Contextual barriers to infection prevention and control program implementation in hospitals in Latin America: a mixed methods evaluation
Authors: Fabre Valeria , Secaira Clara , Herzig Carolyn , Bancroft Elizabeth , Bernachea Maria Paula , Galarza Lucy Anchiraico , Aquiles Bowen , Arauz Ana Belén , Bangher Maria Del Carmen , Bernan Marisa Liliana , Burokas Sol , Canton Alfredo , Cazali Iris L. , Colque Angel , Comas Marisabel , Contreras Rosa Verónica , Cornistein Wanda , Cordoba Maria Gabriela , Correa Silvia Mabel , Campero Gustavo Costilla , Chamorro Ayala Marta Isabel , Chavez Nuria , De Ascencao Gabriela , García Carlos Cruz , Esquivel Clara , Ezcurra Cecilia , Fabbro Leonardo , Falleroni Leandro , Fernandez Johana , Ferrari Sandra , Freire Veronica , Garzón Maria Isabel , Gonzales José Anel , Guaymas Lucrecia , Guerrero-Toapanta Fausto , Laplume Diego , Lambert Sandra , Lemir César Guillermo , Lazarte Paola Romina , Lopez Itzel L. , Maldonado Herberth , Martínez Guadalupe , Maurizi Diego M. , Mesplet Florencia , Moreno Izquierdo Cristina , Moya Gabriela Luciana , Nájera Mariela , Nuccetelli Yanina , Olmedo Argelis , Palacio Belén , Pellice Florencia , Raffo Carla Lorena , Ramos Carolina , Reino Fanny , Rodriguez Viviana , Romero Federico , Romero Juan José , Sadino Graciela , Sandoval Nancy , Suarez Mariana , Suayter Maria Victoria , Ureña Maria Alejandra , Valle Marisol , Vence Reyes Ligia , Perez Silvia Vera Amate , Videla Hugo , Villamandos Silvina , Villarreal Olmedo , Viteri Maria Alejandra , Warley Eduardo , Quiros Rodolfo E. 
Published: November 2024

Abstract
Background
Infection prevention and control (IPC) programs are essential to prevent and control the spread of multidrug-resistant organisms in healthcare facilities (HCFs). The current implementation of these programs in Latin America remains largely unknown.

Methods
We conducted a mixed-methods evaluation of IPC program implementation in HCFs from Guatemala, Panama, Ecuador, and Argentina, March-July 2022. We used the World Health Organization (WHO) IPC Assessment Framework (IPCAF) survey, a previously validated structured questionnaire with an associated scoring system that evaluates the eight core components of IPC (IPC program; IPC guidelines; IPC education and training; healthcare-associated infection [HAI] surveillance; multimodal strategies; monitoring and audit of IPC practices and feedback; workload, staffing, and bed occupancy; and the built environment and materials and equipment for IPC). Each section generates a score 0–100. According to the final score, the HCF IPC program implementation is categorized into four levels: inadequate (0–200), basic (201–400), intermediate (401–600), or advanced (601–800). Additionally, we conducted semi-structured interviews among IPC personnel and microbiologists using the Systems Engineering Initiative for Patient Safety model to evaluate barriers and facilitators for IPC program implementation. We performed directed content analysis of interview transcripts to identify themes that focused on barriers and facilitators of IPC program implementation which are summarized descriptively.

Results
Thirty-seven HCFs (15 for-profit and 22 non-profit) completed the IPCAF survey. The overall median score was 614 (IQR 569, 693) which corresponded to an “advanced” level of IPC implementation (32% [7/22] non-profit vs. 93% [14/15] for-profit HCFs in this category). The lowest scores were in workload, staffing and bed occupancy followed by IPC training and multimodal strategies. Forty individuals from 16 HCFs were interviewed. They perceived inadequate staffing and technical resources, limited leadership support, and cultural determinants as major barriers to effective IPC guideline implementation, while external accreditation and technical support from public health authorities were perceived as facilitators.

Conclusions
Efforts to strengthen IPC activities in Latin American HCFs should focus on improving support from hospital leadership and public health authorities to ensure better resource allocation, promoting safety culture, and improving training in quality improvement.