Barriers to Infection Prevention Adherence and Compliance in Haemodialysis Units in South Africa: A Qualitative Study

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A. Bale, Tendani. R Ramukumba This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6975459/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 01 Dec, 2025 Read the published version in BMC Nephrology → Version 1 posted 10 You are reading this latest preprint version Abstract Introduction: The burden of infections in haemodialysis environments remains worldwide. Owing to the multiple activities within haemodialysis environments, patients, staff, and visitors in dialysis facilities are at high risk of acquiring healthcare-associated infections. This qualitative study aimed to understand barriers to infection prevention and control adherence and compliance among haemodialysis practitioners in the haemodialysis units in the Gauteng Province of South Africa. Methods: A qualitative contextual exploratory-descriptive design was followed. Twenty-four practitioners from haemodialysis units were sampled using purposive sampling. Data were collected through a semi-structured interview and field notes. The data were analysed using Braun and Clarke’s thematic approach to qualitative data. Results: The study revealed several barriers to the requirements of infection control practices among haemodialysis practitioners, categorised into three main portions. First, individual-related barriers included staff members' inappropriate attitudes and inefficient habits towards infection prevention. Second, management-related barriers highlighted inappropriate planning and training and lack of standard operating procedures. Lastly, organisational barriers included staff shortages, a lack of physical resources and personal protective equipment. Conclusions: Several factors lead to non-adherence and suboptimal compliance, which create barriers to infection prevention and control adherence and compliance. Certain barriers necessitate immediate interventions, while others may require extended durations to address effectively. The findings can help directors, executives, stakeholders, and policymakers intervene and improve practitioners' adherence and compliance. Compliance Adherence Infection Prevention and Control Haemodialysis Units Haemodialysis Practitioners Dialysis Nurses Dialysis Clinical Technologists Introduction Healthcare-associated infections (HAIs), known as nosocomial infections, present a severe challenge to healthcare professionals worldwide. Healthcare-associated infections (HAIs) rank among healthcare services' most prevalent adverse effects [1]. To prevent HAIs, the World Health Organisation and the Centres for Disease Control and Prevention recommend that haemodialysis facilities follow infection control standards and precautions, such as hand washing and wearing personal protective equipment [2,3]. Infection prevention and control (IPC) is a practical, evidence-based process to prevent patients and health workers from being harmed by avoidable infections [4]. Effective IPC necessitates constant action at all health system levels, comprising policymakers, managers of establishments, healthcare professionals and those who access health services. IPC is unique in the quality-of-care healthcare provision, as it is broadly relevant to all healthcare professionals and patients at every healthcare interaction [4]. It is estimated that on average, out of every 100 patients in acute-care hospitals, seven patients in high-income countries (HICs) and 15 patients in low- and middle-income countries (LMICs) are at risk of acquiring at least one HAI during their hospital stay [5,6]. Patients undergoing HD as renal replacement therapy (RRT) in HD facilities are at an increased risk of HAI. As chronic kidney disease (CKD) worsens over time, resulting in Kidney Failure (KF), other associated health problems become more likely, such as infections [7]. The importance of infection control in HD environments is emphasised due to the increased risk of infections in patients undergoing dialysis, such as increased movement by staff in HD environments leading to errors [8]. It has been estimated that at least 30 hand hygiene moments are required per dialysis patient in each 4-hour session [8]. HAIs occur in patients receiving medical treatment in a hospital or other healthcare setting that was not present at admission [9]. A survey conducted in Japan found that while certain haemodialysis (HD) facilities were employing various infection control techniques, some could not implement IPC measures effectively [10]. This was primarily due to limited space within the facility, insufficient staffing, and temporary shortages of personal protective equipment [10]. In recent studies, IPC has emerged as a significant global challenge, particularly in HD settings. A study in the United Arab Emirates [11] found that a tertiary-level care hospital’s HD unit substantially complies with IPC guidelines across different categories. Conversely, another study in the United States of America in 800 outpatient HD facilities examined IPC practices and uncovered considerable infrastructure-related challenges [12]. These challenges included insufficient spacing between treatment stations and inadequate isolation facilities. While facilities reported high adherence to cleaning protocols, direct observations revealed that less than sixty percent complied with routine disinfection practices. This discrepancy underscores a significant gap between self-reported adherence and actual compliance, ultimately elevating the risk of infection for patients receiving HD. Infection prevention protocols related to dialysis demand careful focus on complex tasks, skilled manual abilities, and consideration of patient-related factors. Furthermore, several macro ergonomic elements influence human performance [13]. Healthcare workers in HD units frequently interact with patients requiring HD and other related activities, such as follow-ups, meetings, and medication collections. However, data on hospital settings point to hospital-acquired infections (HAIs) as the most frequent health challenge within the hospital setting. A systematic review and meta-analysis in sub-Saharan Africa revealed a high burden of HAIs in SSA, with significant heterogeneity between regions [14]. Amid the HAI burdens and challenges thereof, various associations and organisations have recommended evidence-based methods and programs to alleviate risks associated with HAIs and combat antimicrobial resistance [2,3,15,16,17]. The Sustainable Development Goals (SDGs), especially Goals 3, which aim to promote good health and well-being by 2030, and Goal 8, promoting safe working environments for all staff, emphasise the prevention of infectious diseases as essential for adequate healthcare. The imperative to tackle global health issues such as antimicrobial resistance, which requires undivided attention, is highlighted [17]. South Africa has developed a strategic framework to align these crucial priorities to enhance patient safety, reduce HAIs, and improve comprehensive health outcomes for all citizens [16]. Correct application of infection control measures is essential in HD facilities [7,8]. Moreover, applying IPC best practices reduces HAIs and patient harm. Despite the importance of IPC in mitigating the spread of HAIs in HD environments, there is a paucity of research reporting on healthcare workers’ barriers within the haemodialysis environments related to IPC measures adherence and compliance in South Africa, specifically in the Gauteng Province. The absence of such evidence-based studies makes it challenging to advocate for a positive change and create strategies to mitigate existing barriers. For these reasons, researchers embarked on this research project. METHODS Study design This study followed a contextual exploratory-descriptive qualitative design, which was essential for researching and describing experiences and situations from the perspective of HD practitioners directly involved in HD activities and procedures [18]. Sample and setting Twenty-four HD practitioners participated in the study, including nurses and clinical technologists in the HD units of the two academic hospitals in the Gauteng Province of South Africa. The HD practitioners included dialysis clinical technologists ( n = 4) and nurses ( n = 20). The two academic hospitals selected in this study are classified as central hospitals in South Africa within the Gauteng Province and provide both haemodialysis and peritoneal dialysis services for populations within the Gauteng Province and other nearby provinces. Both HD units have an estimated combined population of approximately 140 HD patients, each with a capacity of close to 12 to 18 HD beds. Purposive sampling was used to select participants based on their work experience and expertise in dialysis. The purposive sampling consisted of interviewing suitable participants meeting the inclusion criteria, including HD practitioners working in the HD units, who were willing and able to share their experiences with the researchers. These criteria were determined by explaining the aim of the study and requesting health care HD practitioners. The inclusion criteria required HD practitioners permanently employed in the selected HD units with at least 6 months’ experience in haemodialysis units and fluency in English. The study excluded participants with a history of mental illness. The sample size of a qualitative research study depends on the data saturation [19], which determines whether necessary data are present to generate a rich and in-depth understanding of a phenomenon being researched [20]. After interviewing 18 participants, the present study reached saturation; however, six additional interviews were conducted to confirm data saturation [19,20]. Data collection procedure Data were collected from June 2024 to September 2024 through semi-structured individual interviews with open-ended questions. The primary researcher, SA, conducted the interviews, and T.L.A. and TS assisted in conducting the last six interviews to confirm data saturation. Initially, some