Abstract
Background
Healthcare-associated infections (HAIs) and antimicrobial resistance (AMR) pose significant challenges to healthcare institutions worldwide. Implementing effective infection prevention and control (IPC) measures is crucial for reducing the risk of HAIs. However, limited research has been conducted on the current status of IPC in secondary and tertiary hospitals in Shaanxi Province, China. This study aims to comprehensively and quantitatively evaluate the IPC practices in these hospitals using the IPC Assessment Framework (IPCAF).
Methods
A cross-sectional study was conducted in Shaanxi Province, China, from February to April 2024, in collaboration with the Provincial Center for Nosocomial Infection Control and Quality Improvement (NICQI) and 10 regional NICQIs. Using a stratified multistage sampling approach, secondary and tertiary hospitals were selected. Data were collected via electronic questionnaires distributed through WeChat groups. To ensure data quality, a pilot survey was performed, and standardized training was provided to all investigators.
Results
A total of 171 hospitals participated in the survey, with 108 secondary hospitals (63.16%) and 63 tertiary hospitals (36.84%). The overall median IPCAF score was 642.5 (inter-quartile range [IQR]: 545–710), with secondary hospitals scoring 600 (IQR: 507.5–682.5) and tertiary hospitals 705 (IQR: 637.5–755), indicating significant differences between hospital grades (P < 0.05). According to WHO criteria, 106 hospitals (61.99%) achieved an "advanced" IPC level. Among core component (CC) scores, CC5 (Multimodal strategies) and CC7 (Workload, staffing and bed occupancy) had the lowest median scores (75), while CC8 (Built environment, materials and equipment for IPC at the facility level) and CC2 (IPC guidelines) had the highest median score.
Conclusions
Secondary and tertiary hospitals in Shaanxi Province have demonstrated a relatively high level of IPC. However, resource allocation and facility upgrades in secondary hospitals require enhancement. The identified strengths and areas for improvement are in accordance with those observed in other upper-middle income countries, particularly with respect to multimodal strategies.
Keywords: Healthcare-associated infection, Infection prevention and control, Survey, WHO, Northwest China
Background
Healthcare-associated infections (HAIs) and antimicrobial resistance (AMR) constitute critical threats to hospitalized patients and major challenges for global healthcare systems. The WHO's May 2022 Global Report on Infection Prevention and Control (IPC) [1] reveals a significant disparity in HAI prevalence: 7% of patients in high-income countries (HICs) versus 15% in low- and middle-income countries (LMICs) experience at least one HAI during hospitalization. HAIs and AMR have imposed a severe global health burden [2, 3], with disability and mortality from the six most common HAIs in EU/EEA countries exceeding the combined burden of 32 other infectious diseases by twofold. Mortality risk is 2–3 times higher in patients with resistant versus susceptible pathogen infections [4]. China experiences significant HAI burdens, with a 2018 incidence rate of 3.12% in mainland hospitals, corresponding to approximately 7.95 million inpatient cases [5]. Compared to non-infected patients, those with HAIs incurred additional costs of ¥24,881.37 (US$3,461.79) for total medical expenses, ¥9,438.46 (US$1,313.02) for medications, and 13.89 extra hospitalization days [6]. The coronavirus disease 2019 (COVID-19) pandemic demonstrated the critical threat of nosocomial pathogen transmission, underscoring the necessity of robust IPC systems in healthcare facilities.
IPC measures form the cornerstone for preventing HAIs and AMR [7, 8]. Studies demonstrate that the implementation of comprehensive IPC measures has reduced the surgical site infection (SSI) rate in congenital heart disease patients from 9.5% in 2010 to 3% in 2021 [9], IPC interventions are estimated to prevent 35% ~ 55% of HAIs [10]. However, significant variations in IPC structures persist due to disparities in healthcare capacities and resource allocation, challenging systematic IPC assessment and targeted improvement.
Since 1986, China has implemented government-led IPC management systems, driving substantial improvements across healthcare tiers. Subsequent regulations issued by health authorities catalyzed structural optimization of IPC frameworks. The 2016 WHO guidelines [11] defined eight core components of IPC, which outline evidence-based standards for strengthening institutional IPC. In September 2018, the WHO released the Infection Prevention and Control Assessment Framework (IPCAF) [12], a structured questionnaire that scores the eight core components outlined above. The framework serves both as a baseline assessment and as a guide for developing improvement plans by evaluating the effectiveness of interventions [13].
