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Introduktion: Sjukvårdspersonal runt om i världen har stått på frontlinjen i stressiga arbetsmiljöer och tagit hand om COVID-19-patienter sedan SARS-CoV-2 förklarades som en global pandemi. Under pandemiska förhållanden står sjukvårdspersonal inför specifika utmaningar, där vissa leder till symptom på psykisk ohälsa. Statliga resurser till sjukvårdspersonal har ofta avsatts för kortsiktiga insatser. Långsiktiga investeringar med fokus på främjande av sjukvårdpersonalens psykiska hälsa behövs för att förhindra förvärrade folkhälsoproblem på grund av SARS-CoV-2. Syfte: Studiens syfte var att belysa hur sjukvårdspersonal rapporterar att deras psykiska hälsa påverkats av SARS-CoV-2-pandemin och vilka erfarenheter från tidigare interventioner för psykisk hälsa som skulle kunna vara användbara för att förbättra sjukvårdspersonals psykiska hälsa genom att belysa några exempel. Metod: En systematisk litteraturöversikt genomfördes, där 20 vetenskapliga artiklar inkluderades och analyserades med tematisk analys. Resultat: Totalt nio teman identifierades: psykisk ohälsa hos sjukvårdspersonal, SARS-CoV-2-pandemin, interventioner för psykisk hälsa, vårdkvalitet, säkerhetskultur, arbetsplatsbaserade tillvägagångssätt, mindfulness och konstaktivitetsmetoder, biomarkörbaserade tillvägagångssätt samt tekniska tillvägagångssätt. Viktiga fynd i denna litteraturöversikt är att teman säkerhetskultur och vårdkvalitet är associerade med de andra teman. Slutsats: När tillvägagångssätt implementeras i insatser för sjukvårdspersonals psykiska hälsa som främjar säkerhetskultur och vårdkvalitet främjar det också, enligt resultaten i denna översikt, långsiktiga effekter på individuell psykisk hälsa hos sjukvårdspersonal. Detta bör omedelbart beaktas av dem som utvecklar nya program för att främja psykisk hälsa för att stödja sjukvårdspersonal i effekterna av pandemin. / Introduction: Healthcare workers around the world have stood on the front lines in stressful work-environments, caring for COVID-19 patients since SARS-CoV-2 was declared a global pandemic. Under pandemic conditions healthcare workers face specific challenges, where some lead to symptoms of mental illness. Governmental resources to the healthcare workforce have often been allocated to short-term efforts. Long-term investments focusing on mental health promotion for HCW are needed to prevent worsening public health issues due to SARS-CoV-2. Aim: The aim of the study was to illuminate how HCW report that their mental health has been affected by the SARS-CoV-2 pandemic and what experiences from previous mental health interventions that may be useful in promoting HCW mental health by highlighting some examples. Methods: A systematic literature review was conducted, including 20 scientific articles analyzed with thematic analysis. Results: A total of nine themes were identified: mental distress in HCW, SARS-CoV-2 pandemic, mental health interventions, quality of care, safety culture, workplace-based approaches, mindfulness and art activity approaches, biomarker-based approaches as well as technology approaches. Important findings in this literature review are the themes safety culture and quality of care being associated with the other themes. Conclusion: When implementing approaches in mental health interventions for HCW that promote safety culture and quality of care, it also promotes, according to the findings in this review, long-term effects in individual mental health in HCW. This should be urgently taken into consideration by those developing new mental health promotion programs to support HCW in the effects of the pandemic.

