Discussion

Overall, HCW perceptions of IPAC practices were positive; thus, targeted efforts to reinforce the importance of IPAC are not needed. Instead, providing an environment conducive to adherence to IPAC practices should be the central focus. Key barriers identified by respondents include inadequate staff to cover sick leave absences (58%), limited space capacity in staff rooms (57%), multibed rooms (51%), and confusing messages about IPAC practices (51%). In addition, barriers related to PPE (limited supply, PPE fatigue, and impaired function) were experienced by almost half of respondents, primarily in non–acute care settings. Common suggestions for improvement included improved IPAC leadership and support (60%), clear communication of IPAC guidelines (56%), and increased PPE and hand hygiene supplies (47%).

Many prepandemic studies examined facilitators and barriers to IPAC practices for respiratory infections, and they were summarized in a review. ^{Reference Houghton, Meskell and Delaney4} Similar to our findings, unclear and/or frequently changing IPAC guidelines, lack of training, and space limitations were commonly reported barriers. Several surveys of facilitators and barriers to IPAC practices among HCWs during the pandemic have been published, but most were limited in scope to only 1 or a few facilities and focused on self-reported compliance. ^{Reference Lai, Wang and Yang16–Reference Sathitakorn, Jantarathaneewat, Weber, Warren and Apisarnthanarak18} A study in Alberta examined barriers to the use of PPE in long-term care settings, ^{Reference Tsang, Holroyd-Leduc, Ewa, Conly, Leslie and Leal5} but to our knowledge, no studies in Canada have focused on HCWs from a variety of work environments. In a national survey conducted in Qatar, lack of PPE was the most commonly reported barrier. ^{Reference Abed Alah, Abdeen and Selim19} Although that was not the most common barrier in our survey, a similar proportion of respondents reported experiencing this scarcity. Similar to our results, perceptions of IPAC in Qatar were generally favorable. However, lack of knowledge and lack of training were far less commonly reported in Qatar compared to British Columbia, suggesting that there may be opportunities for improvement in our setting. Some studies conducted in lower-resource settings have similarly reported gaps in training, along with other barriers. For example, one study conducted throughout a province of PakistanReference Saqlain, Munir and Rehman ²⁰ and another from a city in EthiopiaReference Birihane, Bayih, Alemu and Belay ²¹ both found that overcrowding, lack of IPAC supplies such as PPE, and lack of training were major barriers. However, these latter surveys were all conducted earlier in the pandemic than ours, which may have affected the results. In addition, facilitators and barriers can vary by setting, so having local data is important to targeting quality improvement efforts.

Knowledge gaps were identified among respondents to this survey, with 16% missing at least 1 PPE component required for care of patients with COVID-19. Also, 18% were not aware that alcohol-based hand sanitizer is effective against COVID-19. In addition, almost half of respondents did not feel confident that they knew what PPE to use. Dissemination strategies, such as didactic education from IPAC staff, may have limited ability to improve adherence to IPAC guidelines. ^{Reference Silva, Galvao, Chapman, da Silva and Barreto22} Peer auditing and staff coaching models as alternative behavior change methods may be effective ways to promote education and culture change surrounding IPAC practices. ^{Reference Langston23} Such methods have been successfully implemented during the pandemic to improve PPE donning and doffing by HCWs. ^{Reference Picard, Edlund and Keddie24}

Confusing messaging about IPAC practices was a barrier experienced by approximately half of respondents and may have contributed to the identified knowledge gaps. IPAC teams in British Columbia should prioritize improved support for and communication to frontline staff. To better understand how to improve clarity of communication, further studies are needed to characterize which aspects of current practices are unclear. Development of communication frameworks to clarify target audiences and channels, as well as the use of novel strategies such as storytelling and social marketing, may be worth considering. ^{Reference McAlearney, MacEwan, Gregory, Sova, Hebert and Gaughan25,Reference Roger, Dourgoudian, Mergey, Laplanche, Ecarnot and Sanchez26}

