‘Early intervention’ refers to services provided by HCWs to the population of birth to 3-year-old infants, toddlers and their caregivers (South African Speech-Language-Hearing Association, 2017). ‘Early communication intervention’ is distinguished from early intervention in that it focuses on communication and language skills and is provided by SLTs (South African Speech-Language-Hearing Association, 2017).

During ECI, SLTs are often in close proximity to young children (e.g. when playing, feeding and cleaning) and are exposed to bodily fluids and secretions (e.g. drooling, mouthing, crying, uncontrolled respiratory secretions and incontinence), which places SLTs at risk of exposure to potential infectious agents (Hashikawa et al., 2020; Siegel, Rhinehart, Jackson, & Chiarello, 2007). As young children are not able to adopt the same infection control practices as adults, it is essential that practitioners observe the proper use and disposal of PPE and IPC measures to protect both vulnerable patients and staff.

Personal protective equipment refers to barriers and respirators that are used to reduce contact between infectious agents and airways, skin and clothing. There are different types of PPE, including gloves, gowns, face masks, goggles, face shields and respiratory protection. The PPE is selected according to the most likely mode of transmission and nature of HCW–patient interaction (Siegel et al., 2007).

Infection prevention and control measures are defined as actions that inhibit or reduce the spread of disease within an environment (Khan et al., 2019). Standard precautions should be used for all patients, and additional transmission-based precautions should be used for the management of droplets, close contact and airborne transmissions (Siegel, 2007). Adherence to IPC measures may include implementing teamwork, education and training, screening of patients, hand hygiene, disinfection and isolation of the ill (Khan et al., 2019; Northway, Langley, & Skippen, 2011; Siegel et al., 2007).

The COVID-19 pandemic has compelled HCWs to adopt certain PPE and IPC measures to combat the spread of the disease. This includes wearing face masks, maintaining social distancing, following respiratory etiquette (covering a cough) and handwashing (Chu et al., 2020; Hashikawa et al., 2020). These PPE and IPC measures may present challenges to SLTs providing ECI. For example, face masks cover visual cues and expressions (such as smiles, frowns and smirks) which are crucial when targeting pre-linguistic skills in ECI (Atcherson et al., 2017; Keen et al., 2016). In addition, social distancing may cause speech to be less audible or even completely unheard (Grieco-Calub, 2021).

Furthermore, infants and toddlers can bring about barriers to implementing IPC measures. For example, ECI involves close physical interactions with young children who may not practise proper cough etiquette, and this increases the need for respiratory protection (Northway et al., 2011; Siegel et al., 2007; South African Speech-Language-Hearing Association, 2017). In addition, young children often expel bodily fluids and secretions when held; however, there is little guidance on the frequency of changing gloves and gowns. Lastly, young children frequently mouth their hands and touch surfaces. This requires repeated disinfection of surfaces, which can be challenging in settings with limited time and resources (Hashikawa et al., 2020).

There are strategies that can be implemented to alleviate these challenges. Firstly, coaching parents is an effective method of providing ECI, which can reduce close contact encounters with young children. However, ECI consists of multiple components, of which parent-led intervention is only one (Dathan Rush, 2021). Secondly, virtual communication or telecommunication is recommended as a practical and efficient method of providing care during the social distance restrictions of the COVID-19 pandemic (Sarma et al., 2020). However, virtual communication cannot fully replace in-person encounters, and individuals in LMICs may have technological constraints and/or difficulty accessing networks and the Internet (Manto et al., 2020; Sokunbi et al., 2020).

In South Africa, the majority of children live in underserved and disadvantaged communities. These children are at increased risk for communication delay because of poverty, disease and psychosocial hazards (Du Toit, Van Der Linde, & Swanepoel, 2021; Samuels et al., 2012). In addition, children in low-resource settings are at increased risk of developing healthcare-associated infections (HAIs) because of host factors (e.g. human immunodeficiency virus [HIV] and acquired immunodeficiency syndrome [AIDS], malnutrition) and health system factors (e.g. poor infrastructure and lack of IPC practices) (Rothe, Schlaich, & Thompson, 2013). Consequently, there is a high demand for ECI services which implement efficient IPC measures.