In recent years, Germany [14], Japan [15], Turkey [16], and other countries have utilized IPCAF to assess hospital infection management resources and structures, identifying strengths, weaknesses, and improvement potentials. Currently, there are limited studies on IPC evaluation using IPCAF in China. Ni Kaiwen's [17] study on secondary and tertiary hospitals in Zhejiang Province revealed relatively high-level IPC implementation, with inter-grade variations, and identified improvement areas comparable to those in developed countries.
Shaanxi Province (32°−39°N, 105°−111°E), a regional healthcare hub in Northwest China with 38.76 million residents, serves as a national pilot for tiered healthcare reform. Its infrastructure includes 1,243 primary hospitals and 78 tertiary facilities. Prior studies on HAIs management in Shaanxi relied predominantly on regulation-based questionnaires, lacking multidimensional quantitative assessments. This limitation compromises result comparability and motivated our comprehensive IPC assessment using IPCAF in secondary and tertiary hospitals.
This study quantitatively assessed IPC practices in Shaanxi Province's secondary and tertiary hospitals using IPCAF, aiming to evaluate system implementation, identify deficiencies, and establish an evidence base for targeted IPC improvement strategies.
Methods
Study design
This cross-sectional study was conducted from February to April 2024 in Shaanxi Province, China, targeting secondary and tertiary hospitals accredited by the Shaanxi Provincial Health Commission. In 2001, Shaanxi Province established the Expert Advisory Committee for Nosocomial Infection Management, which began operating as the Center for Nosocomial Infection Control and Quality Improvement (NICQI) in 2005. NICQIs were subsequently established in 10 cities, leading to the gradual development and enhancement of the nosocomial infection management system, as well as strengthened implementation of IPC measures. The study protocol was approved by the Ethics Committee of the Second Affiliated Hospital of Fourth Military Medical University (Approval No. K-HG-202506–12). In this study, informed consent was obtained from all personnel in the IPC departments of the participating hospitals.
This study collaborated with provincial and 10 municipal NICQIs. The IPCAF underwent Chinese translation for investigator comprehension, followed by a pilot survey to refine ambiguous terminology prior to formal deployment. One project leader was selected from each municipal NICQI and underwent standardized training. Guiding documents were distributed, which included study objectives, sampling protocols and terminology definitions. These leaders were tasked with sampling hospitals in their respective jurisdictions, designating the head of each selected hospital’s infection management department as the primary questionnaire respondent. Dedicated survey WeChat groups were established in each municipal jurisdiction, with members including municipal coordinators and designated respondents from sampled hospitals. These groups were utilized for unified training and distribution of electronic questionnaires.
Definition of variables
Hospitals directly administered by the Shaanxi Provincial Health Commission (SPHC) are provincial-level Class III Grade A institutions serving as regional healthcare hubs in northwest China. With bed capacities exceeding 1,000 and advanced clinical facilities, these hospitals manage complex case referrals, lead clinical research, and partner with universities for medical education. As defined by the National Health Commission of China (NHC), hospitals are categorized into three tiers based on their scale, technical capabilities, and service scope. Tertiary hospitals (highest-tier healthcare institutions in China, ≥ 500 beds) house specialized departments for advanced treatments. They function as critical-case referral centers, collaborate with universities for medical education, and lead clinical research initiatives. Secondary hospitals in China are mainly city- or county-level facilities with at least 100 beds, serving as the backbone of regional healthcare systems. They provide comprehensive care for common and acute conditions, act as referral hubs between primary clinics and tertiary hospitals, and are regulated by provincial health authorities.
Sampling method
This study adopted a stratified multi-stage sampling approach to recruit study subjects. First, 24 hospitals directly affiliated with the SPHC were selected. Second, based on bed capacity (maximum, median, minimum), 3 tertiary general/specialized hospitals and 3 secondary general/specialized hospitals were randomly selected in each city. Finally, according to population size (maximum, median, minimum), 3 districts/counties were selected in each prefecture-level city, and then 3 tertiary general/specialized hospitals and 3 secondary general/specialized hospitals were randomly sampled from each selected district/county. For categories with more than 3 districts/counties or hospitals, random sampling was applied; if the number was less than 3, all were included in the study.