Patienter som vårdats på en intensivvårdsavdelning (IVA) och tillfrisknat efter kritisk sjukdom löper stor risk för komplikationer efter att de flyttats till annan vårdavdelning för fortsatt vård. Oförutsedda komplikationer kan ibland leda det till att patienten återinläggs på IVA. Tidig identifiering och nära samarbete mellan IVA och vårdavdelning kring vanliga komplikationer skulle kunna förbättra förutsättningar för effektiv rehabilitering för den enskilda patienten.   Syftet med förbättringsarbetet var att underlätta patientens rehabilitering genom att tillgodose dennes behov av information och specifika rehabiliteringsinsatser som är vanliga efter intensivvård. återhämtning efter intensivvård samt minska risken för återinläggning.    Under förbättringsarbetet infördes ett screeningsinstrument för att tidigt kunna fånga patientens behov av stöd. Förbättringsarbetet utgick från Nolans förbättringsmodell. Resultatet av förbättringsarbetet visar på att det finns behov av tidigare uppföljning av intensivvårdspatienten för att förbättra och stötta patienten i sin återhämtning. Screeningsinstrumentet bidrog till att de patienter som är i behov av stöd fångades upp.    Kunskap om utmaningar och framgångsfaktorer under förbättringsarbete kan bidra till en större förståelse för förbättringskunskapens betydelse vid utveckling av vården. Syftet med studien var att belysa intensivvårdspersonalens erfarenheter av förbättringsarbete inom post-intensivvård.   En kvalitativ studie genomfördes med två fokusgruppsintervjuer bestående av vårdpersonal från en IVA-avdelning. Under intervjuerna fångades vårdpersonalens upplevelse av förbättringsarbete. De transkriberade intervjuerna analyserades med en kvalitativ innehållsanalys. I resultatet av studien framkom både utmaningar och framgångsfaktorer i tre kategorier: ”Skapa mening och förståelse för nytt arbetssätt”, ”Proaktivt arbete med patientfokus” samt ”Förändringströtthet och brist på tid”.   Tidigare uppföljning är en viktig del i patientens återhämtning efter IVA-vård för att förebygga senkomplikationer. Studien visar att tydlig information kring interventioner bidrar till ökad förståelse för förändringsprocessen och skapar drivkraft i förbättringsarbetet. / Patients who recovers from severe illness entails an increased risk of complications when being transferred from intensive care unit (ICU) to ward. Unforeseen complications can sometimes lead to ICU re-admissions. Early identification of common complications and close collaboration between ICU and ward can improve the chances of a successful recovery for the patient.   The purpose of the improvement work was to facilitate the patient's recovery after intensive care and to reduce the risk of readmission. rehabilitation by meeting his or her need for information and specific rehabilitation interventions that are common after intensive care.   During the improvement work, a screening instrument predicting high risk-individuals was introduced to capture the patient's need for support at an early stage. The improvement work was based on Nolan's improvement model. The results of the improvement work showed that there is a need for earlier follow-up of the ICU-patient to improve and support patients in their recovery. The screening instrument helped to catch the patients in need of support.   Knowledge of challenges and success factors during improvement work can contribute to a greater understanding of the importance of improvement knowledge in the developement of care. The purpose of the study was to illuminate intensive care staff's experiences of improvement work in post-intensive care.   A qualitative study was conducted with two focus group interviews consisting of care staff from an ICU department. During the interviews, the care staff's experience of improvement work was captured. The transcribed interviews were analyzed with a qualitative content analysis. Focus group interviews with staff resulted in three categories: "Creat meaning and understanding for a new way of working", "Proactive work with a patient focus" and "Change fatigue and lack of time".  Previous follow-up is an important part of the patient's recovery to detect late complications. The study result concludes that clear information according to interventions during improvement work contributes to increased understanding for the improvement process and creates motivation and drive in the improvement work.

