In recent decades, health care has changed from being predominantly hospital-based to being delivered in settings such as home care and ambulatory services. Therefore, risk assessment and implementation of good infection control practices need to be expanded beyond hospitals [7]. To the best of our knowledge, this is the first exploratory study, using a qualitative approach, to investigate infection prevention in PHC, bringing new insight about the subject and contributing to minimizing the global gap in this field.
Low risk perception
The perception of risk directly influences the adherence of professionals to recommended measures [22]. Even in hospitals, although professionals know how to protect themselves from risks of injuries and infections, they do not always comply with safe practices [23]. The perception of risk and the adoption of biosafety measures constitute a challenge in PHC, and research in this area is scarce. Traditionally, the risks of HAIs in PHC had being considered low, but in a comprehensive literature review, no studies were found to provide epidemiological support for this claim [5].
The low perception of self-risk of infection was also discussed by a multinational study group highlighting the risk of extensively drug-resistant tuberculosis [24].
One study found an increased risk of Mycobacterium tuberculosis infection in health professionals, students, and CHAs, who are six times more likely to acquire the disease while caring for infected patients if they do not use specific protective measures [25].
The perception of low risk can be a major cause of shortcomings in adopting measures to prevent transmission of microorganisms.
Weaknesses in knowledge
Our study demonstrated that health professionals in PHC during the focus groups had an initial perception of their own lack of awareness and knowledge on several issues in infection prevention. They said that they should think and talk more about the subject as a way to dissipate misconceptions and better translate knowledge into practice. Knowledge is known to be a first step for awareness of self-protection and patient protection [26]. Even fundamental knowledge on hand hygiene is far from being good in many outpatient settings [6, 10, 26]. Consequently, hand hygiene is less than optimal. For instance, a Brazilian study showed that hand hygiene was not performed by health professionals in approximately 60% of cases in a home care service. These professionals did not perform hand hygiene in 77% of instances when arriving at a patient’s home and in 38% when leaving them [6]. Another study demonstrated that in a PHC setting hand hygiene was rarely performed before care, ranging from 8% to 53.3% depending on the type of procedure; and after procedures such as capillary blood glucose monitoring only in 20% of instances. In intravenous medication administration, 53.3% washed hands prior to the procedure and 27.3% after that [27]. Nonetheless, this low compliance does not seem to be restricted to Brazil or indeed other low-middle income countries. A Spanish study found out that the adherence rate to hand hygiene was 8.1%, and that professionals washed their hands mainly after contact with the patient rather than before it [5].
Insufficient in-service training
In the present study, when talking about the choice of products for hand hygiene, the professionals pointed to their beliefs of a higher efficacy of water and soap compared to alcohol. This is outdated information as since 2009 the World Health Organization has implemented a worldwide campaign recommending the use of alcohol hand rubs as the first option for hand hygiene [4]. The lack of current information reinforces that PHC is not receiving even minimal in-service education for infection prevention.
Practices need to be sustained by a good level of knowledge and scientific evidence, otherwise they may contribute to the spread of infections in the health care setting [28]. Furthermore, the lack of specific training for CHAs and housekeeping workers is of great concern. These professionals are even more vulnerable than health care professionals because they do not have formal education in health care and therefore, for them, in-service training is imperative [29, 30].
The subject of tuberculosis emerged strongly in the focus groups. Worldwide, patients harbouring Mycobacterium tuberculosis are being cared for in PHC; many of them while at the bacillary phase, mainly in countries with high prevalence [8, 31]. Therefore, it is essential that biosafety measures, such as the use of respiratory protection and cough etiquette, alongside environment control measures, as well as standards for triage and sputum collection from outpatients, are widely adopted in PHC [25, 31, 32]. The data obtained in our study indicated that professionals are unsure about these recommendations, probably due to insufficient in-service standards and training.
When performing home visiting, CHAs could have a key role in the early identification of individuals with respiratory symptoms. This could reduce the likelihood of those individuals attending PHC settings without precautions, thereby minimizing exposure of health professionals and other patients. However, a study demonstrated that CHAs were not able to recognise these symptoms [33]. They have potential extra exposure compared to other health professionals as they perform home visits more frequently. In addition, CHAs come from the same community as their patients, which implies they are experiencing similar social and economic determinants of health.
The stigma associated with tuberculosis may impair the adoption of some of these measures such as the use of respiratory protection (masks) [34]. However, the subject of stigma did not arise in the focus group but rather a lack of knowledge of guidelines. Once more, knowledge is key for awareness. This points to the need of systematic in-service training to minimize risk.
Infrastructure limitations
Waste sharps may be generated due to health care procedures performed at home, particularly for diabetic patients. Nevertheless, professionals complained about a lack of straightforward recommendations on how to deal with them. Other researchers have pointed out the need for guidelines on appropriate disposal, segregation and transport of waste generated by health care provided in the patient’s home. Patients and families of those performing self-administration of injections should be guided about the management of sharps [6, 35]. The participants in the focus group expressed their concern about limitations of material resources, mainly the low quality of gloves provided at PHC. In addition, the PHC premises were unable to adequately accommodate patients with respiratory transmitted diseases such as tuberculosis and chickenpox. Performing good health practice requires the provision of appropriate infrastructure, personal protective equipment, environmental control and proper provision of equipment and supplies. The absence of these conditions affects the adequacy of work, resulting in low quality of care [36, 37].
Altogether, low risk perception, weaknesses in knowledge, insufficient in-service training and Infrastructure limitations show that HAIs prevention is far from being a priority at PHC. Perhaps, in countries where access to health care is very limited, concerns about the prevention of HAIs might be seen to be a luxury [38]. In most low-middle income countries efforts to provide universal health coverage are so challenging that prevention of infections due to health care associated infections might be seen as a secondary target. However, failures in preventing the transmission of microorganisms at PHC level can affect the entire health care system, and contribute to the spread of epidemiologically relevant pathogens. The major pandemics have shown that all health services must be prepared for an efficient and coordinated response to prevent amplification of any epidemic phenomena. This perspective was evident in episodes of Severe Acute Respiratory Syndrome - SARS, pandemic influenza and more recently in the epidemics related to Ebola virus [14, 39]. Nonetheless, the literature from high income countries is also quite silent about potential HAIs due to procedures in PHC, except for some coverage of outbreaks [9, 15,16,17].
We do not intend our data to be fully transferable worldwide. Nevertheless, the results points to the need for guidance, training and adequate provision of supplies and structure to promote compliance with essential measures to prevent HAI across the entire health care system.