Measurement
The study questionnaire comprised three sections. The first section assessed hospital baseline characteristics, including tier (secondary/tertiary), type (general/specialist), bed capacity, and presence of an infection management department (yes/no). The second section collected socio-demographic data on infection managers, including gender (male/female), age (years, continuous), professional background (medical/nursing/public health/medical laboratory/other), and years of experience in IPC (years, continuous). The final section comprised the Chinese version of IPCAF, which includes eight core components (CC): CC1 (IPC programme), CC2 (IPC guidelines), CC3 (IPC education and training), CC4 (HAI surveillance), CC5 (multimodal strategies for IPC interventions), CC6 (monitoring/audit of IPC practices and feedback), CC7 (workload, staffing, and bed occupancy), and CC8 (built environment, materials, and equipment for IPC at the facility level). Each component is scored out of 100, with a total score of 800. Hospital IPC levels were classified according to WHO criteria: 0–200 (inadequate), 201–400 (basic), 401–600 (intermediate), and 601–800 (advanced).
Statistical analysis
All statistical analyses were conducted using SPSS Statistics version 26.0. Quantitative variables were summarized as mean ± standard deviation (SD) or median and inter-quartile range (IQR; P25, P75), with group comparisons performed using the t-test or Wilcoxon test. Qualitative variables were presented as frequency and percentage, and compared across groups using Pearson’s chi-square test. All statistical tests were two-sided, and P-values < 0.05 were considered statistically significant.
Results
Baseline characteristics of participating hospitals
A total of 171 hospitals participated in the survey, including 108 secondary hospitals (63.16%) and 63 tertiary hospitals (36.84%). General and specialized hospitals comprised 68.42% and 31.58%, respectively. Hospital bed capacity was distributed as follows: < 100 beds (11.11%), 101–500 beds (45.62%), 501–1000 beds (26.90%), and > 1001 beds (16.37%). Of these, 84.21% had an independent infection management department, while 6 facilities lacked such a department. Additionally, 77.19% of hospitals had fewer than 5 infection management staff members. Details are presented in Table 1.
Table 1.
Baseline characteristics of participating hospitals
| Number (%) | IPCAF score [Median (IQR)] | |
|---|---|---|
| Hospital type | ||
| Secondary hospital | 108 (63.16) | 600 (507.5,682.5) |
| Tertiary hospital | 63 (36.84) | 705 (637.5,755) |
| Category | ||
| General | 117 (68.42) | 662.5 (585,717.5) |
| Specialist | 54 (31.58) | 605 (507.5,690.5) |
| Hospital beds | ||
| < 100 | 19 (11.11) | 512.5 (335,572.5) |
| 101–500 | 78 (45.62) | 605 (507.5,695) |
| 501–1000 | 46 (26.90) | 662.5 (602.5,735) |
| > 1001 | 28 (16.37) | 715 (672.5,767.5) |
| Region | ||
| Directly Administered by the SPHC | 22 (12.86) | 717.5 (680,760) |
| Xi’an | 18 (10.53) | 672.5 (610,705) |
| Baoji | 18 (10.53) | 592.5 (425,672.5) |
| Hanzhong | 20 (11.70) | 602.5 (517.5,697.5) |
| Xianyang | 17 (9.94) | 665 (567.5,710) |
| Ankang | 12 (7.02) | 597.5 (570,637.5) |
| Weinan | 17 (9.94) | 602.5 (532.5,692.5) |
| Yulin | 15 (8.76) | 677.5 (550,707.5) |
| Yanan | 12 (7.02) | 600 (335,657.5) |
| Shangluo | 12 (7.02) | 605 (400,687.5) |
| Tongchuan | 8 (4.68) | 555 (337.5,585) |
| IPC department | ||
| Yes, independent | 144 (84.21) | 650 (570,715) |
| Yes, belongs to medical/nursing department | 21 (12.28) | 610 (495,695) |
| No | 6 (3.51) | 490 (252.5,530) |
| Number of IPC staff | ||
| 0–2 | 77 (45.03) | 567.5 (440,645) |
| 3–5 | 55 (32.16) | 677.5 (600,715) |
| > 6 | 39 (22.81) | 722.5 (650,767.5) |
| Total | 171 | 642.5(545,710) |
IPCAF infection prevention and control assessment framework, SPHC Shaanxi Provincial Health Commission, IPC Infection prevention and control, IQR inter-quartile range
Baseline characteristics of IPC staff
Female staff comprised 90.84% of the IPC workforce, with a higher proportion in secondary hospitals (95.17%) than in tertiary hospitals (88.13%). The mean age of participants was 40.85 ± 8.92 years, with no significant difference between hospital tiers. Secondary and tertiary hospitals differed significantly in education level, professional background, work experience in IPC, and the number of IPC staff per 100 beds. Details are presented in Table 2.
Table 2.