Les infections associées aux soins de santé ou infections nosocomiales (IN) sont des effets indésirables ayant de graves conséquences sur la santé des patients. Les pathogènes responsables de certaines IN sont transmis par le biais des mains contaminées, entre autres celles des professionnels de la santé (PS). Ces IN sont donc en théorie évitables. L’hygiène des mains (HDM) est considérée comme la pierre angulaire de la prévention et contrôle des infections (PCI). C’est un moyen simple, efficace et peu couteux qui permet d’empêcher la transmission des pathogènes et de réduire la probabilité d’infections ultérieures. Malheureusement, les taux de conformité à l’HDM au sein des PS restent inférieurs à la cible globale de 80% indiquée par l’OMS, malgré de nombreuses campagnes instaurées pour sensibiliser ceux-ci. Considérant les faibles taux de conformité à l’HDM, les autorités sanitaires envisagent d’augmenter cette cible. Le but de mon mémoire est de synthétiser les preuves existantes sur l’association entre le taux de conformité à l’HDM et les taux d’incidence des IN. Ceci permettrait de déterminer s’il y a un taux optimal de conformité à l’HDM qui serait associé au plus faible taux d’incidence des IN. Les résultats obtenus permettront aux autorités sanitaires de considérer la pertinence de viser des cibles d’HDM plus élevées. J’ai effectué une revue systématique de la littérature afin d’analyser les données disponibles sur l’association des taux de conformité à l’HDM et le taux d’incidence des IN. J’ai également analysé les données sur les taux de conformité à l’HDM et les taux d’incidence d’IN des installations de soins de santé du Québec. Les résultats semblent démontrer qu’au-delà d’un taux de conformité à l’HDM de 60%, il y a peu de différence apparente entre un fort taux de conformité à l’HDM et un faible taux d’incidence des IN. L’HDM, quoique mesure très importante, n’est pas le seul facteur servant à réduire les IN. / Healthcare-associated infections (HAIs) are an adverse event with serious consequences on the patients’ health. The pathogens responsible for some HAIs are mainly transmitted through hands, including those of healthcare workers (HCW). These HAIs are therefore theoretically preventable. Hand hygiene (HH) is considered the cornerstone of infection prevention and control. It is a simple, effective, and inexpensive way to prevent the transmission of pathogens and reduce the likelihood of subsequent infections. Unfortunately, HH compliance rates remain suboptimal among HCWs despite numerous HH campaigns. Considering the low HH compliance rates among HCWs, health authorities are considering further increasing the target for HH compliance rates. The goal of my dissertation is to synthesize the current evidence on the association between HH compliance rates and the incidence rates of HAIs to determine if there is an optimal HH compliance rate that is associated with the lowest incidence rate of HAIs. This will provide health authorities intel, to consider the relevance of setting higher HH compliance targets. I performed a systematic review of the literature to analyze the available data on the association of HH compliance rates and HAI incidence rates. I also analyzed HH compliance rates and HAI incidence rates reported by healthcare facilities in the province of Québec. The results seem to show that beyond a HH compliance rate of 60%, there are no clear differences between higher HHC rates and low incidence rates of HAIs. Although very important, HH compliance is not the only factor contributing to the decrease of HAIs.

L'infection congénitale par le cytomégalovirus (CMV) est l'infection congénitale la plus courante, survenant chez 0,2 à 2,0 % des naissances vivantes. Elle représente la principale cause non génétique de surdité neurosensorielle chez les nourrissons. Cette infection entraîne des séquelles neurodéveloppementales permanentes telles que des problèmes de vision, un retard cognitif et, dans certains cas, elle peut même entraîner la mort. Avoir une meilleure compréhension des caractéristiques épidémiologiques de l'infection maternelle par le CMV peut contribuer à améliorer notre compréhension de la transmission de ce virus au fœtus et, par conséquent, à prévenir l'infection congénitale. Cette thèse vise à étudier les aspects épidémiologiques de l'infection maternelle par le CMV et de l'exposition professionnelle au CMV. Le premier objectif consiste à estimer la séroprévalence, l'incidence et les facteurs de risque de l'infection maternelle à CMV pendant la grossesse. Le deuxième objectif examine l'association entre l'infection maternelle à CMV et certaines complications de la grossesse, telles que la prééclampsie et l'accouchement prématuré. Le troisième objectif est une revue systématique et une méta-analyse visant à déterminer la prévalence, l'incidence de l'infection primaire, les risques relatifs et les facteurs de risque au sein de deux groupes exposés professionnellement au CMV, à savoir les travailleurs en service de garde et le personnel de santé. Les données de deux importantes cohortes au Québec, comprenant un total de 6048 participantes (Grossesse