HEALTHCARE ASSOCIATED INFECTIONS

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CHAPTER 3 THEORETICAL FOUNDATIONS OF THE STUDY

INTRODUCTION

This chapter is preoccupied with an explanation of the theoretical foundation. In Chapter 1, this was referred to as the Precede-Proceed Model coupled with the Theory of Planned Behaviour. Presently, the main features of the said model are outlined, showing how its choice has a close relation with the problem under investigation, and how the application of the model helps address the research questions, as framed in Tables 1.1 to 1.4., and Figures 1.4, 3.1 to 3.2. The following are discussed, the Precede-Proceed model coupled with the Theory of Planned Behaviour and the paradigm. Additionally, the components of the model, how the model works singular and in dual operationalisation, phases of the model used, evolution of the model, and, the Theory of Planned Behaviour, as well as organisational change and the educational strategies. This chapter then addresses this model as it is fully applied throughout the study, for the validation and corroboration of results generated guided by the model concepts that lead to the development of guidelines for fostering HCWs hand hygiene compliance to prevent and control HCAIs. Precede-Proceed model is ideal as a visual diagrammatic structuring model that can be used for an entire live health promotion programme effort with link to fostering (hand hygiene compliance) towards prevention and control of a particular disease(s) (Crosby & Noar, 2011:S7). According to Phillips, Rolley and Davidson (2012:1) the Precede-Proceed model, Green and Kreuter (2005:10) has been in use across the world’s healthcare settings to guide the assessment, planning, implementation, and evaluation of various healthcare improvement strategies. Using a reflective case study approach the applicability of the Precede-Proceed model, Green and Kreuter (2005:10) was examined for two Australian populations.

COMPONENTS OF THE PRECEDE-PROCEED MODEL ARE DISPLAYED

Researcher has best worked with Precede part of the model for the needs assessments backwards, in phases 1, 2 and 3. Phase 4 was used in developing guidelines, intervention alignment that influence administrative policies in health programmes to integrate educational strategies and organisational policies and regulations. Health programmes concepts were best worked on in integration downwards, upwards and forwards towards best quality of life when infections are alleviated through healthcare workers’ hand hygiene compliance. Proceed is best dealt with forwards for implementation and evaluation for best outcome.
The Precede-Proceed model has two components: ‘Precede’, and ‘Proceed’. The Precede part has four planning phases. According to Green and Kreuter (2005:9), the planning phases consist of a series of planned assessments and diagnoses that generate information, which in turn is used for educational and ecological evaluation, as well as administrative and policy assessments, all of which in turn influence policy regulation focusing on HCAIs and HCWs hand hygiene compliance. With respect to HCAIs and HCWs’ hand hygiene the assessment phases in ‘Precede’ can be used to evaluate the factors that contribute to hand hygiene compliance.
The Precede stage comprises of four planning phases: social assessment, epidemiological, educational and ecological assessment, administrative policy assessment, and intervention alignment (Green & Kreuter, 2005:10; Crosby & Noar, 2011:S7). Phase 1 of the model (social assessment) relating to HCWs comprises of immunocompromised individuals such as those with HIV or cancer (genetics) (Green & Kreuter, 2005:10). These individuals are at high risk of experiencing profound effects of HCAIs. Therefore, Phase 2 of epidemiology requires close HCAIs surveillance to establish their associated morbidity, mortality rates so that appropriate interventions measures and administrative policy assessments can be employed to protect patients particularly at risk of contracting HCAIs.
The Proceed stage comprises four phases: the implementation phase, driven by the findings from the assessments in the Precede stage. This is followed by three evaluation phases after implementation Phase Five: Phase Six ‘process’, ‘impact’, and Phase Eight ‘outcome’ (Green & Kreuter, 2005:10; Crosby & Noar, 2011: S7). With respect to HCAIs and hand hygiene compliance the implementation phase involves using the findings of surveillances to integrate developed guidelines, which counteracts HCAIs. The implementation phase needs to be evaluated to see if its intervention is significant to alleviate HCAIs. Figure 3.1 shows the influences of health programme policies and inputs.