prepared questions were asked to familiarise the researcher with the HD environment and create a friendly atmosphere with the participants. The interview guide [Addendum A], specifically designed for this study, included questions addressing IPC in HD environments. Field notes were also used during the interview process. Afterwards, the interviews were focused on the study’s aim. Interview periods varied from 18 to 42 minutes each; the researcher encouraged HD practitioners to contribute to the conversation and discussion by sharing their experiences related to IPC. The primary question asked of participants was: “What are the barriers to Infection Prevention and Control adherence and compliance in the HD unit where you work? As part of this study, a voice recorder and field notes were used to record and collect data, and during all visits to the HD units, the environment, situation, and activities were noted. Ethical considerations The study adhered rigorously to the ethical principles of research. Some guiding principles of ethics are respect for human dignity, autonomy, informed consent, vulnerable persons, confidentiality, the lack of harm, maximum benefit, and justice [21, 22]. The study adhered to the Declaration of Helsinki and the ethical principles and respect for human dignity and protection of personal information denoted in the Constitution of the Republic of South Africa and the Protection of Personal Information Act 4 of 2013 [21,22], all the principles were observed. Ethical approval was sought from the Research Ethics Committee of the Tshwane University of Technology (Ref#: REC2023-12-0113 (Science), the National Department of Health (Ref: GP_202405_052) and both selected institutions in the study. After identifying potential participants, the study's aim and objectives were explained to the participants, and informed and written consent was obtained for audio recording before commencement with each interview. Participants were informed about the confidentiality of the data and the right to participate and withdraw from the study voluntarily. Each participant was identified with a number. Interviews were conducted with an individual participant at each point and in a private room. Data analysis A thematic analysis approach was utilised using a six-phase procedure for data engagement, coding, and theme development [23]. The procedure entailed familiarisation with data, orderly coding, generating main themes from the data, developing and rereading themes, refining, defining and naming themes, and writing the report [23]. In the initial stage, each interview was transcribed right after being conducted. The complete texts of the interviews were reviewed multiple times to immerse the researchers in the content and gain a complete understanding. Each interview text was input into the Atlas TI version to facilitate data management. The full interview texts were examined during the second step to classify meaningful elements of data units aligned with the study's objectives. These meaning elements were summarised and allocated appropriate codes in the third stage. The original codes were then prepared and organised into subcategories based on their correspondence in the fourth stage. Throughout the data collection and analysis, the researcher noted any emerging ideas and insights related to the data and unified them into future interviews. SA analysed the interviews [23]. T. L. A. and TS also analysed the data; all authors agreed on the identified categories and themes. To confirm that the results were accurate, participants were invited to a member check, during which they reviewed a summarised report of the analysed data and represented their accurate reflections. All data was transcribed verbatim. Results This study involved twenty-four HD practitioners working in HD units. The analysis of Facilities A and B participants reveals a diverse and specialised workforce dedicated to dialysis care. Facility A comprises primarily female participants aged 35 to 60, with an average age of approximately 41. The experience of individuals ranges significantly, from less than a year to over 32 years, showcasing a rich pool of knowledge. Many have advanced qualifications, including Postgraduate Diplomas in Nephrology Nursing and degrees in Clinical Technology. In contrast, Facility B has a more balanced gender distribution, including male and female participants aged 28 to 53, with an average age of around 43. Participants in this facility have experience in dialysis ranging from 1 to 18 years, indicating a mix of new and seasoned professionals. Educational qualifications in Facility B also mirror those in Facility A, with numerous participants specialising in Nephrology Nursing and Clinical Technology. Together, both HD units highlight the importance of specialised education and varied experiences in fostering quality patient care in the complex field of renal health, specifically in HD. The data analysis identified eight subcategories, three categories, and a primary theme for barriers to IPC compliance. Table 1 summarises the central themes, categories and subcategories. Table 1 Central theme, categories and subcategories. Theme Categories Sub-categories Barriers to Infection Prevention and Control Individual-related barriers • Inappropriate attitudes • HD practitioners' behavioural patterns and bad practices Management-related barriers • Inappropriate planning and training • Lack of HD-specific Standard Operating Procedures and Policies (SOPs) Organisational barriers • Shortage of staff • Lack of physical resources • Lack of Personal Protective Equipment Central theme: Barriers to Infection Prevention Measures Three subcategories were identified based on the analysis of HD practitioners' experiences while working at the selected HD facilities. This section will address barriers associated with individual-based barriers and organisation-based barriers. Category 1: Individual-related barriers According to the participants in this study, inappropriate attitudes, and a lack of prioritisation of IPC among HD practitioners were two barriers to non-compliance. Consequently, negative attitudes towards IPC and HAIs played an essential role in HD practitioners' non-adherence. Subcategory A. Inappropriate attitudes Most participants’ experiences revealed that staff's negative opinions and attitudes toward IPC practices played a critical role in non-compliance with IPC measures because they perform practices that display a negative attitude towards IPC. On the other hand, one aspect of healthcare workers’ attitudes is their impact on other colleagues on the ward. Thus, a negative attitude toward IPC practices could significantly impact the behaviour of other HD practitioners, resulting in less compliance with IPC practices. “Not everyone is taking part to make sure there's prevention of infections." P5F2 “I think people do not care about patients, they just want to come to work, connect patients, disconnect them from the machine and go home.” P3F2. “It is the “I don’t care attitude”, some things do not need the employer to provide you with certain things, you can be told by the employer, it starts from there because some of the things they don't need the facility to provide you with certain things you can improvise into making things proper , P9F1 Subcategory B. HD practitioners' behavioural patterns and bad practices Most participants’ experiences revealed that HD practitioners' practice toward IPC procedures was essential in non-compliance with hand hygiene because of negative ward cultural practices and behaviours of their colleagues toward IPC. Thus, a negative attitude toward hand hygiene could significantly impact the behaviour of other healthcare workers, resulting in less compliance with hand hygiene practices. “We know what is right and what is wrong. So, if we have spoken about it and someone continues to do what they feel, I personally keep quiet. I will try to do my own part like we are all grown-ups. Some people get offended when you tell them they are contaminating” P11F1 Category 2: Management-related barriers Subcategory A. Inappropriate planning and training In most cases, the participants’ experiences revealed that inadequate dialysis-specific IPC training led to HD practitioners not clearly describing their expectations. Therefore, they attend training as a matter of compliance but do not gain meaningful insights that help them better prevent HAIs in the HD units. Participants considered insufficient management control over the need for organised training. “ There are in-service trainings that are organised by the training department that don’t merely focus on infection control, but unfortunately, it doesn’t reach all the people. It’s not always doable because of the shortage of staff. Its general infection control training not dialysis specific, so when you attend for example you have to direct them (infection control training nurse) to the dialysis specific topics, that in dialysis we do this, this and this, is this the way it should be done and what should be used but yeah, we try.” P1F1 “So, there is a need for more training on infection prevention. But the problem is getting them to attend (staff in the HD unit). Because now I've seen, you know towards training being offered, I've never seen people so negative. They didn't even come. Actually, that thing gives you practice in what you do should there be an emergency, should somebody need to be resuscitated. P3F2 Subcategory B: Lack of HD-specific Standard Operating Procedures (SOPs) and Policies The lack of standardised operating procedures and policies in HD practice significantly impacts the consistency and effectiveness of patient care. This absence is a recurring theme among practitioners, as highlighted by their candid reflections. One participant expressed the desire for a unified approach, stating: "I wish we had somebody who would like help with a standard procedure, where we know that when all of us can process everything, the same thing, when you connect, you know that this step is followed by this step” ( P3F1 ). Another participant shared their frustration