en santé et 3D), ainsi que leurs échantillons biologiques, ont été utilisées pour atteindre les objectifs 1 et 2. Dans le cadre de l'objectif 3, une recherche bibliographique a été réalisée en consultant six bases de données électroniques (PubMed [NLM], Ovid MEDLINE, Ovid All EBM Reviews, Ovid Embase, ISI Web of Science et EBSCO CINAHL Complete). Les résultats de l'objectif 1 (article 1), basés sur les données d'une des deux cohortes, révèlent une séroprévalence de 23,4 % (IC à 95 %, 22,1-24,7 %) chez les femmes enceintes, ainsi qu'une incidence d'infection primaire de 1,8 pour 100 années-personnes pendant la grossesse (IC à 95 %, 1,2-2,6). Les facteurs de risque associés à la séropositivité maternelle sont la multiparité (avoir un ou plusieurs enfants), une ethnie autre que caucasienne et un lieu de naissance autre que le Canada et les États-Unis. Les résultats de l'objectif 2 (article 2) ont révélé deux associations importantes : (1) une association entre la séropositivité maternelle au CMV et la prééclampsie, et (2) une association entre la séropositivité maternelle au CMV et l'accouchement prématuré. L'analyse de médiation, en prenant en compte la prééclampsie comme facteur médiateur de l'association entre l'infection maternelle au CMV et l'accouchement prématuré, a montré que la quasi-totalité (96,8 %) de l'effet total de la séropositivité maternelle au CMV agit directement sur l'accouchement prématuré, sans passer par la prééclampsie. La revue systématique et méta-analyse, qui correspond à l'objectif 3 (article 3), souligne l'importance de l'exposition professionnelle au CMV. Dans le groupe des travailleurs en service de garde, la séroprévalence du CMV et l'incidence de l'infection primaire pour 100 personnes-années sont élevées, atteignant respectivement 59,3 % (IC à 95 % : 49,8-68,6) et 7,4 (IC à 95 % : 3,9-11,8). De même, dans le groupe du personnel de santé, ces valeurs s'élèvent à 49,5 % (IC à 95 % : 40,3-58,7) et 3,1 (IC à 95 % : 1,3-5,6) respectivement. La séropositivité au CMV et l'infection primaire sont significativement plus fréquentes chez les travailleurs en service de garde par rapport aux groupes témoins sans exposition professionnelle, avec un RC (Rapport des cotes) de 1,6 (IC à 95 % : 1,2-2,3) et un RR (Rapport des Risques) de 3,4 (IC à 95 % : 1,3-8,8) respectivement. Cependant, aucune différence significative n'a été observée chez le personnel de santé (RC : 1,3 [IC à 95 % : 0,6-2,7] et RR : 0,9 [IC à 95 % : 0,6-1,2]). Dans les deux groupes, la séropositivité au CMV était associée à la multiparité, l'état civil, l'ethnicité et l'âge. En conclusion, cette étude démontre que la séroprévalence du CMV chez les femmes enceintes varie. La parité, l'ethnicité, le lieu de naissance et l'exposition professionnelle sont des facteurs à prendre en compte lors de l'élaboration de mesures préventives contre l'infection maternelle par le CMV. Les résultats de l'article 2 mettent en évidence que la séropositivité maternelle au CMV pourrait être un facteur de risque de prééclampsie et d'accouchement prématuré. Mots clés : cytomégalovirus, prévalence, incidence, séroconversion, grossesse, sérologie, prééclampsie, accouchement prématuré, exposition professionnelle, travailleur en service de garde, garderie, personnel de santé. / Cytomegalovirus infection is the most common congenital infection occurring in 0.2% to 2.0% of all live births. Congenital CMV infection is the most common non-genetic cause of sensorineural hearing loss. It results in permanent neurodevelopmental sequelae such as visual impairment, cognitive delay and in some cases, death. Knowing the epidemiological characteristics of maternal CMV infection could contribute to improve the understanding of the transmission of this virus to the fetus, and then, contribute to the prevention of congenital infection. The present thesis aims to study some epidemiological aspects of maternal CMV infection and occupational exposure to CMV. The first objective sought to estimate the seroprevalence, incidence, and risk factors of CMV infection during pregnancy. The second objective studied the association between maternal CMV infection and some adverse pregnancy outcomes, including preeclampsia and preterm delivery. The third objective was a systematic review and meta-analysis to determine the prevalence, incidence of primary infection, relative risks, and risk factors in the two groups occupationally exposed to CMV, namely childcare workers and healthcare workers. Data from two large Quebec cohorts with 6048 women (“Grossesse en santé” and “3D” cohorts), and their biobanks, were used to address objectives 1 and 2. For objective 3, a literature search was conducted in 6 electronic databases along with a meta-analysis (PubMed (NLM), Ovid MEDLINE, Ovid All EBM Reviews, Ovid Embase, ISI Web of Science, et EBSCO CINAHL complete). The results for objective 1 (article 1) on the data of one of the two cohorts show a seroprevalence of 23,4% among pregnant women (95% CI, 22.1–24.7%), an incidence of primary infection of 1,8 per 100 person-years during pregnancy (95% CI, 1.2–2.6). During the 5 years of the study, seroprevalence was stable