The generic representation of the Precede-Proceed model for health programme involves assessment, planning, setting the programme, and evaluation. Figure 3.1 shows the influences of health programme policies and inputs with a focus to fostering HCWs behavioural improvement in hand hygiene compliance using the developed guidelines to prevent and control HCAIs. As shown by the direction of the arrows, these ultimately influence people’s health and quality of life through reduction or prevention of HCAIs, thus decreasing morbidity and mortality rates contributing to abundant life. The model shows that the direction taken during the first four phases of the model is reversed in the latter four stages; however, it does not show the feedback processes that are built into the system, or any specific social science theories underlying the model (Green & Kreuter, 2005:10). With respect to HCWs hand hygiene compliance there should be a feedback mechanism which shows their progress in hand hygiene compliance. The representation of the evaluation needs assessment tasks of the model in Figure 3.1 suggest that there are other dimensions and factors that might be identified in the Precede assessment process or evaluated as outputs and outcomes in the Proceed stage (Green & Kreuter, 2005:17).
With respect to policies, regulations and organisation factors the policy makers and healthcare organisation should supply adequate resources for HCWs to be able to carry out their hand hygiene. These guidelines will reinforce individuals to use their available resources in their respective healthcare settings (environmental) to enable HCWs and patients to counteract HCAIs incorporating the predisposing component of the model (that includes knowledge and attitudes). The behaviour of HCWs and patients in turn promotes positive health outcomes in terms of infection control and prevention. There is limited availability, accessibility, and affordability of health resources especially in developing countries such as Zimbabwe and this is a critical issue in order to apply effective hand hygiene compliance to counteract HCAIs.

PHASES OF THE PRECEDE-PROCEED MODEL

The Precede-Proceed model has eight phases that are described as follows: The entry point to Phase One of the Precede is a vision of the quality of life, as well as social and health care-based assessment of factors affecting the quality of life. With respect to the thesis this would involve a meticulous health care-based assessment of factors affecting the quality of life with respect to HCAIs, which would significantly help in implementing every possible robust and meticulous measure focused primarily on prevention of the spread of HCAIs and better hand hygiene practices. This would consequently result in lower mortality rates and better quality of life.
Phase Two is an epidemiological assessment of genetics, behaviour and environmental factors contributing to people’s health, and their consequent quality of life. All these factors and the ones below were explored in this study with a focus on enhancing them in order to achieve fostering better HCWs hand hygiene practices to counteract HCAIs.
Phase Three is an educational and ecological assessment of the predisposing, reinforcing and enabling factors (which are linked with genetics, and the behaviour of individuals, groups or communities), and also the environmental factors. With respect to this study, it would involve investigating the predisposing, enabling and reinforcing factors that can help HCWs to improve hand hygiene compliance by enhancement of HCWs behaviours and attitudes in order to comply during patient care. All kinds of factors contribute to HCWs and patients’ health and quality of life free from HCAIs. Theory of Planned Behaviour within the Precede-Proceed model concerns behaviour of HCWs for fostering hand hygiene compliance implementing 5 Moments of Hand hygiene to reduce or prevent HCAIs.
Phase Four comprises administrative and policy assessment, and intervention alignment. This involves planning a health programme, which takes into consideration educational strategies, and the fact that those strategies interlink with policy, regulation and organisation with respect to HCWs hand hygiene compliance and the alleviation or counteracting of HCAIs.
Phase Five is the implementation phase off the Proceed part of the model. Phases Six to Eight form the evaluation component (evaluation, impact evaluation and outcome evaluation, consecutively) (Green & Kreuter, 2005:10). According to Tones and Green (2005:62), further analysis should identify the plethora of factors that influence health behaviour, which in turn are grouped into predisposing factors that influence HCWs’ motivation to change (such as knowledge, beliefs, attitudes and values).
