3.1 Social Demographic factors of the study population
The study was conducted in all ten targeted referral hospitals. Sixteen (80%) IPC ECHO Clinic coordinators participated in indepth interview, among them 12(75%) were women and 4(25%) were men. Majority of interviewed HCWs were Nurse Officers (62.5%), other were Enviromemtal Health Officers 1(6.25%), Assistant Nurse Officer 1(6.25%), Clinical Pharamacist 1(6.25%), Medical Officer 1 (6.25%), Radiologist 1(6.25%) and Nurse Midwife 1(6.25%). Three Focus group discussions were conducted whereby a total of 37 HCWs participated, among them female were 25 and male were 12.
3.2 Participation of both facilities and health care providers in previous scheduled monthly IPC ECHO Clinic in 10 Referral Hospitals
During the ten months of implementation, the ten referral hospitals were to share knowledge and experience in ten areas namely: infectious disease transmission cycle; instrument and equipment processing; health care waste management; water, sanitation and hygiene (WASH) in healthcare facilities; IPC practice in operating theater; prevention of SSIs; preventing maternal and newborn infections; infection monitoring and surveillance; HAIs and Infection prevention in intensive care units (ICU). Results of participation show that all ten referral hospitals participated in presenting their experience according to the date and topic selected. Furthermore, 471 (47.2%) out 1000 targeted HCWs from the ten referral hospitals attended scheduled IPC ECHO session. It was reported that IPCFP and QIFP were mostly used to coordinate IPC ECHO clinic at the facility level, in which they share link from the MoH to other HCWs through different whatsapp groups available at their Hospitals.
3.3 Existing enablers for the implementation of IPC ECHO Clinic in 10 Referral Hospitals
Participants shared their perspectives on key enablers for implementation of IPC ECHO Clinic.These enablers were grouped into four themes such as: availability of infrastructure for ECHO sessions; facility management support; good coordination from the national team; and availability of internet bundle.
3.3.1 Availability of infrastructure for ECHO sessions:
Availability of infrastructure such as rooms, infrastructure for internet connectivity, screen and speakers for ECHO session were mentioned as a major enabler for the implementation of IPC ECHO clinic. One of the interviewed HCW highlighted that: “availability of equiped conference room enable us to join the session, ……. we have a well equiped conference room, we are confortable during the session” (KI Number 3c, IPCFP). It was narrated that “we have ICT officer who is also responsible to help HCWs to connect the session, HCWs use hospital conference hall to join the session, HCWs may also use their personal device when outside” (KII Number 2a, IPCFP). In addition another key informant had this to say “the sessions are taking place at CTC conference room where the screen is big…this enables many HCWs to join session...., we infrom the whole hospital through link whereby those who are out of facility join through mobile phone while those who are in the facility join at the stated venue(CTC)” (KII Number 8c, IPCFP)
3.3.2 Facility management support:
HCWs acknowledge that the support received from facility management is among key enablers for the implementation of IPC ECHO clinic. The support reported include internet bundle, permission to attend orientation session, and infrastructure. It was stated that “Management is supporting us in the implementation of the sessions, for example the facility bought for us mordem to be used during the session as well as they allow use of facility internent to join the sessions… management is supporting us 100% (KI Number 2a, QIFP).
It was emphasized that facility management also alow HCWs to attend orientation session as well as scheduled sessions “Initial orientation to the sessions included awareness and our hospital management provided permission for selected HCWs to attend orientation workshop” (KI Number 10a, QIFP). An IPCFP reported that facility management is working to help HCWs to get room to be used for the sessions. “The room used for ECHO session is under construction and the hospital management has been looking for another venue that will serve the purpose, there is a new ward under construction we are expecting to get the venue from it……….” (KI Number 6c, IPCFP). Another IPCFP emphasized that the facility management provided support in terms of environment for learning purpose “…we thank our hospital management for providing good eviroment for learning purpose, they currently support us with well equiped conference room that has large screen and other facilities that allow us to participate in ECHO sessions (KI Number 3c, IPCFP)
It was also narrated that “at first we did not have a dedicated venue and epuipemnts for all of us to attend the session,we used to join using personal computers or mobile phones, but after we shared this challenge with hospital management…..we are now supported with a room dedicated for all zoom meetings including ECHO sessions” (KII Number 9a, QIFP).
3.3.3 Good coordination from the national team:
QIFP and IPCFP reported that good coordination from national team (MoH and implementing partners – (IPs)) has been among the enablers for the implementation of IPC ECHO Clinic whereby facilitators were well coordinated, HCWs were reminded to join sessions and follow up was done after sessions:
‘we have experienced that national team coordinated well the sessions, facilitators are well coordinated”. Another IPCFP emphised that “national team from MoH and IPs remind us on the topic to be presented five to three days before the session and provide link to us, this help us to share session link timely with the participant…….. follow up to share with partipants was done after session, (KI Number 1c, IPCFP).
3.3.5 Availability of internet bundle:
QIFP and IPCFP who are the coordinators of IPC ECHO session reported that availability of internet bundle has enabled them in implementation of IPC ECHO clinic, as it enables HCWs to join virtual sessions.
