The Influence of National Culture and Context on Healthcare Worker Perceptions of Infection Prevention in Greek Neonatal Intensive Care Units

Vasiliki Triantafillou, Ioannis Kopsidas, Areti Kyriakousi, Theoklis E. Zaoutis, Julia E. Szymczak

Journal of Hospital Infection, 2020 Apr;104(4):552-559. DOI:


Background: Healthcare-associated infections (HAIs) in the neonatal intensive care unit (NICU) result in increased morbidity, mortality, and healthcare costs. Rates of HAIs in Greek NICUs are among the highest in Europe. There is a need to identify the factors that influence the transmission of HAIs and implementation of prevention interventions in this setting.

Aim:To understand healthcare workers’ perceptions about HAI prevention in Greek NICUs.

Methods: We conducted qualitative interviews with NICU staff (physicians and nurses) and infection prevention stakeholders (infectious diseases physicians and infection control nurses) working in three hospitals in Athens. Interviews were conducted in Greek, transcribed and translated into English, and analyzed using a modified grounded theory approach.

Results: Interviews were conducted with 37 respondents (20 physicians and 17 nurses). Four main barriers to HAI prevention were identified: (1) resource limitations leading to understaffing and cramped space; (2) low HAI prevention knowledge; (3) Greek-specific cultural norms, including hierarchy-driven decisions, a reluctance for public workers to do more than they are paid for, a belief that personal experience trumps evidence-based knowledge, and reactive rather than proactive approaches to societal challenges; and (4) lack of a national infection prevention infrastructure. Respondents believed that these barriers could be overcome through organized initiatives, high-quality HAI performance data, interpersonal interactions to build engagement around HAI prevention, and leveraging the hierarchy to promote change from the "top down.".

Conclusion: Implementing HAI prevention interventions in Greek NICUs will require consideration of contextual features surrounding the delivery of care, with particular attention paid to  national culture.