and no seasonality was observed. Risk factors associated with maternal seropositivity were multiparity, i.e., having one or more children, non-Caucasian ethnicity, and place of birth other than Canada and the United States. The results for objective 2 (article 2) highlighted on the one hand the association between maternal CMV seropositivity and preterm birth, and on the other hand the association between maternal CMV seropositivity and preeclampsia. The mediation analysis considering preeclampsia as a mediating factor of the association between maternal CMV infection and preterm delivery showed that almost all the total effect of maternal CMV seropositivity i.e., 96,8%, acts directly on preterm delivery without passing through preeclampsia. The systematic review and meta-analysis (objective 3) noted the importance of occupational exposure to CMV. CMV seroprevalence and incidence of primary infection per 100 person-years remained high in the childcare worker group (59.3% [95% CI: 49.8-68.6] and 7.4 [95% CI: 3.9-11.8], respectively) and the healthcare worker group (49.5% [95% CI: 40.3-58.7] and 3.1 [95% CI: 1.3-5.6], respectively). CMV seropositivity and primary infection are significantly more prevalent among childcare workers compared to the comparison groups without occupational exposure. The Odds ratio (OR) for this difference is 1.6 (95% CI: 1.2-2.3), with a risk ratio (RR) of 3.4 (95% CI: 1.3-8.8). However, these differences are not observed in healthcare workers, where the OR is 1.3 (95% CI: 0.6-2.7) and the RR is 0.9 (95% CI: 0.6-1.2). In both groups, CMV seropositivity shows an association with factors such as multiparity, civil status, ethnicity, and age. In conclusion, this thesis shows that maternal CMV seroprevalence is variable. Parity, ethnicity, place of birth and occupational exposure would be the identified risk factors to consider when defining preventive measures for maternal CMV infection. The results of article 2 highlighted that maternal CMV seropositivity could be a risk factor for preeclampsia and preterm delivery. Keywords: cytomegalovirus, prevalence, incidence, seroconversion, pregnancy, serology, preeclampsia, preterm birth, occupational exposure, daycare worker, daycare center, healthcare workers.

Background: Healthcare workers’ hand hygiene remains a key pillar because it prevents and controls healthcare associated infections. Healthcare Workers’ hand hygiene compliance is suboptimal. Aim: The study developed contextualised guidelines for Healthcare Workers’ hand hygiene and infection control in patient care. Methods: The Precede-Proceed model with Theory of Planned Behaviour guided the study. The study was conducted following the mixed methodology approach, observational survey, exploratory, descriptive and contextual in nature study with mixed thematic analyses in a research wheel process. Data were collected through direct participant observation of hand hygiene opportunities through observing (n=95 Healthcare Workers; n=570 practices). Self-administered questionnaires were used to collect data from Healthcare workers (n=189) regarding challenges they faced in achieving hand hygiene. Structured interviews were conducted with patients (n=574). Retrospective reviews of healthcare associated infections and their associated mortalities were carried out from mortality records. Data were analysed retrospectively. Partly the data were statistically and mixed thematically analysed. Guidelines were developed using intervention alignment throughout, mapping, matching, pooling, patching and validation corroborated with Precede-Proceed models’ best practices. The study was ethically reviewed and approved by University of South Africa and the Medical Research Council of Zimbabwe project numbers, 6067662 and MRCZ/B/208. Results: Hand hygiene non-compliances were mostly found in the following contexts, after touching patients’ surroundings, and before doing an aseptic procedure. A non-hand hygiene compliance of Healthcare workers 167(29.3%) and compliance 403(70.7%) in context was suboptimal with sad patients and challenges faced by Healthcare workers. Conclusion: Healthcare Workers had gaps in hand hygiene compliance and availability of required resources. Gaps were also noted in ongoing hand hygiene promotion educational strategies and guidelines to comply and prevent. Guidelines to enhance hand hygiene included, attend to hand hygiene strictly after touching patient surroundings, bed linen, lockers and curtains to prevent gastroenteritis; follow standard precautions against HCAIs from spreading to patients' environments; and comply with hand hygiene guidelines, policies and regulations for best practice with patients. The study contributes generalisable knowledge. / Health Studies / D. Litt et Phil. (Health Studies)