Enabling factors that support changes in HCWs’ behaviour or work environments include resources availability, skills, and the removal of barriers to achieving hand hygiene compliance. Lastly, reinforcing factors need to be assessed (such as feedback received from HCWs whose behaviour is being targeted). For this study, the factors considered are those that help to foster HCWs’ hand hygiene compliance, resulting in the control and prevention of HCAIs in the Mutoko and Mudzi districts public health care institutions in Zimbabwe.
Handy (1999:29) explains motivation to work that if we could understand [HCWs hand hygiene compliance] and could then predict, the manner in which individuals were motivated, we could influence what they do by changing the components of that motivation process. In certainty such understanding could lead to great power since it would allow the control of human behaviour [to comply] without the visible and unpopular trappings of control and in this study fosters on HCWs hand hygiene compliance and infection control as well as prevention focusing on HCAIs. However, Handy (1999:30) further elaborates that indeed motivation is concerned to find ways by which individual HCWs could put more effort to [own health care settings] as organisations and skills to the service of employer. Motivation of HCWs spares the essential dignity and independence of the individual.

EVOLUTION OF THE PRECEDE-PROCEED MODEL

The Precede-Proceed model is the corner stone of health education and health programme promotion planning, implementation as well as evaluation and is now a recognised tool that employs an educational and ecological approach to public health and population health planning (Green & Kreuter, 2005: xxii; Gielen, McDonald, Gary and Bone, in Glanz, Rimer and Viswanath, 2008:408). This model has enabled the researcher to explore the factors for fostering hand hygiene compliance, and to link them with the findings of this study guided by the model coupled with the theory of planned behaviour and with scientific literature by analysing and linking the relevance of the study’s findings with respect to literature (Grove, Burns & Gray, 2013: 695).
During the early stages in the evolution of the Precede component, it was referred to as a framework. This was a cautionary term used to discourage analysts from perceiving it as a model or theory. The primary purpose of the Precede framework was not to explain and predict phenomena, but to organise existing multiple theories and variables into a cohesive, comprehensive and systematic view of relations among those variables (Green & Kreuter, 2005:25). This helps HCWs to enhance hand hygiene compliance and reduce the HCAIs rates. The Precede-Proceed organises precursors into three categories, within which various concepts and models can be used for planning detailed procedures such as messages, incentives, training and policies (Green & Kreuter, 2005:148). With respect to the study this can involve giving HCWs incentives to motivate them to improve their hand hygiene practices, training them on how to better achieve effective hand hygiene compliance and generating robust guidelines that can guide them to achieve this. Proceed stage with its four phases was added to the Precede component after the extensive application and validation in practice, and after decades of research, it now qualifies to be called a model (Green & Kreuter, 2005:25).
The purpose of a model is not merely to explain and predict a phenomenon, but to give a logical structure that supports a systematic manner of assessing, planning and evaluating health behaviour change. This model with the theory has aided in enabling the study achieve research questions and objectives. The Precede-Proceed model (Green & Kreuter, 2005:18) can also be used as a platform for crafting best practices and evidence-based practical guidelines for HCWs’ hand hygiene compliance in context. The model is used in combination with the organogram of Zimbabwe in conjunction with World Health Organization in partnership to the Government of Zimbabwe in health issues.
However, according to Sundin and Fahy (2008:20) the first contextualisation process that is the repositioning of geographical districts maps with their health care settings, tests and retests explanations in real terms of the worldview by using Precede-Proceed model concepts for the decision making atmospheric processes that are textualised and the second resituation henceforth was the investigated hand hygiene compliances and the experiences as constructs by participants as collected data vis – a – vis infection control and prevention to show concepts systematically, thematically, highlighting points made by sources of information and therefore findings for the meanings are embeded in the data. According to Serrant-Green (2007:3) not only just by presenting findings from the natural settings perspectives of individual participants but also by embedding the social contexts of that experience and expectations in the research process is contextualisation. Data were the information from participants, that data were analysed, interpreted and discussed giving meanings for feeding back the information to the districts. The feedback is the true reality as presented guidelines of HCWs hand hygiene and HCAIs control and prevention in Mutoko and Mudzi districts in Zimbabwe.
