Introduction
Healthcare-associated infections (HAI) are defined as infections that a patient develops after 48 hours of hospitalization that were not present or incubating when they were admitted. Reference Kelly and Monson1 These infections span a wide spectrum of disease but are most frequently associated with surgical site infections, central line-associated infection, catheter-associated urinary tract infections, ventilator-associated pneumonia, and infections with increasingly drug-resistant pathogens such as methicillin-resistant Staphylococcus aureus and vancomycin-resistant enterococci. Reference Kelly and Monson1 HAIs affect millions of patients worldwide and are responsible for worse health outcomes, increased medical costs, increased length of stay, and overall higher rates of patient morbidity and mortality. Reference Allegranzi2
As of 2014, approximately one in 25 US patients contract at least one HAI during the course of their hospital stay which results in hospital costs ranging from US$ 28 to 48 billion. Reference Allegranzi2,Reference Stone3 Surveillance systems to measure the impact of HAI and regulatory oversight exist in many higher income countries but are rare for middle to low- income countries (LMICs) where national surveillance data is limited and the burden of HAI is higher. Reference Kelly and Monson1,Reference Allegranzi2 This poses a large threat to patient safety in developing countries where the HAI burden is estimated to be much higher with more severe outcomes on patient health. Reference Allegranzi, Nejad, Combescure, Graafmans, Attar, Donaldson and Pittet4 Regional reviews done of HAI incidence shows that the rate of adult intensive care unit HAI is three times higher in a resource-limited country compared to industrialized countries, and rates of neonatal HAI ranged from three to twenty times that of industrialized countries. Reference Allegranzi, Nejad, Combescure, Graafmans, Attar, Donaldson and Pittet4,Reference Muvunyi, Mpirimbanyi, Katabogama, Cyuzuzo, Nkubana, Mugema, Musoni, Urimubabo and Rickard5 One 2020 study found that in Rwanda, extended-spectrum β-lactamase-producing Enterobacteriaceae were more often acquired in the hospital rather than in the community. Reference Muvunyi, Mpirimbanyi, Katabogama, Cyuzuzo, Nkubana, Mugema, Musoni, Urimubabo and Rickard5 Thus, strong infection prevention practices and antimicrobial stewardship are critical to decrease hospital acquired infection rates – especially in low-resource settings. Reference Muvunyi, Mpirimbanyi, Katabogama, Cyuzuzo, Nkubana, Mugema, Musoni, Urimubabo and Rickard5
According to the Centers of Disease Control and Prevention the rates of targeted HAIs can be decreased by more than 70% when healthcare facilities, care teams, and individual doctors and nurses are brought together to take measures toward improving infection control. 6 Relevant to this study, in 2016 it was found that implementation of a HAI surveillance system in a Rwandan teaching hospital significantly lowered infection rates. Reference Lukas, Hogan, Muhirwa, Davis, Nyiligira, Ogbuagu and Wong7 The Systems Engineering Initiative for Patient Safety (SEIPS) model provides a framework that can be used to evaluate interactions between structures, processes, and outcomes to identify potential areas of improvement. Reference Carayon, Schoofs Hundt, Karsh, Gurses, Alvarado, Smith and Flatley Brennan8 Although not yet widely used in LMICs, SEIPS is increasingly recognized for it’s adaptability to diverse healthcare environments. Using the SEIPS model, we aimed to identify barriers and facilitators that impact the implementation of Infection Prevention and Control (IPC) procedures at King Faisal Hospital (KFH) in Kigali, Rwanda with the intent of using this information to improve IPC practices and ultimately reduce the rate of healthcare-associated infection.
Methods
Study setting and design
This qualitative study was conducted to evaluate the barriers and facilitators to implementation of effective infection control practices at a large public referral hospital, KFH, in Kigali, Rwanda. The hospital provides comprehensive care to all 13 million citizens of Rwanda. The hospital has an IPC team and a centralized central sterile services department (CSSD). Study recruitment took place over a 2-week period in June 2023.
Study population
For this study, purposive sampling was used to select the participants. Recruitment was guided by hospital administration and the study team. Inclusion criteria included current employment at KFH (clinical or non-clinical) and fluency in English or Kinyarwanda. The goal was to select employees from a wide variety of units to eliminate unit specific biases (Table 1). Interviews continued until theoretical saturation was reached, where no new data was likely to be generated by interviewing more participants. Saturation was assessed during iterative review and weekly team discussions of transcripts and preliminary themes.
Participant Characteristics
Data collection
Interviews followed a semi-structured guide based on the five components of the SEIPS model: person, tasks, physical environment, organizational conditions, and tools and technologies. The guide was refined throughout the study in response to emerging patterns as is standard in qualitative research.
Interviews were conducted and recorded by two of the study authors. One of these authors served as an on-site translator for Kinyarwanda when needed. Each interview, recorded on a handheld device, lasted approximately 30 minutes and was conducted in a private location near the participant’s work area. Verbal consent was obtained after reviewing the study’s information sheet. Interview responses were deidentified and assigned numerical IDs. Only the interviewer had access to the ID code linking participants to responses.