Baseline characteristics of infection control staff
| Secondary hospital | Tertiary hospital | Total | χ2/t | P value* | |
|---|---|---|---|---|---|
| Gender | 9.056 | 0.003 | |||
| Male | 12 (4.83) | 47 (11.87) | 59 (9.16) | ||
| Female | 236 (95.17) | 349 (88.13) | 585 (90.84) | ||
| Age(years,x ± s) | 41.12 ± 8.46 | 40.68 ± 9.19 | 40.85 ± 8.92 | 0.602 | 0.547 |
| 20–30 | 30 (12.10) | 65 (16.41) | 95 (14.75) | 3.954 | 0.266 |
| 31–40 | 92 (37.09) | 136 (34.34) | 228 (35.40) | ||
| 41–50 | 90 (36.29) | 126 (31.82) | 216 (33.55) | ||
| > 50 | 36 (14.52) | 69 (17.42) | 105 (16.30) | ||
| Education level | 87.611 | < 0.001 | |||
| Junior college and below | 70 (28.23) | 44 (11.11) | 114 (17.70) | ||
| Undergraduate | 176 (70.96) | 247 (62.37) | 423 (65.68) | ||
| Postgraduate and above | 2 (0.81) | 105 (26.52) | 107 (16.62) | ||
| Professional Background | 51.662 | < 0.001 | |||
| Clinical medicine | 21 (8.47) | 68 (17.17) | 89 (13.82) | ||
| Nursing | 200 (80.65) | 213 (53.79) | 413 (64.13) | ||
| Public health | 16 (6.45) | 92 (23.23) | 108 (16.77) | ||
| Other | 11 (4.43) | 23 (5.81) | 34 (5.28) | ||
| Years of participated in IPC | |||||
| ≤ 1 | 25 (10.07) | 49 (12.37) | 74 (11.49) | 10.076 | 0.018 |
| 2–5 | 129 (52.02) | 171 (43.19) | 300 (46.58) | ||
| 6–10 | 61 (24.60) | 88 (22.22) | 149 (23.14) | ||
| ≥ 11 | 33 (13.31) | 88 (22.22) | 121 (18.79) | ||
| Number of IPC staff/100 beds | 0.97 ± 0.79 | 0.69 ± 0.63 | 0.87 ± 0.75 | 2.342 | 0.020 |
*Comparing tertiary hospitals and secondary hospitals
The distribution of IPCAF scores
The median IPCAF score across all participating hospitals was 642.5 (IQR: 545–710), with secondary hospitals scoring 600 (IQR: 507.5–682.5) and tertiary hospitals 705 (IQR: 637.5–755), showing a statistically significant difference between the two groups (P < 0.001). Based on WHO criteria, 1 hospital (0.58%) had “inadequate” IPC performance, 15 (8.78%) achieved the “basic” level, 49 (28.65%) reached the “intermediate” level, and 106 (61.99%) attained the “advanced” IPC level (Fig. 1). As presented in Table 3 and Fig. 2, core component scores showed that CC5 and CC7 had the lowest median scores (75), while CC8 and CC2 had the highest (95).
Fig. 1.
Distribution of IPCAF level
Table 3.
Distribution of scores for each CC
| Min | P10 | P25 | Median | P75 | P90 | Max | |
|---|---|---|---|---|---|---|---|
| CC1 | 0 | 37.5 | 60 | 80 | 92.5 | 100 | 100 |
| CC2 | 32.5 | 55 | 80 | 92.5 | 100 | 100 | 100 |
| CC3 | 0 | 55 | 75 | 85 | 95 | 100 | 100 |
| CC4 | 5 | 37.5 | 62.5 | 80 | 95 | 100 | 100 |
| CC5 | 0 | 20 | 40 | 75 | 90 | 95 | 100 |
| CC6 | 0 | 45 | 62.5 | 77.5 | 87.5 | 92.5 | 100 |
| CC7 | 25 | 45 | 55 | 75 | 85 | 95 | 100 |
| CC8 | 45 | 77.5 | 85 | 95 | 100 | 100 | 100 |
| 合计 | 200 | 422.5 | 545 | 642.5 | 710 | 760 | 792.5 |
Min Minimum, P10 10th percentile, P25 25th percentile, P75 75th percentile, P90 90th percentile, Max Maximum
Fig. 2.
The distribution of scores of the eight CC. The maximum score for each CC was 100. Box plot showing the median, inter-quartile range and outliers of CC
IPC programme
A total of 109 hospitals (63.74%) had an IPC programme with clearly defined objectives and annual activity plans. IPC programme in 123 hospitals (71.93%) were supported by IPC teams comprising IPC professionals, with 40.94% of hospitals meeting the staffing ratio of at least one IPC professional per 250 beds. Among IPC teams, 77.19% had dedicated time for IPC activities, and 67.25% included both doctors and nurses. Only 43 hospitals (25.15%) explicitly defined IPC objectives, established measurable outcome indicators, and set future targets. Over 85% of hospitals had IPC committees involving senior facility leadership, senior clinical staff, and facility management. Additionally, 116 hospitals (67.84%) had microbiology laboratories available for daily use with reliable testing capabilities.