According to Green and Kreuter (2005:197) match the live geo-ecological assessment factors with the worldwide programme concepts that is matching the contemporary realistic worldview of HCWs hand hygiene compliance against HCAIs control and prevention in Zimbabwe vis-a-vis the ideal worldwide programme scholarly concepts of international highest reputation by using the Precede-Proceed Model coupled with Theory of Planned behaviour in context. In addition, according to Sundin and Fahy (2008:20) contextualisation was the last step in Denzin’s interpretive interactionism and that the thick interpretation adds depth to the meaning of the guidelines as theory or model (Denzin, 1989:60).
This links best with development of guidelines for fostering hand hygiene compliance and prevention of HCAIs. ‘Precede’ involves sieving and sorting data, integrating the predisposing, reinforcing, and enabling of constructs in educational, ecological diagnosis and evaluation (Green & Kreuter, 2005:9). These components are important with respect to hand hygiene as they influence the continuous chain of fostering hand hygiene compliance. If this chain is broken, it will be impossible to achieving and fostering hand hygiene compliance, which prevents and controls HCAIs. The second part is ‘Proceed’, which involves policy, regulations and organisational constructs in educational and environmental development (Green & Kreuter, 2005:9). This can be incorporated in HCWs fostering hand hygiene compliance by developing effective, robust policies, regulatory and organisational constructs which they can use as guidelines as presented in chapter 8 to help them to improve their compliance. From this HCWs’ hand hygiene and alleviation of HCAIs can be promoted with respect to how improvements are accomplished further and sustained for generations.
Organisations are a part of daily living experiences with a focus on healthcare settings in Zimbabwe. The key to successful organisational programmes such as the HCWs hand hygiene compliance and infection control in the Zimbabwean situation promote better understanding of the needs assessments of the communities and motivations of the people living within the micro-societies cosmos in the contextual question using the Precede- Proceed model and the Theory of Planned Behaviour. Understanding health care settings involves cultures, motivating people in the remote rural communities, leadership, roles of HCWs in healthcare settings, coordinating resources with consultation, responsibility and accountability.
It is this kind of a language that can help in finding new solutions to familiar daily HCWs hand hygiene compliance problems. Organisations need to develop; select, structure, redesign work, resolve political conflicts by utilising guidelines and furthermore plan for the next future generations’ quality of life.

Philosophical underpinnings

Philosophical underpinnings about the qualitative-quantitative approaches (mixed methodology), the third paradigm. Philosophical foundations are critical in the investigation of the problem of HCWs hand hygiene compliance and HCAIs prevention and control in Mutoko and Mudzi districts in Zimbabwe as focused on in the current study.
According to Parahoo (2014:79) qualitative-quantitative approaches are not two camps in opposition. Combining qualitative-quantitative methodologies facilitate one another. Creswell and Plano-Clark (2011:21) view that a combination of both provides the most complete of analyses of problems to be solved. Further researchers resituate numbers to contexts and words from participants and frame numbers, trends and statistics results with words. Such integration is not problematic in any way because there is enhancement of one method by the other. According to Berger et al. (1979:14) a philosopher by whatever methods will inquire into the ontology and epistemology status of conceptions. Epistemology provides philosophical grounding on what kinds of knowing are possible with the study title in context and how it is ensured that the knowledge is adequate and legitimate (Crotty, 1998:8). Out there objects, held no meaning at all (Crotty, 1998:43). This is supported by Giddens (2001:22) who explains that cultures could not exist without societies and vice versa. Without cultures there would not be human beings as understood today, would have no language, no self-consciousness and ability to think or reason severely impaired. This is keyed in Figure 3.2, linking the title to resituated contextual aspects in the model concepts. Henceforth that is why there is the need to identify, explain, and justify the epistemological viewpoint of this study with the concepts of the Precede-Proceed model. Hall (2012:5) is of the same viewpoint that a realist approach has been suggested as an alternative single paradigm. This approach supports the use of mixed methods. Therefore, it is the type of data sought by researcher that determines the methods used (Parahoo, 2014:79).