“The hospital has internent with high speed, this motivate us to join the session even when the provided bundle from IPs has challenges, this enable us not to miss the session”(KI 3c, IPCFP). “Provision of a internet bundle before the session allows staff to attend the session” emphasized IPCFP (KI Number 7b, IPCFP).
In addition, another key informant had this to say: “…………..but we also we receive internet bundle for the sessions and we also have hospital mordem specific for ECHO sessions” (KI Number 2a QIFP).
3.4 Existing barriers for the implementation of IPC ECHO Clinic in 10 Referral Hospitals
IPC ECHO clinic coordinators and other HCWs reported several barriers for implementation of IPC ECHO clinic; these barriers were grouped into four main themes, namely: lack of motivation among attendees; lack of Continuous Professional Development (CPD) points; Shortage of staff and poor internet connectivity.
3.4.1 Lack of motivation among attendees:
Coordinators of IPC ECHO clinic narrated that lack of motivation such as money paid to HCWs, training cerificates, physical workshop were among the barriers for HCWs to attend the session
“barriers are there…..at the beginning we had a good number of HCWs attended sessions, some of them think that may be they will get incentive like monetary allowance when joining the sessions” (KII Number 1a, QIFP). Another key iformat who is IPC ECHO coordinator had this to say “another barrier in HCWs themselves, some of the HCWs did not receive teleconference training positively, they still have notion that they must get something beyond education, e.g., money after training…….hence their participation is low” (KII Number 2a, QIFP). It was narrated that “no recognation of partcipants, some sort of recognitatin such as physical IPC sharing meetings and provision of certificates to those who attended session are needed to motivate partcipants”.
Another key informant added that “trend of attendes from the beginning and currently is not the same, trend is low, some of the trainnes thought that they will get some incentives when joining the session (KII Number 1c, IPC FP). It was reported that failure to provide motivation also is a barrier for HCWs to participate in the session “….. but also, there is one thing called motivation, its true HCWs like to get education but once you told them there is something provided after training the will run to the session, hence lack of motivation is a barrier for HCWs to partipate in the sessions” (KII Number 8a, QIFP).
3.4.2 Lack of Continuous Professional Development (CPD) points:
Responders pointed out that IPC ECHO sessions do not contribute any CPD points to the participants hence this is among the barrier for the implementation of the sessions.
“Lack of CPD Points among attendees also facilitates poor HCWs to join the session” (KII Number 1a, QIFP).
Another responder mentioned that “the main question asked by particpants is if they will get CPD points by joining IPC ECHO clinic,when we answered them no CPD points provided, they do not joint the session” (KII Number 8a, QIFP). It was emphasized that: “IPC ECHO session is not inluded in CPD plartform, HCWs thought that if the session could contribute to their carrier development through CPD points they may participate more” (FDG Number 3).
3.4.3 Shortage of staff:
Interviewed key informants narrated that inadequate staff at the facilities is also a barrier for the implimentation of IPC ECHO clinic such that HCWs are overloaded with clients hence fail to participate in the scheduled ECHO session:
“Shortage of staff in the facility, you might find that few staff are present at work to attend sessions because of roster variation, this lead to inadequate attendance during the session” (KII Number 10a, QIFP).
It was reported that limited number of staff is a barrier for implementation of IPC ECHO clinic as due to available roster only few HCWs might be available at workstation “major challenge we experience is inadequate staff, and the available staff at workstation have another competing duty to perform” (KII Number 7b, IPC FP). Another responder emphasized that “HCWs are few, sometimes there are emergencies, they can not leave what they are doing” (KII Number 2a, QIFP).
3.4.4 Poor internet connectivity:
Responders mentioned that they sometimes experience challenges of internent connectivity hence fail to join the session or fail to follow session proceedings at the mid of the sesion:
“Sometimes there are challenges of internet connection, sometimes we may not hear the presenters hence we are not getting well the session proccedings….” (KII Number 2a, QIFP).
Another key responder highlighted that at their facility internent connectivity is a major barrier as they sometimes fail completely to join the session “the first barrier at our facility is internet connectivity, sometimes we may join for few minutes and the connection cut off and sometimes we want to join the session but we fail completely, this is due to climate challenges at our Region” (KII Number 5a, QIFP).
3.5 Recommendations for improvement of IPC ECHO Clinic
Interviewed IPC ECHO Clinic coordinators and HCWs participated in FGD provided the following recommendations to be considered in order to improve implementation of IPC ECHO clinic: include IPC ECHO clinic in CPD initiatives for all cadres; reviewing time for the sessions; provision of incentives for attendees; improve facilitation techniques among SME’s and facilitators; improve network connectivity; re-sensitization of HCWs to participate in IPC ECHO Sessions: and scale up of IPC ECHO clinic to other referral hospitals and primary health care (PHC) facilities.
3.5.1 Include IPC ECHO clinic in CPD initiatives for all carders
HCWs recommended that IPC ECHO Clinic enables them to gain knowledge and experience in the areas of IPC hence they recommend that this clinic should be accredited under their respective professional councils so as to motivate HCWs to participate in the session since it will help them to receive CPD points after the session as well.