IPC guidelines
A total of 114 hospitals (66.67%) possessed the professional expertise to develop or adapt IPC and/or infectious disease prevention and control guidelines. Most hospitals (over 80%) had established their own IPC guidelines, covering areas such as standard precautions, hand hygiene, and SSI prevention and control. A total of 160 hospitals (93.57%) adjusted guideline implementation based on local needs and resources while maintaining key IPC. Furthermore, 85.38% of healthcare workers had received specific training, and 90.06% of IPC teams conducted regular monitoring of guideline implementation.
IPC education and training
A total of 150 hospitals (87.72%) provided training delivered by personnel with professional expertise in IPC and/or infectious diseases. Among these, 73.09% and 72.51% of hospitals implemented mandatory induction training and regular training for healthcare workers and staff directly involved in patient care, respectively, with 59.65% utilizing interactive training methods. A total of 136 hospitals (79.54%) regularly evaluated training effectiveness, while 40 hospitals (23.39%) integrated IPC training with clinical practice or other professional training programs. Notably, only 59.65% of hospitals provided IPC training for patients or their family members.
HAI surveillance
A total of 161 hospitals (94.15%) integrated HAI surveillance into their IPC programs, with 92.39% designating dedicated personnel for surveillance. Informatics/IT support was available for surveillance in 76.61% of hospitals. Hospitals conducting surveillance for SSI, device-associated infections, and clinically-defined infections accounted for 89.47%, 87.72%, and 85.38%, respectively. However, surveillance for local priority epidemic-prone infections, vulnerable populations, and other infections potentially affecting healthcare workers remained low. A total of 97 hospitals (56.73%) established procedures for regular review of surveillance results. Most hospitals disseminated results to front line health care workers, department leaders, and IPC committees, with 56.14% using presentations or problem-oriented interactive feedback.
Multimodal strategies for IPC interventions
A total of 131 hospitals (76.61%) employed multimodal strategies to implement IPC interventions. However, 58 hospitals (33.92%) did not incorporate safety climate and cultural change into their multimodal strategies. Only 52.63% of hospitals had multidisciplinary team support for implementing these strategies.
Monitoring/audit of IPC practices and feedback
A total of 135 hospitals (78.95%) assigned trained personnel to oversee the implementation and feedback of IPC. Over 90% of hospitals monitored hand hygiene compliance, medical waste management, and medical equipment/instruments disinfection and sterilization. However, monitoring of dressing changes and intravascular catheter care was less common. Feedback from monitoring was integrated into healthcare quality assessments in 74.27% of hospitals.
Workload, staffing and bed occupancy
A total of 91 hospitals (53.22%) assessed staffing ratios using national standards or staff needs assessment tools. Hospitals with staffing ratios meeting standards in over half of their departments accounted for 50.29%, while only 15.97% had all departments meeting staffing standards. Additionally, 80.12% of hospitals had protocols for addressing staffing ratios below standards. Regarding facility design, 102 hospitals (59.65%) ensured bed spacing met standards in all departments. A total of 148 hospitals (86.55%) maintained single-bed occupancy for all departments, and 67.25% avoided placing beds in ward corridors.
Built environment, materials and equipment for IPC at the facility level
Most hospitals provided adequate living facilities and drinking water for staff, patients, and family members, along with reliable energy and power supply. Over 90% of hospitals ensured sufficient personal protective equipment (PPE), medical waste collection containers, compliant sewage treatment systems, and reliable sterilization and disinfection equipment. Additionally, 71.35% of hospitals were equipped with qualified cleaning supplies.
Discussion
This is the first study to evaluate IPC levels in Shaanxi Province's secondary and tertiary hospitals using IPCAF. The findings indicate a median IPCAF score of 642.5, classified as “Advanced” per WHO standards, with tertiary hospitals scoring higher than secondary hospitals. Among the core components, CC8 and CC2 scored highest, while CC5 and CC7 scored lowest.
