Degree Name

Doctor of Public Health


School of Health Sciences


Background A locally adapted comprehensive infection prevention and control programme (IPCP) is imperative to the management of healthcare associated infections. An IPCP is a technology cluster made up of a number of elements which are closely inter-related. IPCPs in high-income countries have demonstrated effective control of infection transmission in healthcare settings. Relative to the experience of high-income countries, low- and middle-income (LMI) countries have adopted IPCPs, or parts thereof, with varying degrees of success.

The country of Kiribati has been most successful in adopting IPCP principles and practices. The ‘atypical’ case of Kiribati raises many questions, primarily ‘How and why did it change?’, ‘What has been the process of the change?’ and ‘Could other countries in the region benefit from the Kiribati experience?’

This study addresses the research questions: How can the success of IPCPs be enhanced in LMI country healthcare settings? Can the classic Diffusion of Innovations model be used to explain the level of success?’

Methods The adoption process of an IPCP in the Republic of Kiribati was investigated with the findings analysed within the framework of Diffusion of Innovations theory. The case study investigation involved:

1. Review and analysis of IPCP adoption literature to identify those studies that have both consciously and unconsciously followed classical Diffusion of Innovations theory processes. This was to find evidence to support the suggestion that the theoretical process of Diffusion of Innovations is a key framework within which to explore and understand the adoption of IPCP in LMI countries.

2. Evaluation of current IPCP status in Kiribati using adapted National Health Service (NHS) and World Health Organization (WHO) IPCP audit tools.

3. Survey of healthcare worker knowledge, application and confidence with infection prevention and control principles and practice using a previously validated tool.

4. Chronological and thematic analysis of Republic of Kiribati IPCP documentation (for example: infection control manuals, infection control committee minutes) and findings and recommendations of IPCP assessments performed by Republic of Kiribati staff and external agencies/consultants.

5. Semi-structured interviews with key informants in the Republic of Kiribati and external agencies (using snow-ball sampling) to explore the key elements that contributed to the adoption of IPCP.

Findings The literature review revealed a scarcity of relevant literature examining the adoption of comprehensive IPCP or associated conceptual frameworks. Only one study was published which demonstrated the Diffusion of Innovations framework, and it is discussed in more detail.

The healthcare worker survey and evaluation of the Kiribati IPCP indicated that the programme had been integrated into healthcare service delivery. The IPCP reached a level of 75% compliance in accordance with the scoring method of the tool.

Two key activities of the organisational innovation process were identified from the interviews and the chronological and thematic analysis of the IPCP documentation. These were: initiation and implementation. The initiation activity included: 1) agenda-setting: preparations for severe acute respiratory syndrome (SARS) in 2003 stimulated the identification of organisational IPCP deficits, and 2) matching: deficits were identified and the decision to adopt an IPCP innovation package was made. Implementation included: a) redefining/restructuring: identification of the components of an IPCP and how they best fit within the local health structure, b) clarifying: integration of IPCP into the health services and defining an infection control role within the nursing division and, c) routinising: the IPCP became an ongoing element in health service delivery.

Conclusions Exploration of the adoption of the Kiribati IPCP provided an important case study for other low- and middle-income countries in how they may overcome barriers to the establishment and integration of a programme into a health service.

The outcome of the literature review identified a clear need for more research into IPCP adoption. The availability of relevant literature would be especially important to low resourced healthcare settings to assist their adoption of comprehensive IPCPs. Opportunities were identified for future expansion of the Kiribati IPCP through the healthcare worker survey and IPCP evaluation.

The adoption of the Kiribati IPCP followed the classic Diffusion of Innovations process for Organisations. The Kiribati case study provides a relevant and useful example of an IPCP adoption model in low- and middle-income healthcare settings and suggests ways other LMI countries may utilise opportunities as they occur during an innovation.

It is recommended that other LMI countries should enhance their adoption of IPCP through applying key components of the Diffusion of Innovations framework to their endeavours.



Unless otherwise indicated, the views expressed in this thesis are those of the author and do not necessarily represent the views of the University of Wollongong.