over the ongoing struggle to obtain proper protocols, saying, "No, we have been trying to get those (SOPs) for many years from our manager and the infection control sister, but we never get them; we are just working because we have been trained as dialysis people. Otherwise, there is no hope here; we are just working to help the poor patients” ( P7F2 ). Category 3: Organisational barriers Several participants mentioned a staff shortage, poor hospital ward design, inadequate equipment, and low-quality equipment. The high workload and activities are worsened by the shortage of staff in HD units, which hinders IPC practices such as hand hygiene. Additionally, lack of resources such as hand soaps, gloves, and PPE contributes to non-adherence as voiced out by participants. Subcategory A. Shortage of staff In most cases, the participants’ experiences revealed that poor staffing ratios affect the IPC practices’ optimal compliance. This led to an insufficient chance for HD practitioners to perform activities that promote compliance with IPC requirements. “We have tried to negotiate with management, but it seems they do not listen; even when people resign, they are not replaced. We are told that posts are frozen by the government, so we work with what we have, and it is really hard sometimes.” ( P8F1 ) "I've been here since 2016, and the issue of shortages is ongoing. You report and complain, yet it's clear that management is aware everyone knows about these issues. It feels as though they're not accountable or responsible, forcing us to think selfishly about our own needs." ( P1F2 ). Subcategory B. Lack of physical resources Participants raised concerns regarding the challenges faced due to inadequate resources in both HD units. Specifically, issues such as the unavailability of warm water and insufficient cleaning supplies have significantly impacted hygiene practices and overall patient care. They identified these barriers as contributing to the non-adherence of IPC efforts within dialysis units. Participant Quotes: " The water, remember, we do not have the warm water. So, in winter, people avoid washing hands at all costs if they can. Because there is no hot water, which is one of the problems as well. We are supposed to have hot water!! ’ P3F2 “ I think, it’s having less resources. For example, the cleaning of the floor is not done daily. That would be based on, I don't know whether to put it on the hospital management or the staff. I don't know. Using cold water to wash our hands on a daily basis. Having to make alternatives when the stock finishes. For example, previously, not sure how long back, the sterile packs were out of stock. So, we had to make an alternative to see how we work around that. I don't know whether that is the management ..." P6F1 Subcategory C: Lack of Personal Protective Equipment An adequate equipment supply in HD units is crucial. Participants highlighted that one of the challenges HD practitioners encounter in maintaining safety standards is the unavailability of essential supplies and protocols. “And another thing, you find that I'm size 6 ( gloves). The hospital only has size 8. How are we going to work with those sizes of gloves? It's a problem. If it's out of stock, the whole hospital is out of stock; they give what they have” P5F2 “ We use what we have, which is not right” P8F2 “We use the same pack for connecting and disconnecting. Connecting rightfully you supposed to use one when we connect after connection we discard amd use another one pack, but due to finances in our institution they say we cannot waste and must use what we have from CSSD” P5F2 DISCUSSION This qualitative study explored haemodialysis practitioners' barriers to IPC adherence in the context of Gauteng Province's haemodialysis units. It showed that multiple factors contribute to non-adherence for healthcare workers in HD units. They encounter several barriers to IPC measures and practices. The analysis of HD practitioners' experiences related to IPC practices in the HD units established that the main categories of barriers to IPC practices adherence and compliance consisted of individual, management, and organisational barriers. The current study revealed multiple barriers that hinder HD practitioners' IPC adherence. The barriers include a lack of HD-specific training related to HD activities, an absence of standard operating procedures, understaffing, management support, a negative ward culture towards IPC, insufficient staff commitment to IPC, and a lack of resources. These findings are supported by a qualitative study conducted in South Africa, which revealed that nurses experienced challenges involving knowledge and attitudes regarding the IPC process, poor hospital infrastructure, and inadequate support from management [ 24 ]. Another study in the United States of America discovered that various factors in HD units, such as physical space, scheduling, leadership, and culture, impact the optimum human routine of practices such as alarms, interruptions, and task-stacking work system design [ 13 ]. Therefore, addressing these identified barriers is essential for enhancing IPC practices in HD units, ultimately ensuring better patient outcomes, and safeguarding public health. Another section of this study revealed that a lack of resources, dialysis-specific IPC training, and lack of management support contribute to HD practitioners' IPC non-adherence. A study in Egypt showed that nurses working in HD units become affected by insufficient resources, including inadequate materials and equipment, disregard attitude, lack of supervision, suboptimal training, and deficient support from management to help them work effectively [ 25 ]. A recent study conducted in Bangladesh among healthcare workers revealed that challenges to IPC guidelines compliance included a lack of formal training, a lack of time, increased workload, and scarcity of PPE [ 26 ]. Another South African study supports this assertion, revealing that sub-optimal hospital infrastructure and lack of management support affected compliance to IPC [ 24 ]. This underscores a pressing challenge that requires a robust multifactorial approach involving HD unit staff, hospital management and the IPC team to address these barriers. The interventions may need to include enhanced training, resource allocation, and stronger management support to improve IPC adherence among HD practitioners and eventually ensure improved patient outcomes. The infrastructure and physical resources challenge in HD environments cannot be ignored. A study in the United Arab Emirates to audit a tertiary-level care hospital’s HD unit indicated substantial compliance with IPC guidelines across various categories [ 11 ]. Another study by [ 12 ] which assessed IPC practices in 800 outpatient HD facilities across the United States, revealed notable infrastructure challenges, including inadequate spacing of treatment stations and insufficient isolation facilities. Despite high self-reported adherence to cleaning protocols, direct observations indicated that a fraction below sixty percent of HD facilities complied with routine disinfection, demonstrating a discrepancy between reported practices and actual compliance [ 12 ]. These notable gaps in HD facilities increase the risk of infection among vulnerable HD patients and highlight the need for enhanced training, resources, and infrastructure improvements. Therefore, this study asserts that the challenges of HD units' infrastructural non-compliances are evident in South Africa as an upper-middle-income country; however, this challenge is prevalent in high-income countries such as the United States of America and the United Arab Emirates [ 11 , 12 ]. Addressing these barriers is crucial for enhancing patient safety and quality of care in dialysis facilities. Strategies to overcome these challenges may involve implementing comprehensive staff training programs, developing, and enforcing standardised operating procedures, ensuring adequate staffing levels, fostering a supportive management environment, promoting a positive ward culture, strengthening staff commitment to IPC through education and engagement, and allocating sufficient resources for IPC measures. By confronting IPC challenges, dialysis facilities can create a safer environment for patients and healthcare workers, ultimately reducing the incidence of HAIs. Future research should focus on longitudinal studies encompassing both public and private sectors with a specific focus on HD units' infrastructure, resource allocation and HD practitioners staff practices. Robust covert observational and mixed methods studies that include multiple stakeholders within HD environments, such as nurses, doctors, patients, management, and IPC teams should be conducted and may yield invaluable insights. These targeted multistakeholder engagements may assist in developing targeted IPC interventions that address the identified gaps, ensuring patients receive safe and effective care in HD settings. Enhanced training, improved infrastructure, and ongoing monitoring of IPC practices will be crucial in mitigating infection risks in these high-risk population environments. Limitations and strengths of the study The limitations of this study include the small sample size and the fact that it was conducted in two public haemodialysis facilities in the Gauteng province. Therefore, generalisations should be made with caution. Despite these limitations, the authors of this study discovered that the issue of barriers to IPC compliance is not only in the public healthcare sector in South Africa but was also mentioned by HD practitioners in the study who sometimes work part-time in private HD facilities within the Gauteng Province. CONCLUSION This study signifies that barriers to IPC compliance exist based on several factors leading to non-adherence, such as lack of resources, staff attitudes, and lack of support by management. However, some barriers persist, resulting in a decline in IPC compliance among HD practitioners. The findings can help directors, executives, stakeholders, and policymakers intervene on barriers to IPC compliance and improve