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Health SA Gesondheid (Online)

versão On-line ISSN 2071-9736
versão impressa ISSN 1025-9848

Health SA Gesondheid (Online) vol.24  Cape Town  2019 



Infection control recommendations for radiology departments in Malawi



Denis NyirendaI; Razana WilliamsII; Wilma ten Ham-BaloyiIII

IDepartment of Radiography, Malawi College of Health Science, Lilongwe, Malawi
IIDepartment of Radiography, Nelson Mandela University, Port Elizabeth, South Africa
IIIFaculty of Health Sciences, Nelson Mandela University, Port Elizabeth, South Africa





BACKGROUND: Guidelines for radiographers contain recommendations related to standard infection control precautions for healthcare-associated infections (HAIs) which are a major cause of mortality and morbidity in hospital settings. However, the implementation of these recommendations has proven to be a challenge in the Malawian radiology departments, as there are no national guidelines or radiology policies for infection control
AIM: This article outlines the development of infection control recommendations that could facilitate sound knowledge and practices of radiographers regarding infection control.
SETTING: Radiology departments in hospitals in Malawi.
METHODS: The recommendations were developed based on data from a questionnaire that measured the knowledge and practices of 62 radiographers regarding infection control as well as data from the literature. The Florence Nightingale environmental theory was used as the conceptual framework for the recommendations, while its development was based on steps of the National Institute for Health and Care Excellence. For the format of the draft recommendations, an adapted version of the Appraisal of Guidelines for Research and Evaluation II tool was used.
RESULTS: Issues identified from the responses to the questionnaire and literature resulted in seven sets of recommendations: hand hygiene, personal hygiene, personal protective gear and the use of appropriate equipment, safe handling of sharps and sharp containers, decontamination and cleaning, housekeeping and routine infection control practices..
CONCLUSIONS: The recommendations can be further reviewed and implemented to improve the implementation of infection control and to reduce HAIs in resource-constrained settings.

Keywords: healthcare-associated infections; infection control; radiographer; recommendations; Malawi.




Infection control concerns the control of the spread of healthcare-associated infections (HAIs) developed by patients who receive care (Boyle & Strudwick 2010) and it is imperative in maintaining patient safety by reducing the effects of HAIs on the health of patients (Zsuzsanna 2010). Healthcare-associated infections are caused by pathogenic microorganisms, which can be detected in the air, in water and on surfaces (National Health Services Professionals Handbook 2010). The modes of spread of HAIs include direct, indirect and airborne contacts.

The most prevalent HAIs that happen within healthcare institutions include respiratory infections, urinary tract infections, blood infections and wound infections succeeding surgical procedures (Infection Control Certification 2013). As radiographers have direct contact with patients, and other hosts, they are reported as being at a high risk of contracting and spreading infections (Ibeziako & Ibekwe 2006). With the introduction of interventional radiological applications such as opening of intravenous lines, catheterisations performed for gastrointestinal radiological examinations, colonography, cystography and other special imaging modalities, the tendency for accidental and infectious pathogens is on the increase. Such an increase has been associated with the fact that radiological examinations require direct contact between patients and radiographers (Jayasinghe & Weerakoon 2014). Other radiological procedures that result in direct contact between radiographers and patients include urethrography, hysterosalpingography and intravenous urography. An important outcome of the introduction of interventional radiology has been an increase in the number of patients seeking radiological services, which has resulted in an increase in the spread of HAIs. According to Rutala and Weber (2008), the major risk of all such invasive procedures is the introduction of pathogens that can lead to the spread of HAIs.

Standard infection control precautions (SICPs) should therefore be adhered to by radiographers in order to prevent these infections. Radiographers thus require acceptable knowledge levels as well as adequate practices related to infection control in order to prevent the effects of HAIs on patient health and safety. Radiographers' roles in infection control include maintaining a safe practice environment at all times: selecting appropriate hazard control and risk management and infection control precautions, and application of reduction or elimination techniques in accordance with the health and safety legislation. Additional roles of radiographers include the use of correct principles and applications of disinfectants, methods for sterilisation and decontamination, and precautions recommended for dealing with waste and spillage correctly (Health & Care Professional Council Handbook 2013). Practising infection control in the radiology department, aiming to control and decrease the spread of HAIs, is therefore imperative (Antwi et al. 2015). Radiographers need to understand SICP and should contribute to strategies to decrease the risk of infection to patients, as well as their own personal protection, by complying with these precautions (Sukumar & Yadav 2012). However, low rates of compliance with SICP among healthcare workers, which include radiographers, have been reported globally, as a systematic review found that compliance with SICP is sub-optimal on a global basis (Gammon, Morgan-Samuel & Gould 2008). Standard infection control precautions are paramount to minimise HAIs and high healthcare costs or burdens associated with them (McGaw et al. 2012). Strict adherence to SICP by radiographers may control the risks of HAIs, making it necessary for them to have adequate knowledge and skilled practices about SICP (Phillips & Ker 2006).