There is limited research on the implementation of IPC measures by South African SLTs during the COVID-19 pandemic (Adams, Seedat, Coutts, & Kater, 2021). A study by Adams et al. (2021) highlighted the impact of COVID-19 on the services delivered by SLTs. Although the study did not focus on ECI, the findings indicated that paediatric and high-risk patients were most impacted by disrupted outpatient services during the pandemic. Furthermore, Blignaut et al. (2020) described South Africa’s response capacity to the pandemic in comparison to HICs. South Africa was described as having additional challenges such as a lack of resources (e.g. PPE) and chronic infrastructure challenges (e.g. regular electricity and water shortages) (Blignaut et al., 2020). Challenges to implementing infection control existed in South Africa prior to the COVID-19 pandemic. According to Dramowski, Cotton and Whitelaw (2017), previously existing environmental challenges to HAI prevention in neonates and children included overcrowding, high patient-to-staff ratios, lack of IPC provision, lack of isolation facilities, inadequate cleaning and reuse and sharing of equipment. These previous inadequacies in healthcare have most likely worsened because of the COVID-19 pandemic (Sokunbi et al., 2020). The purpose of this study was to describe PPE and IPC measures used in early intervention through a scoping review of existing and recent literature and consultation with South African SLTs who provide ECI.

According to Levac et al. (2005), the purpose of the scoping review should be considered whilst articulating the research question. The purpose of this scoping review was to describe PPE and IPC measures used in early intervention as reported in the current literature and to reflect on the scoping review findings by consulting with stakeholders, namely South African SLTs involved in ECI. Therefore, the research question and sub-question were as follows: (1) what is known from the existing international literature about the available PPE and IPC measures used within early intervention? and (1.1) how do SLTs in South Africa who provide ECI relate to the literature (scoping) review findings with regard to PPE and IPC measure used for ECI?

The JBI’s (Peters et al., 2020) three-step iterative search strategy was used to guide the identification of relevant studies. Firstly, a search of the topic was conducted on nine online databases. This was followed by an analysis of the text words in the title, abstract and index terms used to describe the retrieved sources. A second search was then conducted across 13 databases using the identified keywords and index terms. The databases included Clinical Key, Cochrane Library, PubMed, Science Direct, Scopus, Web of Science, Google Scholar, University of Stellenbosch Library, Sabinet African Journals, African Journals Online, African Digital Repository Web of Science, African Education Research Database and EBSCOhost Research Databases.

Because of the extensive number of keywords used across studies, 16 different combinations of search strategies were developed. An example of the combination of keywords included [‘personal protective equipment’ OR ‘personal protection equipment’ OR ‘risk control equipment’] AND [‘infection prevention and control measures’ OR ‘infection control’] AND [‘health care professionals’ OR ‘health care providers’ OR ‘health care workers’ OR ‘health care staff’] AND [‘early childhood intervention’ OR ‘early childhood development’ OR ‘early communication intervention’]. Then, a third search was undertaken using the reference lists of identified sources. Professionals and scholars in the field were also contacted to provide any additional relevant literature not identified through the database searches (Peters et al., 2020).

Any existing literature (published or unpublished) which met the inclusion criteria were accepted, for example, primary research studies, reviews, letters, guidelines, meta-analyses, websites and books. The selected studies were those which:

The first author independently screened the titles of the search results, and the collected sources were cross-checked by the RA. Then, both the first author and the RA conducted an abstract and full-text review. The inclusion of studies within the data set was discussed upon the completion of each screening process. The suitability of each study was determined by the inclusion criteria. In instances where a consensus could not be reached, a successive screening process was conducted. For example, the abstract review was succeeded by a full-text review, which was then succeeded by a preliminary data extraction exercise. Studies were included if the information provided in the data extraction process was sufficient to answer the research question.

The data charting process was iterative and included an initial trial to ensure that all relevant results were extracted through the data charting form (Levac et al., 2010; Peters et al., 2020). The final data chart included space to record the authors, year of publication, source, country where the research was conducted, research design, research setting, PPE and/or IPC measure(s) described, function of or rationale for the PPE and IPC measures, person or team involved, age range of children, duration of data collection, aims, results, limitations and recommendations (see Appendix 2). The RA cross-checked the data extracted from a random selection of 28.57% of the selected studies. This was above Naudé and Bornman’s (2018) recommended cross-checking of 20% of the data to increase reliability. A trial analysis was conducted to reach a consensus on any discrepancies.