healthcare workers’ adherence to IPC measures. Abbreviations Table 2: List of abbreviations Abbreviations Full definitions CKD Chronic Kidney Diseases HAIs Healthcare-associated Infections HD Haemodialysis IPC Infection Prevention and Control KF Kidney Failure KRT Kidney Replacement Therapies RRT Renal Replacement Therapy SSA Sub-Saharan Africa Declarations Data availability statement The datasets analysed during the current study are available from the corresponding author on reasonable request. Author contributions S.A. conceptualised and designed this study. T. L. A. and T.S. supervised from the onset to the finish. SA, T.S. and TLA prepared the interview guide and analysed the interviews. S. A. conducted the interviews. SA, TLA, and TS reviewed and corrected the written version. All authors read and confirmed the final version of the manuscript. Acknowledgments The researchers genuinely appreciate all the participants for their involvement in the study and for providing their valuable insights. They also thank the South African National Department of Health and the Gauteng Department of Health for allowing the researchers to use their facilities for the study, the Tshwane University of Technology, Faculty of Science, and Adelaide Tambo School of Nursing Science. Conflict of interest The authors declare that the research was conducted without financial relationships, which could create a conflict of interest. Funding The study received no funding from any organisation. Clinical trial number Not applicable. References Alrebish SA, Yusufoglu HS, Alotibi RF, Abdulkhalik NS, Ahmed NJ, Khan AH. Epidemiology of healthcare-associated infections and adherence to the HAI prevention strategies. Healthcare. 2022;11(1):63. World Health Organization. WHO launches first-ever global report on infection prevention and control [Internet]. 2022 [cited 2025 Mar 25]. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-6975459","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":482605941,"identity":"4d8ed15b-1b77-4844-b074-0346e45ba461","order_by":0,"name":"Siyanda A Ngema","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA/0lEQVRIiWNgGAWjYBADHhAhwVDBwGBAopYzJGgBAwnGNiK0mPMvPrrhB0OdjMHxswdv/Jx3WN6cvfkAw4+KbTi1WM54lnazh+Ewj8GZvGTL3m2HDXf2HEtg7DlzG6cWgxtnzG7wMBzgMTiQYybBu+0w44YbOQbMjG34tJz/dvMPQx2Pwfk3ZpJ/5xy2J6zlfA/bbR4GZh6DGzlm0rwNhxOJsIXN7LYM0C+SN94YW8scS0/ecOZYwkG8fjl/+NnNNwx19nzncwxvvqmxtt1wvPnggx8VuLUwSCQwMDD+Y2BQOADmNoPJA7jVAwE/VFq+AUzV4VU8CkbBKBgFIxMAABphYDoqEiq7AAAAAElFTkSuQmCC","orcid":"","institution":"Tshwane University of Technology, City of Tshwane","correspondingAuthor":true,"prefix":"","firstName":"Siyanda","middleName":"A","lastName":"Ngema","suffix":""},{"id":482605942,"identity":"1196c6d0-bdde-4de5-a7eb-2539b9592609","order_by":1,"name":"Thabiso L. A. Bale","email":"","orcid":"","institution":"Tshwane University of Technology, City of Tshwane","correspondingAuthor":false,"prefix":"","firstName":"Thabiso","middleName":"L. A.","lastName":"Bale","suffix":""},{"id":482605943,"identity":"1dc4bbbb-73b1-471e-bd79-3a3c6373c60c","order_by":2,"name":"Tendani. R Ramukumba","email":"","orcid":"","institution":"Tshwane University of Technology, City of Tshwane","correspondingAuthor":false,"prefix":"","firstName":"Tendani.","middleName":"R","lastName":"Ramukumba","suffix":""}],"badges":[],"createdAt":"2025-06-25 13:53:19","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-6975459/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-6975459/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s12882-025-04666-3","type":"published","date":"2025-12-01T15:57:24+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":97723806,"identity":"a1a35ad7-d5cc-4a68-8117-c71bb02b46fb","added_by":"auto","created_at":"2025-12-08 16:07:11","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":688478,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6975459/v1/9ad2f29f-de9c-4d6e-81ae-c897235e4f43.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Barriers to Infection Prevention Adherence and Compliance in Haemodialysis Units in South Africa: A Qualitative Study","fulltext":[{"header":"Introduction","content":"\u003cp\u003eHealthcare-associated infections (HAIs), known as nosocomial infections, present a severe challenge to healthcare professionals worldwide. Healthcare-associated infections (HAIs) rank among healthcare services' most prevalent adverse effects [1]. To prevent HAIs, the World Health Organisation and the Centres for Disease Control and Prevention recommend that haemodialysis facilities follow infection control standards and precautions, such as hand washing and wearing personal protective equipment [2,3].\u003c/p\u003e\n\u003cp\u003eInfection prevention and control (IPC) is a practical, evidence-based process to prevent patients and health workers from being harmed by avoidable infections [4]. Effective IPC necessitates constant action at all health system levels, comprising policymakers, managers of establishments, healthcare professionals and those who access health services. IPC is unique in the quality-of-care healthcare provision, as it is broadly relevant to all healthcare professionals and patients at every healthcare interaction [4]. It is estimated that on average, out of every 100 patients in acute-care hospitals, seven patients in high-income countries (HICs) and 15 patients in low- and middle-income countries (LMICs) are at risk of acquiring at least one HAI during their hospital stay [5,6].\u003c/p\u003e\n\u003cp\u003ePatients undergoing HD as renal replacement therapy (RRT) in HD facilities are at an increased risk of HAI. As chronic kidney disease (CKD) worsens over time, resulting in Kidney Failure (KF), other associated health problems become more likely, such as infections [7]. The importance of infection control in HD environments is emphasised due to the increased risk of infections in patients undergoing dialysis, such as increased movement by staff in HD environments leading to errors [8]. It has been estimated that at least 30 hand hygiene moments are required per dialysis patient in each 4-hour session [8]. HAIs occur in patients receiving medical treatment in a hospital or other healthcare setting that was not present at admission [9]. A survey conducted in Japan found that while certain haemodialysis (HD) facilities were employing various infection control techniques, some could not implement IPC measures effectively [10]. This was primarily due to limited space within the facility, insufficient staffing, and temporary shortages of personal protective equipment [10].\u003c/p\u003e\n\u003cp\u003eIn recent studies, IPC has emerged as a significant global challenge, particularly in HD settings. A study in the United Arab Emirates [11] found that a tertiary-level care hospital’s HD unit substantially complies with IPC guidelines across different categories. Conversely, another study in the United States of America in 800 outpatient HD facilities examined IPC practices and uncovered considerable infrastructure-related challenges [12]. These challenges included insufficient spacing between treatment stations and inadequate isolation facilities. While facilities reported high adherence to cleaning protocols, direct observations revealed that less than sixty percent complied with routine disinfection practices. This discrepancy underscores a significant gap between self-reported adherence and actual compliance, ultimately elevating the risk of infection for patients receiving HD.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eInfection prevention protocols related to dialysis demand careful focus on complex tasks, skilled manual abilities, and consideration of patient-related factors. Furthermore, several macro ergonomic elements influence human performance [13]. Healthcare workers in HD units frequently interact with patients requiring HD and other related activities, such as follow-ups, meetings, and medication collections. However, data on hospital settings point to hospital-acquired infections (HAIs) as the most frequent health challenge within the hospital setting. A systematic review and meta-analysis in sub-Saharan Africa revealed a high burden of HAIs in SSA, with significant heterogeneity between regions [14].\u003c/p\u003e\n\u003cp\u003eAmid the HAI burdens and challenges thereof, various associations and organisations have recommended evidence-based methods and programs to alleviate risks associated with HAIs and combat antimicrobial resistance [2,3,15,16,17]. The Sustainable Development Goals (SDGs), especially Goals 3, which aim to promote good health and well-being by 2030, and Goal 8, promoting safe working environments for all staff, emphasise the prevention of infectious diseases as essential for adequate healthcare. The imperative to tackle global health issues such as antimicrobial resistance, which requires undivided attention, is highlighted [17]. South Africa has developed a strategic framework to align these crucial priorities to enhance patient safety, reduce HAIs, and improve comprehensive health outcomes for all citizens [16].\u003c/p\u003e\n\u003cp\u003eCorrect application of infection control measures is essential in HD facilities [7,8]. Moreover, applying IPC best practices reduces HAIs and patient harm. Despite the importance of IPC in mitigating the spread of HAIs in HD environments, there is a paucity of research reporting on healthcare workers’ barriers within the haemodialysis environments related to IPC measures adherence and compliance in South Africa, specifically in the Gauteng Province. The absence of such evidence-based studies makes it challenging to advocate for a positive change and create strategies to mitigate existing barriers. For these reasons, researchers embarked on this research project.\u0026nbsp;\u003c/p\u003e"},{"header":"METHODS","content":"\u003cp\u003eStudy design\u003c/p\u003e\n\u003cp\u003eThis study followed a contextual exploratory-descriptive qualitative design, which was essential for researching and describing experiences and situations from the perspective of HD practitioners directly involved in HD activities and procedures [18].