Our study found 61.99% of hospitals at the “Advanced” level, slightly lower than findings in Zhejiang Province, China [16] and significantly lower than German hospitals [14], but comparable to other middle-high-income countries. WHO data across 81 countries showed median IPCAF scores of 657.5 (High-income), 632.5 (Upper-middle-income), 500.4 (Lower-middle-income), and 385 (Low-income) [7]. China initiated hospital infection management in 1986, continuously learning experiences from middle- and high- income countries, drawing on foreign guidelines for hospital infection control and prevention, and integrating them into management practices with Chinese characteristics. Although it started late, it has developed rapidly, especially after the 2003 SARS outbreak and the 2020 COVID-19 pandemic. The regulatory standards for hospital infection management have been gradually improved, the implementation of IPC measures has been continuously consolidated, and the IPC system has been increasingly sound. However, Shaanxi Province is located in the northwest of China. Due to the combined effects of various factors such as weak economic foundation, uneven allocation of medical resources, insufficient policy implementation efficiency, and unbalanced regional development, its IPC level is relatively low and needs further improvement.
Most hospitals in Shaanxi had well-established IPC programs, properly constituted IPC committees, and context-specific IPC guidelines. Studies in Bangladesh and Austria also reported relatively high CC2 scores [18, 19]. China mandates the establishment of IPC committees and the development/revision of guidelines. Post-COVID-19, national regulations have further improved, strengthening hospital IPC plans, committees, and implementation of key measures, which explains the high scores for CC1 and CC2. The WHO 2024 report on Water, Sanitation and Hygiene (WASH) in healthcare facilities [20] revealed that 37% of healthcare facilities in fragile contexts lacked basic water services. In contrast, China demonstrates comparative advantages in resources such as water supply, power infrastructure, and standardized waste/effluent management systems.
Hospitals generally prioritized IPC training for medical and other staff, reflecting China’s established clinical training systems embedded in policies/regulations and hospitals’ focus on staff competency and IPC awareness. The use of interactive training methods (59.65%) aligned with findings in prior studies [14, 21]. Although convenient online training is increasingly adopted, its lack of interaction and real-time feedback may compromise training quality compared to in-person sessions. Families play a crucial role in patient care [22], and targeted IPC training for them (e.g., hand hygiene, cough etiquette) has been increasingly recognized as an important IPC measure [23, 24] though its implementation rate remained low (59.65%) in this study.
Multi-modal strategies, a concept first introduced by WHO in 2009 and embedded in IPCAF CC5 [25], showed low scores, consistent with findings from other national and international studies [18, 26]. This may be attributed to the concept’s complexity, its relatively recent adoption, and limited penetration in Chinese hospitals, leading to insufficient understanding and practical experience. Evidence indicates an inverse relationship between multimodal strategy implementation and HAI rates [27], highlighting their potential effectiveness. This underscores the urgent need for clearer guidance, improved systems, and enhanced utilization of multi-modal strategies in IPC practice.
Our study revealed significant staffing challenges: 45.03% of IPC departments had ≤ 2 staff members; only 40.94% met the standard of ≥ 1 dedicated staff per 250 beds; and over half of hospitals reported relative staff shortages. Inadequate staffing severely hinders IPC implementation [28], with prior studies demonstrating associations between low staffing levels and increased HAI rates [29, 30]. This reflects human resource deficiencies in some hospitals, potentially due to insufficient leadership prioritization of IPC and competing clinical demands. Additionally, limited career advancement opportunities and lower salaries discourage healthcare professionals from pursuing full-time IPC roles.
While this pioneering IPCAF study in Shaanxi provides valuable insights, several limitations should be acknowledged. First, self-reported data may overestimate the effectiveness or importance of IPC practices. Second, primary-level hospitals were excluded from the study. As these facilities constitute a large proportion of healthcare institutions in China but typically have fewer resources for IPC compared to secondary/tertiary hospitals, the results do not fully represent the overall IPC status across all Chinese healthcare settings. Third, despite the pre-designed sampling plan, variations in the number of hospitals per city may have introduced sampling bias. Finally, although the translated questionnaire underwent pilot testing, training, and explanatory guidance, potential differences in interpretation among respondents could still introduce bias.
Conclusion
The IPC capacity of secondary and tertiary hospitals in Shaanxi Province is rated as high, though structural components and facility-level resources for IPC require strengthening. The identified strengths and areas for improvement align with those reported in other upper-middle-income countries, particularly with respect to multimodal IPC strategies.
Acknowledgements
We would like to thank all participating hospitals in the study.