Ethical considerations
Ethical approval was obtained from both King Faisal Hospital, Kigali and the University of Wisconsin Madison Institutional Review Boards.
Data analysis
Interview recordings were transcribed for thematic analysis. The transcriptions were done manually by reviewing the audio recordings and typing the transcripts by the authors who conducted the interviews. All data were entered by the same author who did each interview, respectively. The interview transcriptions were then analyzed and coded in accordance to the SEIPS framework themes. Themes were designated as barriers or facilitators. Specific quotes were selected and included in results to highlight common themes in interviewees’ own words.
Results
Participant characteristics
Twenty-five hospital employees were interviewed. Participants were selected from a variety of roles as well as an array of hospital units in order to get as whole of a picture of KFH as possible (Table 1). In total, 14 different units were represented.
Themes
Common themes are shown in Table 2 by frequency and divided into barriers and facilitators. Representative quotes are included in Appendix.
Barriers and facilitators to infection control, categorized by components of the Systems Engineering Initiative for Patient Safety (SEIPS)
Person
While some interviewees reported that they do receive IPC training, most noted that training was infrequent and inconsistent. Most respondents reported that staff don’t receive regular IPC training but some noted initial new-hire training. Many staff reported a desire for more consistent training in this area. When asked about their knowledge and perception of their respective unit’s HAI data, most interviewees reported not having much, if any, knowledge of current data. If they did, it was mainly a vague descriptor – not a percentage. Moreover, most staff also reported feeling as though they did not have enough knowledge about infection control, or that they felt they needed a refresher to keep up with the most current practices. When asked what barriers to hand hygiene were at KFH, the overwhelming answer was personal staff behaviors and attitudes rather than lack of supplies or knowledge. There was a perception that this was particularly true for new staff who get hired from other hospitals not as strict about hand hygiene as KFH.
Organization
Most interviewees were aware the KFH had designated IPC staff and a CSSD department but note that monitoring and interaction with these departments has been limited and infrequent. For example, one interviewee noted the drop of hand hygiene practices once the unit staff know it is not their designated time to be assessed. Another common practice noted at KFH is to have non-CSSD staff monitor IPC practices in units. However, this practice was reported to be more of a barrier than a facilitator as it lacks consistency in enforced best practices and lessons learned from prior experiences. It was also noted that the accountability of this rotating “person in charge” is low as it lacks enforcing power. Consequently, IPC practices have not been seen to improve from those monitoring activities.
Technologies and tools
One of the barriers commonly identified by staff was the lack of sufficient isolation rooms. Those that exist are not well equipped to properly care for a patient in isolation. Staff also reported that there is no clear, consistent guidance that describes the rules for staff entering an isolation room. This clearly has the potential to endanger staff who enter patient room without the proper PPE. A few interviewees also reported that while supply of soap and water is not an issue at KFH, there have been instances where lack of paper towels has been a barrier to hand hygiene. Since staff would have no way to dry their hands after washing, some would elect to just not wash.
Tasks
Many of the participants reported that overall, there is a lack of staff adherence to the IPC measures that are in place. Also, it was reported that adherence varies with role; however, there was no clear consensus among interviewees as to which roles are better or worse. Another reported barrier was the location of the sterilization department. This unit was on the bottom level and far from many operation-heavy units (surgery, ICU, etc), which makes it more difficult to properly and safely transport equipment to and from those locations.
Environment
While KFH is in the process of expanding at the time of this study, overcrowding was still reported to be an issue by staff. Staff report that patients may not have as much personal space as needed for proper IPC procedures, as some rooms separate patients by only a dividing drape. It was also reported by staff that sink locations should be improved on each unit. Many of the staff interviewed recommend having a sink station at least at the entrance of every unit so faculty and staff who enter and exit the rooms will have easy access.
Process
All interviewed staff knew the recommended process for what to do if they get sick; however, many reported that they would still come to work unless the condition was serious. Each staff member’s sick leave at KFH needs to be approved by a physician at KFH. This process likely leads to staff working while ill which risks transmission to patients or other staff. Many staff also report being knowledgeable about the process which would be in place if a patient was diagnosed with viral hemorrhagic fever. Another broad barrier staff reported is the easy access in the community for anyone to purchase antibiotics over the counter from pharmacies; this was seen to be a contributor to the high antimicrobial resistance rates seen in hospitals.
Discussion
This qualitative analysis at King Faisal Hospital in Rwanda has identified major facilitators and barriers for IPC processes which can be used to guide quality improvement. Major barriers included themes of overcrowding, lack of isolation rooms, new staff attitudes, infrequent training, and inconsistent monitoring programs. These findings support the need for structural changes to the IPC program in order to increase the frequency of IPC training and hospitalwide IPC monitoring. Common themes noted to be facilitators included adequate supplies of hand sanitizer, soap and water, and personal protective equipment (PPE) as well as quality IPC policies and procedures set in place by hospital administration.