\u003c/p\u003e\n\u003ch2\u003eSample and setting\u003c/h2\u003e\n\u003cp\u003eTwenty-four HD practitioners participated in the study, including nurses and clinical technologists in the HD units of the two academic hospitals in the Gauteng Province of South Africa. The HD practitioners included dialysis clinical technologists (\u003cem\u003en\u0026nbsp;\u003c/em\u003e= 4) and nurses (\u003cem\u003en\u0026nbsp;\u003c/em\u003e= 20). The two academic hospitals selected in this study are classified as central hospitals in South Africa within the Gauteng Province and provide both haemodialysis and peritoneal dialysis services for populations within the Gauteng Province and other nearby provinces. Both HD units have an estimated combined population of approximately 140 HD patients, each with a capacity of close to 12 to 18 HD beds.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003ePurposive sampling was used to select participants based on their work experience and expertise in dialysis. The purposive sampling consisted of interviewing suitable participants meeting the inclusion criteria, including HD practitioners working in the HD units, who were willing and able to share their experiences with the researchers. These criteria were determined by explaining the aim of the study and requesting health care HD practitioners. The inclusion criteria required HD practitioners permanently employed in the selected HD units with at least 6 months\u0026rsquo; experience in haemodialysis units and fluency in English. The study excluded participants with a history of mental illness. The sample size of a qualitative research study depends on the data saturation [19], which determines whether necessary data are present to generate a rich and in-depth understanding of a phenomenon being researched [20]. After interviewing 18 participants, the present study reached saturation; however, six additional interviews were conducted to confirm data saturation [19,20].\u003c/p\u003e\n\u003ch2\u003eData collection procedure\u003c/h2\u003e\n\u003cp\u003eData were collected from June 2024 to September 2024 through semi-structured individual interviews with open-ended questions. The primary researcher, SA, conducted the interviews, and T.L.A. and TS assisted in conducting the last six interviews to confirm data saturation. Initially, some prepared questions were asked to familiarise the researcher with the HD environment and create a friendly atmosphere with the participants. The interview guide [Addendum A], specifically designed for this study, included questions addressing IPC in HD environments. Field notes were also used during the interview process. Afterwards, the interviews were focused on the study\u0026rsquo;s aim. Interview periods varied from 18 to 42 minutes each; the researcher encouraged HD practitioners to contribute to the conversation and discussion by sharing their experiences related to IPC. The primary question asked of participants was: \u0026ldquo;What are the barriers to Infection Prevention and Control adherence and compliance in the HD unit where you work? As part of this study, a voice recorder and field notes were used to record and collect data, and during all visits to the HD units, the environment, situation, and activities were noted.\u003c/p\u003e\n\u003ch2\u003eEthical considerations\u003c/h2\u003e\n\u003cp\u003eThe study adhered rigorously to the ethical principles of research. Some guiding principles of ethics are respect for human dignity, autonomy, informed consent, vulnerable persons, confidentiality, the lack of harm, maximum benefit, and justice [21, 22]. The study adhered to the Declaration of Helsinki and the ethical principles and respect for human dignity and protection of personal information denoted in the Constitution of the Republic of South Africa and the Protection of Personal Information Act 4 of 2013 [21,22], all the principles were observed. Ethical approval was sought from the Research Ethics Committee of the Tshwane University of Technology (Ref#: REC2023-12-0113 (Science), the National Department of Health (Ref: GP_202405_052) and both selected institutions in the study. After identifying potential participants, the study\u0026apos;s aim and objectives were explained to the participants, and informed and written consent was obtained for audio recording before commencement with each interview. Participants were informed about the confidentiality of the data and the right to participate and withdraw from the study voluntarily. Each participant was identified with a number. Interviews were conducted with an individual participant at each point and in a private room.\u003c/p\u003e\n\u003cp\u003eData analysis\u003c/p\u003e\n\u003cp\u003eA thematic analysis approach was utilised using a six-phase procedure for data engagement, coding, and theme development [23]. The procedure entailed familiarisation with data, orderly coding, generating main themes from the data, developing and rereading themes, refining, defining and naming themes, and writing the report [23]. In the initial stage, each interview was transcribed right after being conducted. The complete texts of the interviews were reviewed multiple times to immerse the researchers in the content and gain a complete understanding. Each interview text was input into the Atlas TI version to facilitate data management. The full interview texts were examined during the second step to classify meaningful elements of data units aligned with the study\u0026apos;s objectives. These meaning elements were summarised and allocated appropriate codes in the third stage. The original codes were then prepared and organised into subcategories based on their correspondence in the fourth stage. Throughout the data collection and analysis, the researcher noted any emerging ideas and insights related to the data and unified them into future interviews. SA analysed the interviews [23]. T. L. A. and TS also analysed the data; all authors agreed on the identified categories and themes. To confirm that the results were accurate, participants were invited to a member check, during which they reviewed a summarised report of the analysed data and represented their accurate reflections. All data was transcribed verbatim.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eThis study involved twenty-four HD practitioners working in HD units. The analysis of Facilities A and B participants reveals a diverse and specialised workforce dedicated to dialysis care. Facility A comprises primarily female participants aged 35 to 60, with an average age of approximately 41. The experience of individuals ranges significantly, from less than a year to over 32 years, showcasing a rich pool of knowledge. Many have advanced qualifications, including Postgraduate Diplomas in Nephrology Nursing and degrees in Clinical Technology. In contrast, Facility B has a more balanced gender distribution, including male and female participants aged 28 to 53, with an average age of around 43. Participants in this facility have experience in dialysis ranging from 1 to 18 years, indicating a mix of new and seasoned professionals. Educational qualifications in Facility B also mirror those in Facility A, with numerous participants specialising in Nephrology Nursing and Clinical Technology. Together, both HD units highlight the importance of specialised education and varied experiences in fostering quality patient care in the complex field of renal health, specifically in HD.\u003c/p\u003e\u003cp\u003eThe data analysis identified eight subcategories, three categories, and a primary theme for barriers to IPC compliance. Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e summarises the central themes, categories and subcategories.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eCentral theme, categories and subcategories.\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"3\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eTheme\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eCategories\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eSub-categories\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e\u003cp\u003eBarriers to Infection Prevention and Control\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eIndividual-related barriers\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u0026bull; Inappropriate attitudes\u003c/p\u003e\u003cp\u003e\u0026bull; HD practitioners' behavioural patterns and bad practices\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eManagement-related barriers\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u0026bull; Inappropriate planning and training\u003c/p\u003e\u003cp\u003e\u0026bull; Lack of HD-specific Standard Operating Procedures and Policies (SOPs)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eOrganisational barriers\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u0026bull; Shortage of staff\u003c/p\u003e\u003cp\u003e\u0026bull; Lack of physical resources\u003c/p\u003e\u003cp\u003e\u0026bull; Lack of Personal Protective Equipment\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003e\u003cb\u003eCentral theme: Barriers to Infection Prevention Measures\u003c/b\u003e\u003c/p\u003e\u003cp\u003eThree subcategories were identified based on the analysis of HD practitioners' experiences while working at the selected HD facilities. This section will address barriers associated with individual-based barriers and organisation-based barriers.\u003c/p\u003e\u003cp\u003e\u003cb\u003eCategory 1: Individual-related barriers\u003c/b\u003e\u003c/p\u003e\u003cp\u003eAccording to the participants in this study, inappropriate attitudes, and a lack of prioritisation of IPC among HD practitioners were two barriers to non-compliance. Consequently, negative attitudes towards IPC and HAIs played an essential role in HD practitioners' non-adherence.\u003c/p\u003e\u003cp\u003e\u003cb\u003eSubcategory A. Inappropriate attitudes\u003c/b\u003e\u003c/p\u003e\u003cp\u003eMost participants\u0026rsquo; experiences revealed that staff's negative opinions and attitudes toward IPC practices played a critical role in non-compliance with IPC measures because they perform practices that display a negative attitude towards IPC. On the other hand, one aspect of healthcare workers\u0026rsquo; attitudes is their impact on other colleagues on the ward. Thus, a negative attitude toward IPC practices could significantly impact the behaviour of other HD \u003cem\u003epractitioners, resulting in less compliance with IPC practices.