Abbreviations
- IPCAF
Infection prevention and control assessment framework
- IPC
Infection prevention and control
- HAIs
Healthcare-associated infections
- NICQI
Nosocomial infection control and quality improvement
- CC
Core component
- AMR
Anti-microbial resistance
- SARS
Severe acute respiratory syndrome
- COVID-19
Coronavirus disease 2019
- SPHC
Shaanxi Provincial Health Commission
- SSI
Surgical site infections
Authors' contributions
JY, XW, LF and FS contributed to research design, training and data collection. JY, XW contributed to data collection, analysis and drafted the manuscript. FS and SY has made strict revisions to the manuscript. All authors read and approved the final manuscript.
Funding
This study was not funded.
Data availability
No datasets were generated or analysed during the current study.
Declarations
Competing interests
The authors declare no competing interests.
Footnotes
Publisher's Note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
Yafei Jin and Wen Xu contributed equally to this work as co-first authors.
Contributor Information
Shanhong Fan, Email: 1213476457@qq.com.
Yao Suo, Email: suoyaoxa@163.com.
References
- 1.Balakrishnan VS. WHO’s first global infection prevention and control report. Lancet Infect Dis. 2022;22(8):1122. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 2.Cassini A, Plachouras D, Eckmanns T, Abu Sin M, Blank HP, Ducomble T, et al. Burden of six healthcare-associated infections on European population health: estimating incidence-based disability-adjusted life years through a population prevalence-based modelling study. PLoS Med. 2016;13(10):e1002150. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 3.Guest JF, Keating T, Gould D, Wigglesworth N. Modelling the annual NHS costs and outcomes attributable to healthcare-associated infections in England. BMJ Open. 2020;10(1):e033367. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 4.Suetens C, Latour K, Kärki T, Ricchizzi E, Kinross P, Moro ML, et al. Healthcare-Associated Infections Prevalence Study Group. Prevalence of healthcare-associated infections, estimated incidence and composite antimicrobial resistance index in acute care hospitals and long-term care facilities: results from two European point prevalence surveys, 2016 to 2017. Euro Surveill. 2018;23(46):1800516. [DOI] [PMC free article] [PubMed]
- 5.Wang J, Liu F, Tartari E, Huang J, Harbarth S, Pittet D, et al. The prevalence of healthcare-associated infections in Mainland China: a systematic review and meta-analysis. Infect Control Hosp Epidemiol. 2018;39(6):701–9. [DOI] [PubMed] [Google Scholar]
- 6.Liu X, Spencer A, Long Y, Greenhalgh C, Steeg S, Verma A. A systematic review and meta-analysis of disease burden of healthcare-associated infections in China: an economic burden perspective from general hospitals. J Hosp Infect. 2022;123(2022):1–11. [DOI] [PubMed] [Google Scholar]
- 7.Tomczyk S, Twyman A, de Kraker MEA, et al. The first WHO global survey on infection prevention and control in health-care facilities. Lancet Infect Dis. 2022;22(6):845–56. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 8.Chua AQ, Verma M, Hsu LY, Legido-Quigley H. An analysis of national action plans on antimicrobial resistance in Southeast Asia using a governance framework approach. Lancet Reg Health West Pac. 2021;23(7):100084. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 9.Montoya AM, Roncancio GE, Franco L, López L, Vargas AR, Suárez S, et al. Preventive strategies in paediatric cardiovascular surgery: impact on surgical site infections and beyond. J Hosp Infect. 2024;150:114–24. [DOI] [PubMed] [Google Scholar]
- 10.Schreiber PW, Sax H, Wolfensberger A, Clack L, Kuster SP; Swissnoso. The preventable proportion of healthcare-associated infections 2005–2016: systematic review and meta-analysis. Infect Control Hosp Epidemiol. 2018;39(11):1277–1295. [DOI] [PubMed]
- 11.Storr J, Twyman A, Zingg W, Damani N, Kilpatrick C, Reilly J, et al. WHO Guidelines Development Group. Core components for effective infection prevention and control programmes: new WHO evidence-based recommendations. Antimicrob Resist Infect Control. 2017;6:6. [DOI] [PMC free article] [PubMed]
- 12.WHO. Infection prevention and control assessment framework: World Health Organization. 2018. Available at: https://www.who.int/publications/i/item/WHO-HIS-SDS-2018.9. Accessed 2 June 2025.