Additionally, a new born human must learn the culture of its society and becomes an identified member of that society (Haralambos & Holborn, 2008:2). However, Berger et al. (1979:149) explains that on one hand a child is not born a member of society on the other hand is born with a predisposition towards being socialised to become a member of society. In lives of all individuals there is a temporal induction period in the participation in the societal dialectic.
According to Creswell and Plano Clark (2011:38) the philosophical assumptions do provide foundation for the study as worldviews, using and relating these assumptions to mixed methodology procedures. A framework is therefore needed in planning how philosophical assumptions fit into the mixed methodology design (Creswell & Plano Clark, 2011:38). Further, Creswell and Plano Clark (2011:39) indicate four levels for developing a research study as follows: paradigm worldviews to get answers such as ontology, epistemology, methodology, theoretical lens such as in the use of the Precede-Proceed model and or social science theory in this study specifically Theory of Planned Behaviour. Further there is mixed methodological approach influencing methods of data collection as observational and interviews thereafter data analyses influence guidelines development from evidence-based findings.
Logic is defined as a branch of philosophy that analyses patterns of reasoning, structured method of reasoning for evidences, particular system of reasoning that is reasoned thought or argument (Black, Grove, Hucker & McKeown, 2011:589). In this study it is logical to see patterns unfolding in complex phenomena of HCWs hand hygiene compliance for the purpose of developing guidelines for fostering the compliance. According to Haralambos et al. (2013:886) a phenomenon comprises anything that human beings live experience and phenomenology being the nature of social reality. This is code able moment seen or seen like as it is in reality (Boyatzis, 1998:1).
According to Ivankova (2015:239) coding is a central issue in inductive qualitative data analyses because it helps give meanings and then to integrate them in a new way into groups or categories and this is reconstruction of participants’ common experiences with the study title. Therefore, coding generates true pictures of phenomena (Craig, 2009:189). However Black, Grove, Hucker and McKeown (2011:762) define a phenomenon as anything perceived as an occurrence or fact and additionally phenomenalism is a philosophical stance that all knowledge comes from human senses perceptions as one of the views of epistemology of the phenomenal worldview.
According to Meleis (2012:195), there is a logical representation and clarity in the Precede-Proceed model concepts, and both the model and the Theory of Planned Behaviour demonstrates consistency, simplicity, complexity, and usefulness in the development of guidelines for HCWs hand hygiene compliance: “The hallmarks of the Precede-Proceed model are its flexibility and scalability in addressing a wide range of ecological levels, settings, and populations. The results of using it are evidence-based and evaluable, and they provide a platform for Evidence-Based Best Practice” (Green & Kreuter, 2005:18). Additionally, Burns and Grove (2009:601) report ‘‘comprehension, comparison, analysis, evaluation and conceptual clustering to provide an empirical knowledge base of a phenomenon’’.
According to Parahoo (2014:162), in order to assess the value of operational constructs sample definitions in confirmatory research, researchers use the five criteria: clarity, precision, validity, reliability, and consensus; whereas in exploratory research, the report must give a clear detailed account of the study as thick descriptions and beyond, concepts investigated, methods used, and findings from which guidelines evidence based are developed henceforth trustworthiness focusses on consistences of judgements: dependability equivalent to reliability. According to Brink in Morse (1991a:167) on information judgement in qualitative research is of the stance that trustworthiness pertains to credibilty of a concept implying accurate judgement decisions according to some standard judgements. In research measurement is frequently associated with numerical or quan instruments. In qual, measurement refers to the series of judgements made by the researcher about collected information in relation to representation of the truth about the subjective reality of a phenomenon to be believed as true.