\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;Not everyone is taking part to make sure there's prevention of infections.\"\u003c/em\u003e \u003cb\u003eP5F2\u003c/b\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;I think people do not care about patients, they just want to come to work, connect patients, disconnect them from the machine and go home.\u0026rdquo;\u003c/em\u003e \u003cb\u003eP3F2.\u003c/b\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;It is the \u0026ldquo;I don\u0026rsquo;t care attitude\u0026rdquo;, some things do not need the employer to provide you with certain things, you can be told by the employer, it starts from there because some of the things they don't need the facility to provide you with certain things you can improvise into making things proper\u003c/em\u003e, \u003cb\u003eP9F1\u003c/b\u003e\u003c/p\u003e\u003cp\u003e\u003cb\u003eSubcategory B. HD practitioners' behavioural patterns and bad practices\u003c/b\u003e\u003c/p\u003e\u003cp\u003e Most participants\u0026rsquo; experiences revealed that HD practitioners' practice toward IPC procedures was essential in non-compliance with hand hygiene because of negative ward cultural practices and behaviours of their colleagues toward IPC. Thus, a negative attitude toward hand hygiene could significantly impact the behaviour of other healthcare workers, resulting in less compliance with hand hygiene practices.\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;We know what is right and what is wrong. So, if we have spoken about it and someone continues to do what they feel, I personally keep quiet. I will try to do my own part like we are all grown-ups. Some people get offended when you tell them they are contaminating\u0026rdquo;\u003c/em\u003e \u003cb\u003eP11F1\u003c/b\u003e\u003c/p\u003e\u003cp\u003e\u003cb\u003eCategory 2: Management-related barriers\u003c/b\u003e\u003c/p\u003e\u003cp\u003e\u003cb\u003eSubcategory A. Inappropriate planning and training\u003c/b\u003e\u003c/p\u003e\u003cp\u003eIn most cases, the participants\u0026rsquo; experiences revealed that inadequate dialysis-specific IPC training led to HD practitioners not clearly describing their expectations. Therefore, they attend training as a matter of compliance but do not gain meaningful insights that help them better prevent HAIs in the HD units. Participants considered insufficient management control over the need for organised training.\u003c/p\u003e\u003cp\u003e\u003cb\u003e\u0026ldquo;\u003c/b\u003e\u003cem\u003eThere are in-service trainings that are organised by the training department that don\u0026rsquo;t merely focus on infection control, but unfortunately, it doesn\u0026rsquo;t reach all the people. It\u0026rsquo;s not always doable because of the shortage of staff. Its general infection control training not dialysis specific, so when you attend for example you have to direct them (infection control training nurse) to the dialysis specific topics, that in dialysis we do this, this and this, is this the way it should be done and what should be used but yeah, we try.\u0026rdquo;\u003c/em\u003e \u003cb\u003eP1F1\u003c/b\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;So, there is a need for more training on infection prevention. But the problem is getting them to attend (staff in the HD unit). Because now I've seen, you know towards training being offered, I've never seen people so negative. They didn't even come. Actually, that thing gives you practice in what you do should there be an emergency, should somebody need to be resuscitated.\u003c/em\u003e \u003cb\u003eP3F2\u003c/b\u003e\u003c/p\u003e\u003cp\u003e\u003cb\u003eSubcategory B: Lack of HD-specific Standard Operating Procedures (SOPs) and Policies\u003c/b\u003e\u003c/p\u003e\u003cp\u003eThe lack of standardised operating procedures and policies in HD practice significantly impacts the consistency and effectiveness of patient care. This absence is a recurring theme among practitioners, as highlighted by their candid reflections. One participant expressed the desire for a unified approach, stating:\u003c/p\u003e\u003cp\u003e\u003cem\u003e\"I wish we had somebody who would like help with a standard procedure, where we know that when all of us can process everything, the same thing, when you connect, you know that this step is followed by this step\u0026rdquo; (\u003c/em\u003e\u003cb\u003eP3F1\u003c/b\u003e\u003cem\u003e).\u003c/em\u003e\u003c/p\u003e\u003cp\u003e Another participant shared their frustration over the ongoing struggle to obtain proper protocols, saying,\u003c/p\u003e\u003cp\u003e\u003cem\u003e\"No, we have been trying to get those (SOPs) for many years from our manager and the infection control sister, but we never get them; we are just working because we have been trained as dialysis people. Otherwise, there is no hope here; we are just working to help the poor patients\u0026rdquo; (\u003c/em\u003e\u003cb\u003eP7F2\u003c/b\u003e\u003cem\u003e).\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cb\u003eCategory 3: Organisational barriers\u003c/b\u003e\u003c/p\u003e\u003cp\u003eSeveral participants mentioned a staff shortage, poor hospital ward design, inadequate equipment, and low-quality equipment. The high workload and activities are worsened by the shortage of staff in HD units, which hinders IPC practices such as hand hygiene. Additionally, lack of resources such as hand soaps, gloves, and PPE contributes to non-adherence as voiced out by participants.\u003c/p\u003e\u003cp\u003e\u003cb\u003eSubcategory A. Shortage of staff\u003c/b\u003e\u003c/p\u003e\u003cp\u003eIn most cases, the participants\u0026rsquo; experiences revealed that poor staffing ratios affect the IPC practices\u0026rsquo; optimal compliance. This led to an insufficient chance for HD practitioners to perform activities that promote compliance with IPC requirements.\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;We have tried to negotiate with management, but it seems they do not listen; even when people resign, they are not replaced. We are told that posts are frozen by the government, so we work with what we have, and it is really hard sometimes.\u0026rdquo; (\u003c/em\u003e\u003cb\u003eP8F1\u003c/b\u003e\u003cem\u003e)\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003e\"I've been here since 2016, and the issue of shortages is ongoing. You report and complain, yet it's clear that management is aware everyone knows about these issues. It feels as though they're not accountable or responsible, forcing us to think selfishly about our own needs.\" (\u003c/em\u003e\u003cb\u003eP1F2\u003c/b\u003e\u003cem\u003e).\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cb\u003eSubcategory B. Lack of physical resources\u003c/b\u003e\u003c/p\u003e\u003cp\u003eParticipants raised concerns regarding the challenges faced due to inadequate resources in both HD units. Specifically, issues such as the unavailability of warm water and insufficient cleaning supplies have significantly impacted hygiene practices and overall patient care. They identified these barriers as contributing to the non-adherence of IPC efforts within dialysis units. Participant Quotes:\u003c/p\u003e\u003cp\u003e\"\u003cem\u003eThe water, remember, we do not have the warm water. So, in winter, people avoid washing hands at all costs if they can. Because there is no hot water, which is one of the problems as well. We are supposed to have hot water!!\u003c/em\u003e\u0026rsquo; \u003cb\u003eP3F2\u003c/b\u003e\u003c/p\u003e\u003cp\u003e\u0026ldquo;\u003cem\u003eI think, it\u0026rsquo;s having less resources. For example, the cleaning of the floor is not done daily. That would be based on, I don't know whether to put it on the hospital management or the staff. I don't know. Using cold water to wash our hands on a daily basis. Having to make alternatives when the stock finishes. For example, previously, not sure how long back, the sterile packs were out of stock. So, we had to make an alternative to see how we work around that. I don't know whether that is the management\u003c/em\u003e...\" \u003cb\u003eP6F1\u003c/b\u003e\u003c/p\u003e\u003cp\u003e\u003cb\u003eSubcategory C: Lack of Personal Protective Equipment\u003c/b\u003e\u003c/p\u003e\u003cp\u003eAn adequate equipment supply in HD units is crucial. Participants highlighted that one of the challenges HD practitioners encounter in maintaining safety standards is the unavailability of essential supplies and protocols.\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;And another thing, you find that I'm size 6 ( gloves). The hospital only has size 8. How are we going to work with those sizes of gloves? It's a problem. If it's out of stock, the whole hospital is out of stock; they give what they have\u0026rdquo;\u003c/em\u003e \u003cb\u003eP5F2\u003c/b\u003e\u003c/p\u003e\u003cp\u003e\u0026ldquo;\u003cem\u003eWe use what we have, which is not right\u0026rdquo;\u003c/em\u003e \u003cb\u003eP8F2\u003c/b\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003e\u0026ldquo;We use the same pack for connecting and disconnecting. Connecting rightfully you supposed to use one when we connect after connection we discard amd use another one pack, but due to finances in our institution they say we cannot waste and must use what we have from CSSD\u0026rdquo;\u003c/em\u003e \u003cb\u003eP5F2\u003c/b\u003e\u003c/p\u003e"},{"header":"DISCUSSION","content":"\u003cp\u003eThis qualitative study explored haemodialysis practitioners' barriers to IPC adherence in the context of Gauteng Province's haemodialysis units. It showed that multiple factors contribute to non-adherence for healthcare workers in HD units. They encounter several barriers to IPC measures and practices. The analysis of HD practitioners' experiences related to IPC practices in the HD units established that the main categories of barriers to IPC practices adherence and compliance consisted of individual, management, and organisational barriers.