- 13.Tomczyk S, Aghdassi S, Storr J, Hansen S, Stewardson AJ, Bischoff P, et al. Testing of the WHO Infection Prevention and Control Assessment Framework at acute healthcare facility level. J Hosp Infect. 2020;105(1):83–90. [DOI] [PubMed] [Google Scholar]
- 14.Aghdassi SJS, Hansen S, Bischoff P, Behnke M, Gastmeier P. A national survey on the implementation of key infection prevention and control structures in German hospitals: results from 736 hospitals conducting the WHO Infection Prevention and Control Assessment Framework (IPCAF). Antimicrob Resist Infect Control. 2019;2019:73. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 15.Nomoto H, Saito H, Ishikane M, Gu Y, Ohmagari N, Pittet D, et al. First nationwide survey of infection prevention and control among healthcare facilities in Japan: impact of the national regulatory system. Antimicrob Resist Infect Control. 2022;11(1):135. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 16.Azak E, Sertcelik A, Ersoz G, Celebi G, Eser F, Batirel A, et al, Turkish Hospital Infection Research Group. Evaluation of the implementation of WHO infection prevention and control core components in Turkish health care facilities: results from a WHO infection prevention and control assessment framework (IPCAF)-based survey. Antimicrob Resist Infect Control. 2023;12(1):11. [DOI] [PMC free article] [PubMed]
- 17.Ni K, Jin D, Wu Z, Sun L, Lu Q. The status of infection prevention and control structures in Eastern China based on the IPCAF tool of the World Health Organization. Antimicrob Resist Infect Control. 2022;11(1):46. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 18.Aghdassi SJS, Grisold A, Wechsler-Fördös A, Hansen S, Bischoff P, Behnke M, et al. Evaluating infection prevention and control programs in Austrian acute care hospitals using the WHO Infection Prevention and Control Assessment Framework. Antimicrob Resist Infect Control. 2020;9(1):92. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 19.Harun MGD, Anwar MMU, Sumon SA, Hassan MZ, Haque T, Mah-E-Muneer S, et al. Infection prevention and control in tertiary care hospitals of Bangladesh: results from WHO infection prevention and control assessment framework (IPCAF). Antimicrob Resist Infect Control. 2022;11(1):125. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 20.WHO. WASH in health care facilities 2023 data update. 2024. https://www.who.int/publications/m/item/wash-in-health-care-facilities-2023-data-update . Accessed 2 June 2025.
- 21.Supriadi IR, Haanappel CP, Saptawati L, Widodo NH, Sitohang G, Usman Y, et al. Infection prevention and control in Indonesian hospitals: identification of strengths, gaps, and challenges. Antimicrob Resist Infect Control. 2023;12(1):6. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 22.Kang G, Zhang H, Zhou J, Wan D. The WeChat platform-based health education improves health outcomes among patients with stable coronary artery disease. Patient Educ Couns. 2023;111(2023):107704. [DOI] [PubMed] [Google Scholar]
- 23.Park JY, Pardosi JF, Respati T, Nurhayati E, Islam MS, Chowdhury KIA, et al. Exploring factors influencing the compliance of patients and family carers with infection prevention and control recommendations across Bangladesh, Indonesia, and South Korea. Front Public Health. 2022;22(10):1056610. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 24.Park JY, Pardosi JF, Seale H. Examining the inclusion of patients and their family members in infection prevention and control policies and guidelines across Bangladesh, Indonesia, and South Korea. Am J Infect Control. 2020;48(6):599–608. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 25.WHO. WHO multimodal improvement strategy. Available from: https://www.who.int/publications/m/item/who-multimodal-improvement-strategy. Accessed 6 June 2025.
- 26.Yilma M, Taye G, Tefera M, Tassew B, Fentie AM, Abebe W. Infection prevention and control practices in the Pediatrics and Child Health Department of Tikur Anbessa Specialized Hospital, Ethiopia. Front Public Health. 2024;19(12):1329410. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 27.Vicentini C, Bussolino R, Gastaldo C, Castagnotto M, D’Ancona FP, Zotti CM, et al. Level of implementation of multimodal strategies for infection prevention and control interventions and prevalence of healthcare-associated infections in Northern Italy. Antimicrob Resist Infect Control. 2024;13(1):39. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 28.Lowe H, Woodd S, Lange IL, Janjanin S, Barnet J, Graham W. Challenges and opportunities for infection prevention and control in hospitals in conflict-affected settings: a qualitative study. Confl Health. 2021;15(1):94. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 29.Cimiotti JP, Aiken LH, Sloane DM, Wu ES. Nurse staffing, burnout, and health care-associated infection. Am J Infect Control. 2012;40(6):486–90. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 30.Manojlovich M, Sidani S, Covell CL, Antonakos CL. Nurse dose: linking staffing variables to adverse patient outcomes. Nurs Res. 2011;60(4):214–20. [DOI] [PubMed] [Google Scholar]
Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Data Availability Statement
No datasets were generated or analysed during the current study.