TABLE OF CONTENTS
LIST OF TABLES
LIST OF FIGURES
LIST OF BOXES
LIST OF ANNEXES
LIST OF ABBREVIATIONS
CHAPTER 1 ORIENTATION TO THE STUDY
1.1 INTRODUCTION
1.2 BACKGROUND INFORMATION ABOUT THE RESEARCH PROBLEM
1.3 STATEMENT OF THE RESEARCH PROBLEM
1.4 THE PURPOSE OF THIS STUDY
1.5 SIGNIFICANCE OF THE STUDY
1.6 DEFINITIONS OF KEY CONCEPTS: CONCEPTUAL AND OPERATIONAL WORK
1.7 OPERATIONALISING THE PRECEDE-PROCEED MODEL CONCEPTS
1.8 INTRODUCTION TO METHODOLOGY
1.9 ETHICAL CONSIDERATIONS
1.10 SCOPE OF THE STUDY
1.11 STRUCTURE OF THE THESIS
1.12 SUMMARY OF THE DEVISED AND ADOPTED EMERGED MIXED METHODOLOGY FRAME WORK
1.13 CONCLUSION
CHAPTER 2 LITERATURE REVIEW
2.1 INTRODUCTION
2.2 HEALTHCARE ASSOCIATED INFECTIONS
2.3 POLICIES AND STANDARDS
2.4 PRINCIPLES FOR EFFECTIVE HAND HYGIENE
2.5 METHODS OF CLEANSING HANDS
2.6 HAND HYGIENE: TRANSMISSION OF PATHOGENS BY HANDS, METHODS USED FOR HAND HYGIENE
2.7 HEALTHCARE WORKERS’ OVERALL HAND HYGIENE COMPLIANCE
2.8 HAND HYGIENE COMPLIANCE BY HEALTHCARE WORKERS: MODELS OF HAND HYGIENE, ADHERENCE TO HAND HYGIENE
2.9 BARRIERS OR CHALLENGES TO HEALTHCARE WORKERS’ HAND HYGIENE COMPLIANCE
2.10 CONCLUSION
CHAPTER 3 THEORETICAL FOUNDATIONS OF THE STUDY
3.1 INTRODUCTION
3.2 COMPONENTS OF THE PRECEDE-PROCEED MODEL DISPLAYED
3.3 PHASES OF THE PRECEDE-PROCEED MODEL
3.4 EVOLUTION OF THE PRECEDE-PROCEED MODEL
3.5 THE THEORY OF PLANNED BEHAVIOUR
3.6 ORGANISATIONAL CHANGE AND EDUCATIONAL STRATEGIES
3.7 APPLICATION OF DATA USING PRECEDE-PROCEED MODEL
3.8 APPLICATION OF THE PRECEDE-PROCEED MODEL AND THE THEORY OF PLANNED BEHAVIOUR FOR VALIDATION OF FINDINGS
3.9 ANALYSES, INTERPRETATIONS AND REPORTING PROGRAMME PLANNING EVALUATION QUALITY CONTROL CRITERIA
3.10 CONCLUSION
CHAPTER 4 RESEARCH DESIGN AND METHODOLOGY
4.1 INTRODUCTION
4.2 RESEARCH DESIGN
4.3 MIXED METHODS RESEARCH
4.4 NON-EXPERIMENTAL RESEARCH DESIGN
4.5 CONTEXTUAL DESIGN
4.6 ORGANISATION OF THE STUDY IN STRANDS GUIDED BY THE PRECEDE-PROCEED MODEL COUPLED WITH THEORY OF PLANNED BEHAVIOUR IN THE HEALTH CARE INSTITUTIONS
