 12 to support coding and analysis.

The data was triangulated, and similar codes were grouped into categories. Initial codes were

descriptive and close to the data [57]. The categories were then regrouped into subthemes and

themes. Our theoretical orientation was drawn from the positioning theory [28, 34] which

informed the framework for analysis. The initial reading of the transcripts was done by all

authors. GSM conducted the majority of the analysis; however, the co-authors (KS and BPT)

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