“we think that we may tackle the challenge of inadeqaute partcipation of HCWs in ECHO session by including IPC ECHO session in CPD platform…..HCWs will see they get credit from session” (FDG Number 1).
It was emphasized that “MoH to provide information to HCWs on how many CPD points HCWs will receive by joining IPC ECHO sessions” (KII Number 1a, QIFP).
3.5.2 Reviewing time for the sessions
It was proposed that time for the session should be reviewed so as to allow more HCWs to participate in IPC ECHO session.
“…currently the sessions are conducted at peak hours where there is lot of patients…time for session should be reviewed to 14:00 Hrs to allow more partcipation.”. (FDG Number 1).
“I think time for the session should be reviewed and insteady of 13:00HRs, the session may start from 15:30HRS, this is good time as HCWs will be free from most of the major activities at the hospital also this time will allow those who are on duty at operating theater to attend the session” (FDG Number 2).
It was further emphasized that current time is not conducive for the HCWs as some of them will be in mosque and for other it is the time for daily report exchange “If we can change time and day it will be good, since from 13:00 to 14:00 some of the HCWs will be in mosque, so we may think on few Friday the sessions to start at 15:00PM” (KII Number 3a, QIFP).
“Time for session is not conducive for us, session are conducted at the time where HCWs exchange daily report, we suggest time to be between 10:00HRS and 13:00HRS” (KII Number 5a, QIFP).
3.5.3 Provision of incentives for attendees
Study participants recomend the need of providing incentives to attendees so as to motivate more participation. The recommended incentives include certificates of attendance, organizing physical IPC meetings and allowances in terms of money.
“MoH to plan for incentives to attendances, just small incentive... so as to motivate and encourage HCWs to join the session” (KII Number 1a, QIFP). It was further emphasized that:
“recognition of attendees through physical meetings, monetary allowances and provision of certificates for attendiees” (KII Number 4a, QIFP);
“If we can be facilitated to get incentives for attendees it may improve partcipation” highlighted facility QIFP (KII Number 2a QIFP).
3.5.4 Improve facilitation techniques among SME’s and facilitators
Responders provided their perspectives regarding facilitation of the IPC ECHO sessions and provide recommendations to improve facilitation in the areas of environment used by facilitators and SMEs during session, their appearance and managing of time:
“Enviroment where experts are, and their apperance should be looked over as in other session this was a challenge, good environment and appearance highlight that we are more serious” (FDG Number 3) “Time management during the session, facilitators should ensure that there are no excuses of delay to start or end the session” (KII Number 4a, QIFP).
Use of data to support subject presented was also recommended for facilitators and SMEs during the session. “SMEs should give more information and data rather than what is available in the guidelines because for the last sessions more of the content was from our guidelines we need more contents from research work…” (FDG Number 3).
Another key informant added that:
“SMEs and facilitators should conclude the topic by real data from our country for recent we need to hear may be by practising standards precautions we were able to reduce SSIs by what %” (KII Number 4a, QIFP).
3.5.5 Improve network connectivity
Partcipants extensively discussed how internet connectivity is sometimes a challenge for them and recommend that there should be plans to manage the challenge both at SMEs/facilitators side as well as at their respective health facilities.
“…….. we get so much challenges in connecting to the sessions, I wish we should improve on internet connection” (FDG Number 2).
“…… aaah.. I can not understand if its nertwork or, but I think you should work on internent connection as in other sessions we may not hear facilitators well.....” (KII Number 4a, QIFP).
“We should ensure availability of network whenever sessions are carrying on as we frequently join late due to network challenges” insisted facility IPCFP (KII Number 8c, IPCFP).
3.5.6 Re sensitization of HCWs to participate in IPC ECHO Sessions
Many partcipants frequently recommended that there is a need to sensitize HCWs and facility management on the need and the importance of participating in IPC ECHO sessions.
“More awareness and sensitization to hospital management on IPC ECHO Clinic should be done” (FDG Number 1). Additionaly, it was emphasized that “my request is that…….sensitization to Management Teams on IPC ECHO clinic should be done as it will improve implementation at the facility level” (FDG Number 3).
It was narrated that sensitization may also be done through reminding health facilities with official letter from the MoH, “…..I think MoH should write official letter to remind health facilities and HCWs to participate in session” (FDG Number 2). Another responder had this to say, “I think we should sensitize staff on importance of attending virtual sessions while at work station in order to easily manage human resource for better service delivery” (KII Number 5c, IPC FP).
1.5.7 Scale up of IPC ECHO clinic to other referral hospitals and PHC facilities;
HCWs recognize the knowledge gain through IPC ECHO sessions and recommended that it is high-time to include more referral hospitals in this session as well as scale up the clinic to PHC facilities.
“MoH should think of rollout IPC ECHO Clinic to more health facilities especially PHC facilities, as well as other referral hospitals…..we receive a lot of referrals from PHC facilities and we think that if they had chances to receive what we learn through ECHO session we may see changes, as currently they are still behind on IPC practices” (FDG Number 3).