4.7 ASSUMPTIONS OF ANOVA TO DEVELOP THE CONFIRMATORY EXPLANATION FOR THE DATA
4.8 GENERALISED LINEAR MODELS
4.9 RESEARCH GEOGRAPHICAL SETTINGS: STAFFING LEVELS IN 2011
4.10 SELECTION CRITERIA OF STUDY SITES AS PART OF SAMPLING
4.11 OBSERVATION OF HEALTHCARE WORKERS AND HAND HYGIENE OPPORTUNITIES
4.12 DATA COLLECTION
4.13 DATA COLLECTION METHODS
4.14 DEVELOPMENT AND TESTING OF THE DATA COLLECTION INSTRUMENTS
4.15 INTERVIEWING OF PATIENTS USING INTERVIEW SCHEDULE
4.16 HEALTHCARE WORKERS AND THE CHALLENGES THEY FACE
4.17 RETROSPECTIVE REVIEW OF HEATLTHCARE ASSOCIATED INFECTIONS ASSOCIATED MORTALITIES
4.18 ETHICAL CONSIDERATIONS
4.19 VALIDITY OF THE STUDY
4.20 BIAS CONTROL
4.21 CONCLUSION
CHAPTER 5 ANALYSIS, PRESENTATION AND DESCRIPTION OF THE RESEARCH FINDINGS
5.1 INTRODUCTION
5.2 DATA MANAGEMENT AND ANALYSES
5.3 RESULTS OBSERVED HEALTHCARE WORKERS’ HAND HYGIENE
5.4 DEMOGRAPHIC FINDINGS PATIENTS AND HEALTHCARE WORKERS.
5.5 RESULTS FOR THE INTERVIEWED PATIENTS
5.6 PERCEIVED PROMOTION HAND HYGIENE AMONG 574 PATIENTS
5.7 DEMOGRAPHIC FINDINGS OF THE INTERVIEWED 574 PATIENTS
5.8 FINDINGS OF THE INTERVIEWED PATIENTS
5.9 RELATIONSHIPSHIP AMONG VARIABLES
5.10 PRESENTATION OF RESULTS FOR HEALTHCARE WORKERS QUESTIONED
5.11 HCWs’ DATA: STATISTICAL CONSULTATION TESTS FOR 189 HCWs’ HAND HYGIENE COMPLIANCE QUESTIONNAIRE ON CHALLENGES FACED IN ACCOMPLISHING HAND HYGIENE COMPLIANCE
5.12 FINDINGS FOR THE HEALTHCARE WORKERS QUESTIONED
5.13 RETROSPECTIVE HCAIs AND THEIR ASSOCIATED MORTALITIES FROM RECORDS AT MUTOKO AND MUDZI DISTRICTS
5.14 CONCLUSION
CHAPTER 6 INTERPRETATIONS AND DISCUSSION OF THE FINDINGS
6.1 INTRODUCTION
6.2 HEALTHCARE WORKERS HAND HYGIENE PRACTICES
6.3 THE INTERVIEWED PATIENTS
6.4 HEALTHCARE WORKERS ON CHALLENGES FACED
6.5 THE RETROSPECTIVE REVIEWED INFECTIONS HCAIs AND ASSOCIATED MORTALITIES FROM RECORDS AT MUTOKO AND MUDZI DISTRICTS
6.6 CULTURES, CONTEXTS AND LANGUAGES IN HAND HYGIENE AND INFECTION CONTROL
6.7 CONCLUSION
CHAPTER 7 TRUSTWORTHINESS, VALIDITY AND DEVELOPMENT OF GUIDELINES
7.1 INTRODUCTION
7.2 THE BEST PROCESSES OF DEVELOPING GUIDELINES
7.3 CONCLUSION
CHAPTER 8 PRESENTATIONS OF GUIDELINES
8.1 INTRODUCTION
8.2 QUALITY OF LIFE
8.3 SOME PATIENTS ARE IMMUNOCOMPROMISED
8.4 HCWs’ HAND HYGIENE BEHAVIOURS WITHIN PRECEDE-PROCEED MODEL
8.5 PREDISPOSING
8.6 REINFORCING
8.7 ENABLING
8.8 EDUCATIONAL STRATEGIES
8.9 ORGANISATION POLICIES, REGULATIONS AND GUIDELINES
8.10 ENVIRONMENT
8.11 CONCLUSION
CHAPTER 9 SUMMARY, CONCLUSIONS AND RECOMMENDATIONS
9.1 INTRODUCTION
9.2 SUMMARY OF THE STUDY
9.3 CONCLUSIONS OF THE STUDY
9.4 CONCLUSIONS OF THE STUDY BY QUESTIONS AND OBJECTIVES
9.5 CONTRIBUTIONS OF THE STUDY
9.6 RECOMMENDATIONS OF THE STUDY
9.7 LIMITATIONS OF THE STUDY
9.8 GENERALISATION, TRANSFERABILITY OF RESEARCH FINDINGS
9.9 CONCLUSION
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