\u003c/p\u003e\u003cp\u003eThe current study revealed multiple barriers that hinder HD practitioners' IPC adherence. The barriers include a lack of HD-specific training related to HD activities, an absence of standard operating procedures, understaffing, management support, a negative ward culture towards IPC, insufficient staff commitment to IPC, and a lack of resources. These findings are supported by a qualitative study conducted in South Africa, which revealed that nurses experienced challenges involving knowledge and attitudes regarding the IPC process, poor hospital infrastructure, and inadequate support from management [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]. Another study in the United States of America discovered that various factors in HD units, such as physical space, scheduling, leadership, and culture, impact the optimum human routine of practices such as alarms, interruptions, and task-stacking work system design [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. Therefore, addressing these identified barriers is essential for enhancing IPC practices in HD units, ultimately ensuring better patient outcomes, and safeguarding public health.\u003c/p\u003e\u003cp\u003eAnother section of this study revealed that a lack of resources, dialysis-specific IPC training, and lack of management support contribute to HD practitioners' IPC non-adherence. A study in Egypt showed that nurses working in HD units become affected by insufficient resources, including inadequate materials and equipment, disregard attitude, lack of supervision, suboptimal training, and deficient support from management to help them work effectively [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]. A recent study conducted in Bangladesh among healthcare workers revealed that challenges to IPC guidelines compliance included a lack of formal training, a lack of time, increased workload, and scarcity of PPE [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e]. Another South African study supports this assertion, revealing that sub-optimal hospital infrastructure and lack of management support affected compliance to IPC [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]. This underscores a pressing challenge that requires a robust multifactorial approach involving HD unit staff, hospital management and the IPC team to address these barriers. The interventions may need to include enhanced training, resource allocation, and stronger management support to improve IPC adherence among HD practitioners and eventually ensure improved patient outcomes.\u003c/p\u003e\u003cp\u003eThe infrastructure and physical resources challenge in HD environments cannot be ignored. A study in the United Arab Emirates to audit a tertiary-level care hospital\u0026rsquo;s HD unit indicated substantial compliance with IPC guidelines across various categories [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. Another study by [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e] which assessed IPC practices in 800 outpatient HD facilities across the United States, revealed notable infrastructure challenges, including inadequate spacing of treatment stations and insufficient isolation facilities. Despite high self-reported adherence to cleaning protocols, direct observations indicated that a fraction below sixty percent of HD facilities complied with routine disinfection, demonstrating a discrepancy between reported practices and actual compliance [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. These notable gaps in HD facilities increase the risk of infection among vulnerable HD patients and highlight the need for enhanced training, resources, and infrastructure improvements. Therefore, this study asserts that the challenges of HD units' infrastructural non-compliances are evident in South Africa as an upper-middle-income country; however, this challenge is prevalent in high-income countries such as the United States of America and the United Arab Emirates [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eAddressing these barriers is crucial for enhancing patient safety and quality of care in dialysis facilities. Strategies to overcome these challenges may involve implementing comprehensive staff training programs, developing, and enforcing standardised operating procedures, ensuring adequate staffing levels, fostering a supportive management environment, promoting a positive ward culture, strengthening staff commitment to IPC through education and engagement, and allocating sufficient resources for IPC measures. By confronting IPC challenges, dialysis facilities can create a safer environment for patients and healthcare workers, ultimately reducing the incidence of HAIs.\u003c/p\u003e\u003cp\u003eFuture research should focus on longitudinal studies encompassing both public and private sectors with a specific focus on HD units' infrastructure, resource allocation and HD practitioners staff practices. Robust covert observational and mixed methods studies that include multiple stakeholders within HD environments, such as nurses, doctors, patients, management, and IPC teams should be conducted and may yield invaluable insights. These targeted multistakeholder engagements may assist in developing targeted IPC interventions that address the identified gaps, ensuring patients receive safe and effective care in HD settings. Enhanced training, improved infrastructure, and ongoing monitoring of IPC practices will be crucial in mitigating infection risks in these high-risk population environments.\u003c/p\u003e\u003cp\u003e\u003cb\u003eLimitations and strengths of the study\u003c/b\u003e\u003c/p\u003e\u003cp\u003eThe limitations of this study include the small sample size and the fact that it was conducted in two public haemodialysis facilities in the Gauteng province. Therefore, generalisations should be made with caution. Despite these limitations, the authors of this study discovered that the issue of barriers to IPC compliance is not only in the public healthcare sector in South Africa but was also mentioned by HD practitioners in the study who sometimes work part-time in private HD facilities within the Gauteng Province.\u003c/p\u003e"},{"header":"CONCLUSION","content":"\u003cp\u003eThis study signifies that barriers to IPC compliance exist based on several factors leading to non-adherence, such as lack of resources, staff attitudes, and lack of support by management. However, some barriers persist, resulting in a decline in IPC compliance among HD practitioners. The findings can help directors, executives, stakeholders, and policymakers intervene on barriers to IPC compliance and improve healthcare workers\u0026rsquo; adherence to IPC measures.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eTable 2: List of abbreviations\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eAbbreviations\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eFull definitions\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eCKD\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eChronic Kidney Diseases\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eHAIs\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eHealthcare-associated Infections\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eHD\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eHaemodialysis\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eIPC\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eInfection Prevention and Control\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eKF\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eKidney Failure\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eKRT\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eKidney Replacement Therapies\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eRRT\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eRenal Replacement Therapy\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eSSA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\"\u003e\n \u003cp\u003eSub-Saharan Africa\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e"},{"header":"Declarations","content":"\u003cp\u003eData availability statement\u003c/p\u003e\n\u003cp\u003eThe datasets analysed during the current study are available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003eAuthor contributions\u003c/p\u003e\n\u003cp\u003eS.A. conceptualised and designed this study. T. L. A. and T.S. supervised from the onset to the finish. SA, T.S. and TLA prepared the interview guide and analysed the interviews. S. A. conducted the interviews. SA, TLA, and TS reviewed and corrected the written version. All authors read and confirmed the final version of the manuscript.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAcknowledgments\u003c/p\u003e\n\u003cp\u003eThe researchers genuinely appreciate all the participants for their involvement in the study and for providing their valuable insights. They also thank the South African National Department of Health and the Gauteng Department of Health for allowing the researchers to use their facilities for the study, the Tshwane University of Technology, Faculty of Science, and Adelaide Tambo School of Nursing Science.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eConflict of interest\u003c/p\u003e\n\u003cp\u003eThe authors declare that the research was conducted without financial relationships, which could create a conflict of interest.\u003c/p\u003e\n\u003cp\u003eFunding\u003c/p\u003e\n\u003cp\u003eThe study received no funding from any organisation.\u003c/p\u003e\n\u003cp\u003eClinical trial number\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n \u003cli\u003eAlrebish SA, Yusufoglu HS, Alotibi RF, Abdulkhalik NS, Ahmed NJ, Khan AH. Epidemiology of healthcare-associated infections and adherence to the HAI prevention strategies. Healthcare. 2022;11(1):63.\u003c/li\u003e\n \u003cli\u003eWorld Health Organization. WHO launches first-ever global report on infection prevention and control [Internet]. 