PhD (Public Health) / Department of Public Health / Medical waste is a special type of hazardous waste generated from healthcare facilities. Mismanagement of this waste has a negative impact on healthcare workers, patients and their relatives, medical waste handlers and the community. South Africa, like many other developing countries, is resource-constrained in the management of medical waste and poor practices have been reported across the country, especially in the urban health facilities that have received more attention from researchers. This study was conducted to explore the practices and challenges of medical waste management in Vhembe District, a largely rural district in Limpopo province and develop intervention strategies for better management of the waste in the District. A convergent parallel approach of mixed method design was adopted to achieve the objectives of this study. The target population included the main stakeholders of medical waste management in the district: the Department of Health, healthcare facilities and the waste management company responsible for the treatment and disposal of medical waste in Limpopo Province. The study population from the Department of Health included representatives from the medical waste management section while the waste management company was represented by the manager of the company in Limpopo Province. The samples for the healthcare facilities were drawn from fifteen randomly selected healthcare facilities in the district and included the administrative heads, medical waste generators and medical waste handlers. The study was conducted in three phases. Phase 1 was a qualitative study during which the administrative heads of the selected healthcare facilities, personnel directly involved in medical waste management at the healthcare facilities as well as the representatives from the Department of Health and waste management company were engaged in in-depth interviews. This phase also involved voice recording, observations, field documentation and taking of relevant pictures. Thematic content analysis was used to analyze the data obtained. During phase 2 (quantitative study), a semi-structured questionnaire was employed for data collection from medical waste generators and handlers at the healthcare facilities. A total of 229 questionnaires were retrieved from the participants and were analyzed with the Statistical Package for Social Sciences version 25.0. Descriptive statistical analyses were performed; Chi-square and Cramer’s V tests were used to determine the associations between dependent and independent variables, as well as the strength of association where significant relationships exist. Statistical significant level was set at p<0.05 and the results are presented in tables and graphs. The results from both phases were interpreted and discussed simultaneously. Respondents and participants were assured of anonymity of their identities and confidentiality of the information they provided. They were given adequate information about the study and only those who volunteered participated in the study after appending their signatures on the informed consent form. In phase 3, the Medical Research Council Framework was used to develop intervention strategies for improved medical waste management in Vhembe District based on the Strength, Weakness, Opportunity and Threat (SWOT) and Political, Economic, Social, Technological, Environmental and Legal (PESTEL) analysis techniques. The study revealed inefficient practices of medical waste management in all the healthcare facilities. Rate of medical waste generation was 338.15kg/day, 19.2kg/day and 15.5kg/day of HCRW from the hospitals, community health centers and clinics respectively. Segregation practices were poor, and only 28.4% of respondents rated their healthcare institutions as being excellent with medical waste segregation. The type of occupation was found to be significantly associated with exposure to training (p=0.000) and the level of knowledge about medical waste management (p=0.000). Also, the use of personal protective equipment was found to be significantly associated with training (p=0.011). Transportation and temporary storage were not done according to the recommendation in the guidelines and incineration was the main means of treatment of the waste. The final product of waste treatment is being disposed into an hazardous waste landfill. The challenges encountered in the process of managing medical waste include lack of adequate funding and budget for medical waste management, ineffective and irregular training of healthcare workers, non-compliance to medical waste management guidelines, insufficient bins, substandard central storage rooms, insufficient personal protective equipment and unavailability of Hepatitis B vaccine. The strength, weakness, opportunities and threats of medical waste management in Vhembe District were analyzed and specific intervention strategies were developed to improve on the strength, minimize the weakness, take advantage of the opportunity and combat the threats. The developed strategies were validated. This study provides the evidences of poor management of medical waste in Vhembe District, and shows the need for urgent intervention measures to be put in place. We therefore recommend that the intervention strategies proposed here be evaluated and implemented to mitigate the untoward effects of poor medical waste management among healthcare workers and the community as a whole. / NRF