Problem statement

The first author observed that there was low compliance to the application of SICP by radiographers in radiology departments in government referral hospitals in Malawi. For example, radiographers failed to wash their hands after treating each patient and used the same gown as well as disposable gloves for a number of patients (Nyirenda 2017). Furthermore, currently no national guideline, policy or recommendations regarding infection control in Malawi are available for radiographers when implementing infection control in the radiology departments. The observed discrepancies in the application of SICP could be linked to the absence of a national guideline or policy.


This study aimed to develop infection control recom-mendations that could facilitate sound knowledge and practices of radiographers regarding infection control in radiology departments in government referral hospitals in Malawi.

Contribution to the field

The study was unique as it was the first study conducted in this setting and reflects the second phase of a larger study that was conducted to develop an infection control guideline for radiographers in radiology departments in Malawi. The first phase included a questionnaire that was administered to 62 radiographers to determine their knowledge of and practices related to infection control in the respective radiology departments (Nyirenda 2017).

Definition of key concepts

Healthcare-associated infections

Healthcare-associated infections refer to infections associated with healthcare delivery in a hospital or ambulatory setting (Friedman et al. 2011). In this study, HAIs are infections one gets upon exposure to infected places where radiological examinations are performed.

Infection control

Infection control refers to processes and activities aimed at identifying and reducing the risks of obtaining and transferring prevalent or widespread infections among people (David & Famurewa 2010). For the purpose of this study, infection control refers to a practice of ensuring that the environment is free from pathogenic microorganisms.


A radiographer is an allied health professional, who is registered with an appropriate professional board, and performs diagnostic examinations on patients using a variety of imaging modalities, including radiography, computed tomography (CT), magnetic resonance imaging (MRI), mammography and cardiovascular interventional technology (Ehrlich & Daly 2009). In this study, a radiographer is a person who performs radiological diagnostic examinations and is involved in infection control. Radiographers are the target population for the infection control guideline developed in this study.


Recommendations are suggestions regarding the best course of action, which are intended to assist providers and recipients of healthcare, and other stakeholders, to make informed decisions (WHO 2012). Recommendations that are developed in this study include written statements expressing procedures or protocols on how implementation of infection control should be conducted in a radiology department.


Research method and design


During the period of the study, there were 31 radiology departments in Malawi of which 27 were in government district hospitals and four in government referral hospitals. The recommendations were developed for radiology departments in four government referral hospitals located in the major cities of Malawi. The four government referral hospitals were targeted because those are the only hospitals in Malawi that conduct invasive procedures and, therefore, carry a bigger risk for HAIs.


The recommendations were developed by the first author, while being supervised by the second and third authors in April 2017 based on data from a questionnaire that measured the knowledge and practices of 62 radiographers regarding infection control as well as a narrative literature review. The narrative literature review used the following databases: EBSCOhost including CINAHL with Full Text, Health Source-Consumer Edition, Health Source: Nursing/Academic Edition, MasterFILE Premier, MEDLINE, PsycINFO. In addition, ScienceDirect and Google Scholar were searched and a manual search in Google and the reference lists of relevant articles was also done. Keywords included "infection control" OR "infect*" AND "radiograp*" AND "principle*" OR "practice*" OR "measure*".

The conceptual framework for the recommendations entailed Florence Nightingale's environmental theory (Nightingale 1969). This theory encourages the configurations of environmental settings appropriate for restoration of health (Wayne 2014). It was used as no published radiography model or theory related to infection control and the environment was available. Nightingale emphasised the responsibility of nurses to put patients in the best situation for the environment to allow them to heal (Nightingale 1969). The patient (client) and a radiographer (instead of a nurse) and the major environmental concepts must be in balance. In the case of this study, a radiographer's responsibility was to maintain an environment that will prevent patients from obtaining HAIs during a radiological procedure (George 2011).

For this study, two major aspects of Florence Nightingale's environmental theory were identified, which need to be controlled for the prevention of HAIs: health of houses and cleanliness, the latter being subdivided into cleanliness of the rooms and personal cleanliness (see Table 1).

Furthermore, the recommendations were developed based on steps derived from the National Institute for Health and Care Excellence (NICE) method (NICE 2012), and for the format of the draft, an adapted version of the Appraisal of Guidelines for Research and Evaluation II (AGREE II) tool (AGREE 2009) was used (see Table 2).

