This multinational cross-sectional study aimed to assess implementation of infection prevention and control (IPC) measures and factors associated with IPC adherence in low-resource healthcare settings during the COVID-19 pandemic. Data were collected between February and November 2022 using standardized questionnaires administered to healthcare workers (HCWs) and healthcare facilities (HCFs). Descriptive analyses summarized IPC measures overall and by country and facility level. Partial proportional odds models were used to evaluate factors associated with HCW compliance with hand hygiene and mask wearing.
The survey was conducted in four sub-Saharan African countries: Côte d'Ivoire, Democratic Republic of Congo, Madagascar and Nigeria. A total of 6,749 HCWs were enrolled across 324 HCFs representing different facility types and levels of care, including primary non-hospitals and tertiary HCFs. Standardized facility-level and HCW-level questionnaires captured reported IPC programmes, screening practices, availability of materials such as handrub, masks and respirators, HCW training, and self-reported compliance with IPC practices.
Reported presence of institutional IPC programmes varied by facility level. Among surveyed HCFs, IPC programmes were present in 51.4% (n=111) of primary non-hospitals and in 83.3% (n=18) of tertiary facilities. More than half of facilities—57.4% (n=186)—reported no patient or HCW screening for COVID-19. These findings indicate heterogeneous adoption of IPC infrastructure and limited implementation of screening protocols in a majority of surveyed HCFs.
Only 19.8% (n=64) of HCFs reported having handrub available at the point of care in every room. Reported availability of protective equipment favored surgical masks over respirators: 62.7% (n=4,231) of HCWs reported sufficient availability of masks, whereas only 28.5% (n=1,926) reported sufficient availability of respirators. The limited presence of alcohol-based handrub at the point of care and lower respirator availability highlight material gaps that can impede adherence to recommended IPC measures.
Of the 6,749 HCWs enrolled, 54.0% reported working in high-risk patient care areas. HCW-reported perceptions of equipment sufficiency showed higher reported access to masks compared with respirators. The dataset captured HCW receipt of IPC training and presence of facility-level IPC programmes, both of which were evaluated as potential drivers of reported compliance with IPC behaviours.
Partial proportional odds models identified several factors associated with higher HCW compliance with hand hygiene and mask wearing. Presence of a facility IPC programme was associated with improved compliance for hand hygiene (OR 1.3, 95% CI 1.2 to 1.5) and mask wearing (OR 1.4, 95% CI 1.2 to 1.6). IPC training received by individual HCWs was also associated with higher compliance (hand hygiene OR 1.5, 95% CI 1.3 to 1.7; mask wearing OR 1.3, 95% CI 1.2 to 1.5). Material availability showed strong associations: availability of handrub was associated with higher hand hygiene compliance (OR 5.9, 95% CI 4.1 to 8.4) and availability of masks was associated with higher mask wearing compliance (OR 2.3, 95% CI 2.0 to 2.7). These modeled associations suggest both organisational structures (programmes and training) and access to supplies materially influence self-reported IPC adherence.
The study documents critical gaps in IPC capacity across surveyed facilities during the COVID-19 pandemic: uneven presence of IPC programmes, widespread absence of routine screening for patients and HCWs, limited point-of-care handrub availability, and constrained access to respirators. These gaps were associated with lower reported HCW compliance with recommended IPC practices. The findings indicate that improvements in both institutional IPC programmes and reliable provision of basic materials and equipment are likely needed to enhance routine infection control and pandemic preparedness in low-resource settings.
In this large, multi-country survey of HCFs and HCWs in sub-Saharan Africa, important deficiencies in IPC programmes, screening practices and availability of IPC supplies were identified during the COVID-19 pandemic. Presence of IPC programmes, IPC training for HCWs, and availability of handrub and masks were all associated with higher HCW compliance with hand hygiene and mask wearing. The authors conclude that continued focus on strengthening IPC programmes and ensuring access to essential materials and equipment is essential to improve infection control and preparedness in low-resource healthcare settings.