Low adherence to hand hygiene is not unique to KFH. A 2016 study of a hospital in Gitwe, Rwanda found that, the baseline hand hygiene rates of staff at their institution to be around 34%. Reference Holmen, Seneza, Nyiranzayisaba, Nyiringabo, Bienfait and Safdar11 This is even further echoed by the World Health Organization’s review that documented the average hand hygiene compliance worldwide to be less than 40%. 12 While adherence to IPC practice seems to be a barrier, our study shows that staff of KFH have the proper knowledge of the correct IPC practice. This is echoed in other relevant study from 2023, where knowledge of hand hygiene practices at Kirehe District Hospital in Rwanda was found to be near 80%. Reference Umuhoza, Kamugisha, Nashwan and Soko13 However, as suggested in our results, actual hand hygiene compliance is often much lower, in that study noted at less than 25%. Reference Umuhoza, Kamugisha, Nashwan and Soko13
To improve adherence to policies and procedures the current literature suggests that the frequency of training and monitoring is extremely valuable. The same aforementioned study in Gitwe, Rwanda which found baseline hand hygiene compliance rates to be 34% also found that postintervention, the compliance rate increased to nearly 70%. Reference Holmen, Seneza, Nyiranzayisaba, Nyiringabo, Bienfait and Safdar11 It has also been shown that increased time between training and monitoring is associated with drastically lower adherence rates. Another study at a Rwandan hospital found that hand hygiene adherence rates decreased over 32% only one year after intervention. Reference Holmen, Niyokwizerwa, Nyiranzayisaba, Singer and Safdar14 Therefore, it is expected that developing a training and monitoring schedule for hand hygiene at KFH that is consistent and at a regular frequency, engaging all faculty and staff will result in sustained improvements. This is likely applicable to hand hygiene but also other IPC interventions like isolation/PPE use and other HAI prevention tools like catheter management or use of prevention bundle measures.
A common barrier to HAI prevention worldwide is not having a designated IPC team. In fact, a qualitative study utilizing the SEIPS model of analysis in the Philippines identified the presence of an effective IPC committee as a major facilitator of IPC. Reference Mitchell, Barker, Abad and Safdar15 KFH does have an organized and recognized team; this is a strong facilitator that allows for expansion of good practices. At KFH, the next step is to improve the frequency and intensity of employee education and training and communication with staff to implement evidence-based interventions. Reference Storr, Twyman and Zingg16 Successful IPC programs throughout the world are engaged in continuous quality improvement and this study provides areas for focus specific to KFH. In order for any program engaged in quality improvement and patient safety to be successful, leaders of the IPC program have to be empowered by the institution and provided the necessary resources. Beyond the hospital level, common themes noted here may inform national IPC strategy. Standardizing staff training requirements, mandating regular IPC audits, and investing in physical infrastructure such as isolation rooms can help raise IPC performance across the country. Additionally, legislative policies that regulate non-prescription antibiotic use are critical to addressing antimicrobial resistance. A stronger national framework can both reinforce local hospital efforts and support Rwanda’s broader goals of improving patient safety.
Recommendations
To address the barriers identified in this study, a more robust IPC training program for staff is essential, alongside securing necessary funding to support these efforts. Prioritizing interventions such as increasing the frequency of IPC training and establishing more consistent hospitalwide monitoring are crucial first steps. Additionally, creating sufficient and effective isolation rooms for each unit will help mitigate the risks associated with overcrowding and limited patient space. On a broader scale, legislative policies at the national level are needed to limit the non-prescribed use of antibiotics, a major contributor to antimicrobial resistance. For these initiatives to succeed, hospital administration must play an active role by regularly monitoring compliance with IPC guidelines, providing timely feedback to staff, and empowering leaders of the IPC program. These leaders must be given the institutional support and authority necessary to implement and sustain improvements effectively.
Study strengths and limitations
This study presents several strengths, including the use of the SEIPS model, which provided a structured framework for evaluating the multifaceted nature of infection prevention and control (IPC) practices at King Faisal Hospital. The qualitative design allowed for in-depth exploration of the perspectives of a diverse group of hospital employees, capturing barriers and facilitators across multiple departments. Another strength is the study’s setting within a busy referral hospital in a resource-limited environment offers insights that may be applicable to other similar settings. However, there are limitations. The study relied on purposive sampling, which may introduce selection bias, as participants who are more engaged or interested in IPC practices may have been more likely to participate. This also resulted in heterogeneity in interviewees which must be taken into account when interpreting results but also may give a comprehensive view of the IPC program. The interviews were conducted largely in English, which could have led to unrecognized potential language barriers or misinterpretation of questions and/or responses. Lastly, the data reflects a single time point and may not capture fluctuations in IPC practices or adherence over time.
The Systems Engineering Initiative for Patient Safety (SEIPS) model.
Supplementary material
The supplementary material for this article can be found at https://doi.org/10.1017/ash.2025.10111.
Acknowledgements
Special thanks to all members of the UW Division of Infectious Disease—especially program coordinator Abigail Mapes—and staff at KFH Rwanda for all of their help, guidance, and hospitality.
Financial support
This project is supported by the Shapiro Summer Research Program at the University of Wisconsin School of Medicine and Public Health.
Competing interests
All authors report no conflicts of interest relevant to this article.
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