2022 [cited 2025 Mar 25]. Available from: https://www.who.int/news/item/06-05-2022-who-launches-first-ever-global-report-on-infection-prevention-and-control\u003c/li\u003e\n \u003cli\u003eO\u0026apos;Grady NP, Alexander M, Burns LA, Dellinger EP, Garland J, Heard SO, et al. Guidelines for the prevention of intravascular catheter-related infections. Clin Infect Dis. 2011;52(9):e162-e193.\u003c/li\u003e\n \u003cli\u003eWorld Health Organization. Infection prevention and control [Internet]. [cited 2025 Apr 20]. Available from: https://www.who.int/health-topics/infection-prevention-and-control#tab=tab_1\u003c/li\u003e\n \u003cli\u003eAllegranzi B, Bagheri Nejad S, Combescure C, Graafmans W, Attar H, Donaldson L, et al. Burden of endemic health-care-associated infection in developing countries: systematic review and meta-analysis. Lancet. 2011;377(9761):228-41.\u003c/li\u003e\n \u003cli\u003eWorld Health Organization. Report on the burden of endemic health care-associated infection worldwide. Geneva: World Health Organization; 2011 [cited 2024 Nov 8]. Available from: https://apps.who.int/iris/handle/10665/80135\u003c/li\u003e\n \u003cli\u003ePark HC, Lee YK, Yoo KD, Jeon HJ, Kim SJ, Cho A, et al. Korean clinical practice guidelines for preventing the transmission of infections in hemodialysis facilities. Kidney Res Clin Pract. 2018;37(1):8-19.\u003c/li\u003e\n \u003cli\u003eKarkar A. Infection control guidelines in hemodialysis facilities. Kidney Res Clin Pract. 2018;37(1):1-7.\u003c/li\u003e\n \u003cli\u003eKhan HA, Baig FK, Mehboob R. Nosocomial infections: Epidemiology, prevention, control and surveillance. Asian Pac J Trop Biomed. 2017;7(5):478-82.\u003c/li\u003e\n \u003cli\u003eSugawara Y, Iwagami M, Kikuchi K, Yoshida Y, Ando R, Shinoda T, et al. Infection prevention measures for patients undergoing hemodialysis during the COVID-19 pandemic in Japan: a nationwide questionnaire survey. Ren Replace Ther. 2021;7(1):27.\u003c/li\u003e\n \u003cli\u003eAlMheiri K, Thomas D, Jagdale R. Infection Prevention and Control Audit of a Tertiary-Level Care Hospital Hemodialysis Unit in the United Arab Emirates at Times of COVID-19 Pandemic-A Case Study. J Commun Dis. 2022;54(2):222-38.\u003c/li\u003e\n \u003cli\u003eGualandi NR, Novosad SA, Perz JF, Hopkins LR, Hsu S, Segura S, et al. Assessments and observations of infection prevention and control practices in US outpatient hemodialysis facilities, 2015-2018: important opportunities for improvement. Infect Control Hosp Epidemiol. 2024;45(9):1137-42.\u003c/li\u003e\n \u003cli\u003eParker SH, Jesso MN, Wolf LD, Leigh KA, Booth S, Gualandi N, et al. Human factors contributing to infection prevention in outpatient hemodialysis centers: a mixed methods study. Am J Kidney Dis. 2024;84(1):18-27.\u003c/li\u003e\n \u003cli\u003eMelariri H, Freercks R, van der Merwe E, Ten Ham-Baloyi W, Oyedele O, Murphy RA, et al. The burden of hospital-acquired infections (HAI) in sub-Saharan Africa: a systematic review and meta-analysis. EClinicalMedicine. 2024;71:102569.\u003c/li\u003e\n \u003cli\u003eWorld Health Organization. The case for investment and action in infection prevention and control. Geneva: World Health Organization; 2025. Available from: https://www.who.int/publications/i/item/B09330 [accessed 21 April 2025].\u003c/li\u003e\n \u003cli\u003eNational Department of Health. Practical Manual for Implementation of the National Infection Prevention and Control Strategic Framework. Pretoria: Government Printer; 2020.\u003c/li\u003e\n \u003cli\u003eUnited Nations Department of Economic and Social Affairs. The Sustainable Development Goals Report 2024. New York: UN DESA; 2024. Available from https://unstats.un.org/sdgs/report/2024/ [Accessed: 24 September 2024].\u003c/li\u003e\n \u003cli\u003eGrove SK, Gray JR. Understanding nursing research: Building an Evidence-Based Practice. 8th ed. St. Louis: Elsevier; 2023.\u003c/li\u003e\n \u003cli\u003eVasileiou K, Barnett J, Thorpe S, Young T. Characterising and justifying sample size sufficiency in interview-based studies: systematic analysis of qualitative health research over a 15-year period. BMC Med Res Methodol. 2018;18(1):148.\u003c/li\u003e\n \u003cli\u003eHennink M, Kaiser BN. Sample sizes for saturation in qualitative research: a systematic review of empirical tests. Soc Sci Med. 2022;292:114523.\u003c/li\u003e\n \u003cli\u003eConstitution of the Republic of South Africa. Pretoria: Government Printer; 1996.\u003c/li\u003e\n \u003cli\u003eSwales L. The Protection of Personal Information Act 4 of 2013 in the Context of Health Research: Enabler of Privacy Rights or Roadblock? Potchefstroom Electron Law J. 2022;25:1-32.\u003c/li\u003e\n \u003cli\u003eBraun V, Clarke V. One size fits all? What counts as quality practice in (reflexive) thematic analysis? Qual Res Psychol. 2021;18(3):328-52.\u003c/li\u003e\n \u003cli\u003eMagadze TA, Nkhwashu TE, Moloko SM, Chetty D. The impediments of implementing infection prevention control in public hospitals: Nurses\u0026apos; perspectives. Health SA Gesondheid. 2022;27:2033.\u003c/li\u003e\n \u003cli\u003eMohamed RE, El-Sayed NM, Alanwer HM. Nurses\u0026apos; compliance with infection control standard precautions in dialysis units. Alexandria Sci Nurs J. 2021;23(1):116-26.\u003c/li\u003e\n \u003cli\u003eRahman SU, Hayat S, Ahmad A, Ali NM. Barriers to the Adoption of Infection Prevention Control (IPC) Guidelines among Health Care Workers at Saidu Group of Teaching Hospital (SGTH), SWAT - A Cross Sectional Study. Int J Med Res Health Sci. 2023;12(4):101942.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-nephrology","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bnep","sideBox":"Learn more about [BMC Nephrology](http://bmcnephrol.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bnep/default.aspx","title":"BMC Nephrology","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Compliance, Adherence, Infection Prevention and Control, Haemodialysis Units, Haemodialysis Practitioners, Dialysis Nurses, Dialysis Clinical Technologists ","lastPublishedDoi":"10.21203/rs.3.rs-6975459/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6975459/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eIntroduction: The burden of infections in haemodialysis environments remains worldwide. Owing to the multiple activities within haemodialysis environments, patients, staff, and visitors in dialysis facilities are at high risk of acquiring healthcare-associated infections. This qualitative study aimed to understand barriers to infection prevention and control adherence and compliance among haemodialysis practitioners in the haemodialysis units in the Gauteng Province of South Africa.\u003c/p\u003e\n\u003cp\u003eMethods: A qualitative contextual exploratory-descriptive design was followed. Twenty-four practitioners from haemodialysis units were sampled using purposive sampling. Data were collected through a semi-structured interview and field notes. The data were analysed using Braun and Clarke’s thematic approach to qualitative data.\u003c/p\u003e\n\u003cp\u003eResults: The study revealed several barriers to the requirements of infection control practices among haemodialysis practitioners, categorised into three main portions. First, individual-related barriers included staff members' inappropriate attitudes and inefficient habits towards infection prevention. Second, management-related barriers highlighted inappropriate planning and training and lack of standard operating procedures. Lastly, organisational barriers included staff shortages, a lack of physical resources and personal protective equipment.\u003c/p\u003e\n\u003cp\u003eConclusions: Several factors lead to non-adherence and suboptimal compliance, which create barriers to infection prevention and control adherence and compliance. Certain barriers necessitate immediate interventions, while others may require extended durations to address effectively. The findings can help directors, executives, stakeholders, and policymakers intervene and improve practitioners' adherence and compliance.\u003c/p\u003e","manuscriptTitle":"Barriers to Infection Prevention Adherence and Compliance in Haemodialysis Units in South Africa: A Qualitative Study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-07-11 11:34:59","doi":"10.21203/rs.3.rs-6975459/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-08-26T17:16:31+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-08-26T11:30:24+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-08-10T02:42:05+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"134013100100205280711461395532740347351","date":"2025-08-03T16:30:27+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"121698453266624580114350381274321017594","date":"2025-07-20T21:49:05+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-07-08T17:49:04+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-07-08T14:47:44+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2025-07-08T06:31:26+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-07-06T17:51:45+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Nephrology","date":"2025-07-06T17:48:59+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-nephrology","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bnep","sideBox":"Learn more about [BMC Nephrology](http://bmcnephrol.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bnep/default.aspx","title":"BMC Nephrology","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"11632f2f-c98e-4a1d-949f-08ad6512d2ee","owner":[],"postedDate":"July 11th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2025-12-08T16:00:32+00:00","versionOfRecord":{"articleIdentity":"rs-6975459","link":"https://doi.org/10.1186/s12882-025-04666-3","journal":{"identity":"bmc-nephrology","isVorOnly":false,"title":"BMC Nephrology"},"publishedOn":"2025-12-01 15:57:24","publishedOnDateReadable":"December 1st, 2025"},"versionCreatedAt":"2025-07-11 11:34:59","video":"","vorDoi":"10.1186/s12882-025-04666-3","vorDoiUrl":"https://doi.org/10.1186/s12882-025-04666-3","workflowStages":[]},"version":"v1","identity":"rs-6975459","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6975459","identity":"rs-6975459","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}