Striving: A Grounded Theory of Healthcare Workers’ Struggles in Implementing Infection Prevention and Control Guidance in Uganda

  • Andrew Owen Kalule

Student thesis: Doctoral ThesisDoctor of Philosophy (PhD)


Background: Healthcare-Associated Infections (HAIs) are those infections acquired after hospitalisation and manifest 48 hours after admission to the hospital. It is estimated that 5-10% of in-patients develop an HAI during their stay (Gaid et al., 2017). Infection Prevention and Control (IPC) presents the cheapest and best solution to curb increasing HAI rates, with 30% of HAI preventable if key IPC components are adequately followed (Storr et al., 2017; WHO, 2018). It is widely accepted that any IPC guidance or recommendations should be evidence-based (Storr et al., 2017; WHO, 2016). The World Health Organization (WHO) released evidence-based recommendations in 2016, including strategies for preventing HAIs and controlling the spread of infections within healthcare facilities. A systematised literature review conducted between February 2018 – March 2018 to inform this study revealed very little research conducted on the implementation of IPC guidance at the health facility level in low-income countries and a dearth of qualitative research in this area. As such, there is a need to understand the implementation of IPC guidance in low-middle countries using a qualitative approach.Therefore, this study aimed at exploring the implementation of IPC guidance at the health facility level in Uganda and to generate a theoretical explanation for the processes involved in the implementation of this guidance in these settings.

Methods: This study employed a qualitative research design based on the constructivist grounded theory research methodology (Charmaz, 2006). Individual interviews were conducted with 13 frontline health workers involved in implementing and applying IPC guidance at a tertiary hospital in Uganda. The study also employed the theoretical domains framework (TDF) and behaviour change wheel (BCW)/COM-B model for behavioural analysis in order to analyse the identified factors which may present as barriers and enablers to the implementation of IPC guidance and to make preliminary recommendations for intervention design.

Findings: The main findings from the study indicate that in trying to implement IPC guidance, Healthcare Workers (HCWs) go through a process of ‘striving for improved practice’, which consists of four phases; recognising the importance of IPC, playing a role, encountering challenges and overcoming challenges. However, they never quite come close to full implementation because of the organisational and individual challenges within these contexts. The theoretical code that explains this process is "asymptote", which means coming close but not close enough. The findings also identify enabling factors within these contexts that facilitate implementation whilst revealing a high degree of improvisation among HCWs in ensuring the effective practice of IPC measures. By applying behaviour change theory, the study also identifies the most important behavioural influences on implementation that include opportunity, capability and motivation that can be targeted to improve implementation. Key intervention functions such as enablement, environmental restructuring, training and education, persuasion, and incentivisation are also identified that can be used to design interventions to improve the implementation of this IPC guidance within these settings.

Conclusion: Implementing IPC guidance in low-resource Uganda is a complex process involving unique challenges. This study presented a substantive theory that provides insight into the implementation of this IPC guidance in this low-resource context. The study also provided a theoretical basis for intervention design and development through the use of the TDF, COM-B and BCW while identifying some key recommendations to improve the implementation of this IPC guidance within these contexts.
Date of Award2023
Original languageEnglish
Awarding Institution
  • Glasgow Caledonian University
SupervisorLesley Price (Supervisor) & Kay Currie (Supervisor)

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