Healthcare-Associated Infections (HAI) in Kazakhstan: Can We Trust Reporting? A Mixed-Methods Study of Institutional Culture, Context and Leadership in Hospitals and State Public Health Agencies

Abstract

Background. Health care-associated infections (HAI) are among the most common adverse events in health care delivery globally, with up to 7% of patients in high-income countries and up to 15% in low- and middle-income countries acquiring one during their hospital stay [1]. However, HAI rates in Kazakhstan did not exceed a fraction of one percent for decades [2, 3]. While up to 70% of HAI are preventable through effective infection prevention and control (IPC) practices [1], not knowing the real rate reduces the sense of urgency for national and local leaders and delays action to improve patient safety. Such low HAI rates in Kazakhstan led public health leaders to suspect underreporting, prompting a WHO-sponsored pilot point-prevalence survey, which found a 3.2% HAI rate in 2022, 90 times higher than the reported rate of 0.35% for the same year [4]. This study aimed to find out why health care organizations (HCO) are not reporting HAIs to health authorities, and based on the influence of institutional culture, organizational and country context, how public health leaders can best improve HAI surveillance. Methods. This is a mixed-methods study that used triangulation and grounded theory to analyze data collected in 4 stages: 1) desk review of national policies; 2) secondary datasets collected in a national study of 78 hospitals; 3) qualitative primary data collected from 12 key informants (public health leaders); 4) repeated desk review. safety and get involved in IPC. Epidemiologists from public health agencies must become the source of methodological support and have their training needs met as well. While this study generated evidence in support of multiple recommendations, the water of systems change model [9] can help policymakers appreciate the importance of implicit change conditions such as the culture, often ignored in change efforts undertaken in the post-Soviet countries. Conclusions. HAI rate remains abnormally low in Kazakhstan due to the long-lasting effect of the Soviet approach to IPC and the resulting punitive culture and punitive policies that deter providers from reporting. Findings from this study should be used by national, regional and HCO leaders in Kazakhstan and other countries with similar context to prioritize and design system-wide improvements in IPC and HAI surveillance. Recommendations should not be limited to traditional leadership actions such as policy change, more training and introduction of evidence-based protocols and procedures, but also include an implicit change condition – culture change – to create an environment conducive of truthful reporting of adverse events such as HAIs.