Other commonly reported barriers related to physical infrastructure, PPE limitations, staffing, and sick-leave policies extend beyond the scope of IPAC teams but are important to address to optimize adherence to IPAC practices. For example, a higher proportion of private patient rooms was associated with a lower risk of healthcare-associated infections prior to the pandemic. ^{Reference Park, Stockbridge, Miller and O’Neill27,Reference Leal, O’Grady and Armstrong28} During the pandemic, more crowded long-term care facilities were found to have more than double the rate of COVID-19 mortality. ^{Reference Brown, Jones and Daneman29,Reference Estabrooks, Ewa, Keefe and Straus30} Addressing these operational challenges will require collaboration among multidisciplinary teams, including IPAC, across the healthcare system.

Notably, limited access to PPE was highlighted by a significant proportion of respondents (44%), and this was more commonly experienced in non–acute care settings. The survey asked respondents about experiences since the start of the pandemic, so it may be that limitations were experienced during the early waves. Shortages of PPE were common in 2020 for multiple reasons and were often more pronounced in non–acute care settings. ^{Reference Mathews, Ryan and Hedden31,Reference Cohen32} In addition to limited supply, PPE fatigue and impaired function were commonly reported in our survey, consistent with published literature showing these to be barriers to IPAC practices. ^{Reference Podgorica, Zenzmaier, Rungg, Bertini and Perkhofer33}

Further qualitative research to better understand barriers from the frontline worker experience would be an excellent complement to this study, particularly focused on groups that may have been underrepresented among respondents in our survey, such as physicians or care providers without regular access to computers (eg, environmental services staff). Our study also found differences in non–acute care work environments, such as greater limitations to PPE resources and lower perceived priority of IPAC practices. We have published our findings in LTC/AL settings, ^{Reference Srigley, Cheng and Collet9} but further research to better characterize differences in other populations is warranted. In addition, cost-effectiveness studies would be helpful to quantify the impacts of improving hospital infrastructure on adherence to IPAC practices.

This study had several strengths, including being the first Canadian survey to comprehensively assess barriers to IPAC practices among HCWs during the COVID-19 pandemic with broad representation across job types and healthcare settings. However, this study had several limitations. First, the survey was closed between August 25 and 29, 2021, and eligibility for the cash prize was modified, in response to a bot attack. However, a sensitivity analysis did not find clear evidence of contamination (Supplementary Materials online). Second, the overall response rate was low. Overall, there are 120,000 employees of health authorities in British Columbia and >16,000 medical staff, although not all would have been eligible to participate (eg, administrative staff, other nonclinical workers). We did obtain responses from all health authorities and in proportions that were generally similar to their respective proportion of employees. Regardless, the sample of responses might not be fully representative of BC HCWs overall and results are further limited by selection bias given the online survey methodology. Furthermore, respondents had to be employees of a health authority in British Columbia so survey results would not apply to non–health authority settings, such as non–hospital-based outpatient clinics and privately owned and operated LTC/AL facilities. Additionally, our results are not likely generalizable to low- and middle-income countries. Finally, this survey was conducted >1 year into the COVID-19 pandemic, which may have helped to avoid bias from early supply and distribution issues of PPE and cleaning materials. However, responses may have also been affected by the widespread and ongoing promotion of IPAC. Regardless, there were likely challenges with barriers to following IPAC practices both during and prior to the pandemic. As such, our findings may be emphasizing a pre-existing issue that became more prevalent during pandemic times.

Our findings highlight frontline HCW perspectives on the priority areas needing improved IPAC interventions. As barriers were identified at the individual, institutional and systems levels of the healthcare system, we hope our findings will help fuel advocacy in multifaceted ways and stimulate changes. These results can inform future IPAC interventions for health authorities across the province, with the goal of preventing transmission of COVID-19 as well as future emerging infections.