Quality of data

In this study, face validity of the recommendations was ensured by requesting the review of the recommendations by the second and third authors, while reliability of the recommendations was ensured by applying NICE's validated steps (NICE 2012) during its development. The conceptual framework for the recommendations entailed the environmental theory of Florence Nightingale (Nightingale 1969). The content of the recommendations was based on data from the self-administered questionnaire and a narrative literature review. The adapted version of the AGREE II tool (AGREE 2009) was used for the format of the draft recommendations.



The title of the recommendations reads 'Recommendations to facilitate infection control for radiology departments in Malawi'. The recommendations aim to facilitate sound knowledge and practices of radiographers regarding infection control among radiographers in radiology departments in Malawi. Seven sets of recommendations were developed (see Table 3).



Globally, infection control in radiography departments is recognised as imperative and this is visible through various infection control policies. These policies focus on a range of infection control principles, including hand hygiene (e.g. handwashing and alcohol-based hand rub), isolation (contact, airborne and droplet), the use of personal protective equipment, as well as managing contaminated equipment and cleaning and disinfecting of equipment (Department of Radiology 2009; Montana State Hospital 2017; Radiology Compliance Branch 2015). The developed recommendations focused on hand and personal hygiene, personal protective gear and the use of appropriate equipment, safe handling of sharps and sharp containers as well as housekeeping and cleaning and routine infection control practices. These practices have been found to be effective in reducing HAIs if well adhered to by radiographers (Chingarande & Chidakwa 2014; Crofton & Foley 2018). In order to adhere to the infection control practice, implementation of the recommendations is therefore important, which was not done in this study. It is thus suggested that the recommendations should be reviewed by experts prior to their implementation (NICE 2012). The expert panel can include a Ministry of Health official representing radiographers, principal radiographers from government referral hospitals and radiography lecturers from radiography training institutions in Malawi. Recommendations for clinical infection control provide comprehensive endorsements for preventing HAIs in hospitals (Loveday et al. 2014). Similarly, the recommendations for infection control developed by the researcher can then be used to facilitate the sound infection control knowledge and practices of radiographers in radiology departments in hospitals in Malawi. However, for proper implementation of the recommendations, leaders (management and radiographers) at all levels of the hospital should be committed to support the facilitation of its implementation (Registered Nurses' Association of Ontario 2012). Currently, the radiology departments have inadequate infection control resources, which include patient gowns, personal protective equipment (e.g. gloves) and cleaning materials (e.g. detergents). A context analysis should therefore be performed to identify the required resources for implementation of the recommendations. The recommendations should also be made available in various formats (print and electronic) to the radiographers in order to enforce their implementation. Furthermore, documentation (e.g. logs or charts) indicating the infection control practices and procedures that need to be followed should be made available and radiographers should be trained to complete these forms (Radiology Compliance Branch 2015).

Furthermore, there is a need to further explore the knowledge and practices of radiographers regarding infection control in Malawi. Based on this, the recommendations can be further developed and reviewed. An intervention study using a pre- and post-knowledge and practice questionnaire as well as workshops on the sets of recommendations, in order to evaluate the recommendations' effect on the infection control knowledge and practices of radiographers, can be conducted. The recommendations, once reviewed and further developed, should be updated with recent literature at least every 5 years so that the recommendations are current.

Limitations of the study

The study has some limitations. The recommendations were developed by a single author and have not been reviewed by experts in the field. It is suggested to have the draft recommendations reviewed by experts before implementation (NICE 2012). In order to develop the recommendations, only the databases of the university to which the researcher had access were used, which may have resulted in some documents not being available, and therefore not being included. The recommendations have not been implemented and suggestions for a pilot study to implement the recommendations were made. The current recommendations may not be applicable for all radiographers in Malawi because the study was limited to radiology departments in the four government referral hospitals. Suggestions to replicate the study using a bigger sample size were made.



Infection control recommendations including seven sets of recommendations were developed for radiographers who are operating in radiology departments of Malawian government referral hospitals. The recommendations identified ways to further facilitate infection control. The recommendations require expert review for further validation. After implementation, the seven sets of recommendations may provide radiographers with the knowledge of infection control as well as guidance on sound infection control practices in radiology departments. However, for successful implementation of the set of recommendations, the radiographers will also need resources such as gowns, gloves and detergents, as well as support from the management or authorities. Engagement of professional associations in the implementation of the set of recommendations will be crucial as they are the key in safeguarding the scope of practice.



The authors would like to thank Natalie Stear for editing the article.

Competing interests

The authors declare that they have no financial or personal relationships that may have inappropriately influenced them in writing this article.

Authors' contributions

D.N. conducted the data collection and data analysis and wrote the draft version of the article. R.W. and W.t.H.-B. made conceptual contributions to the study and critically reviewed the article.



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Wilma ten Ham-Baloyi

Received: 01 Dec. 2017
Accepted: 25 Aug. 2018
Published: 27 Mar. 2019

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