Numerical analysis was used to describe the characteristics of the studies selected in step 4 (Arksey & O’Malley, 2005; see Appendix 3). Thematic analysis was used for qualitative data to identify, analyse and provide a detailed report on patterns (themes) of meaning (Braun & Clarke, 2006). Braun and Clarke’s (2006) six phases of thematic analysis were utilised and included (1) familiarisation, (2) generating codes, (3) searching for, (4) reviewing, (5) defining themes and (6) producing the report. The RA reviewed the completed thematic analysis of step 5 to ensure that the themes and codes were aligned with the research question and objectives. No changes were required in this regard.

A consultation exercise was conducted to share the preliminary scoping review findings (of steps 1–5) with local stakeholders to validate the findings and to inform future research (Levac et al., 2010; Pollock et al., 2021). The target population comprised registered SLTs who provided ECI in South Africa during the COVID-19 pandemic. Participants were selected using the nonprobability sampling technique of critical case sampling. This involved the researcher purposefully selecting individuals based on specific characteristics or inclusion criteria (Onwuegbuzie & Collins, 2007). To be included in the consultation, participants had to:

Participants were recruited through an online advert to take part in the research. The advert was posted on the social medial platforms Facebook and WhatsApp and was also distributed via e-mail. Speech–language therapists who were interested in participating in the study were required to complete an eligibility survey based on the inclusion criteria.

Participants were required to complete an informed consent form before they were included in the study. Twelve participants took part in one of two online FGDs. The FGDs included a 20-minute presentation of the preliminary findings of steps 1–5 of the scoping review as well as a 60-minute semistructured group interview, both conducted by the first author (B.A.). The second author (B.G.) attended both online FGDs to provide technical or any other support required. The interview questions were directly related to the scoping review findings (see Appendix 3). This enabled the researcher to describe the extent to which South African SLTs related to the research findings in terms of their own experiences, challenges and perceptions.

Prior to the online FGDs, a face-to-face pilot study was undertaken by the first author with five SLTs to determine the suitability of the presentation and interview questions, as well as to become more familiar with the process of facilitating FGDs. The pilot study also provided information on possible biases within the FGD design (Naudé & Bornman, 2018). This was done by using an anonymous feedback questionnaire which enabled the pilot study participants to comment on the presentation and FGD questions and provide suggestions for improvement. The feedback resulted in minimal changes to the presentation (e.g. repeating abbreviations and reducing the pace of the presentation) and no changes to the FGD interview questions.

Data from the pilot study were included in the results of the scoping review, along with the main FGD findings. Therefore, a total of 17 clinicians took part in the consultation phase. Clinicians were all registered SLTs who provided ECI within different provinces of South Africa, in both the private and public sectors. All clinicians had at least 3 months’ ECI work experience during the COVID-19 pandemic, which necessitated the use of PPE and IPC measures when providing ECI.

The online and pilot FGDs were transcribed and analysed using thematic analysis. A theoretical (deductive) approach to thematic analysis was followed (Braun & Clarke, 2006) as the transcripts were analysed based on the findings of steps 1–5 of the scoping review. ATLAS.ti version 9 software was used to aid the data coding process and create visual representations of the data. A summary of the results was sent to participants as a form of member checking to increase the credibility of the research findings (Varpio, Ajjawi, Monrouxe, O’Brien, & Rees, 2017). Out of the 17 participants included in the study, 13 responded to the member checking. All clinicians who responded agreed with the research findings and no changes were suggested by the clinicians.

Ethical approval to conduct the study was obtained from the Health Research Ethics Committee (HREC) of Stellenbosch University (ethical clearance number S21/03/047).

The literature search and selection of sources are depicted in a PRISMA-ScR flow diagram (Figure 1). There were 113 820 024 sources identified in the initial search across 13 online databases. A total of 30 282 studies were screened after duplicates were removed. ‘Other sources’ included the search of reference lists, which resulted in the identification of 31 studies, as well as contact with relevant professionals, which provided an additional nine studies. Within the data extraction, more than half (nine) of the studies were obtained through ‘other sources’. This demonstrates the importance of expanding the literature search beyond electronic databases.

Appendix 4 represents the characteristics of the 14 studies included in the scoping review. Studies were published over a 10-year period between 2011 and 2020. There was no relevant grey literature identified for inclusion in the study. According to the World Bank Classification (ChartsBin Statistics Collector Team, 2016), the majority of studies (n = 9) were conducted in HICs. Furthermore, the only study to include a nonmedical setting was that of Ibfelt, Engelund, Schultz and Andersen (2015).

There were no studies identified which discussed PPE and IPC measures used by SLTs in providing ECI. The included studies all discussed PPE and IPC measures used by HCWs who provided early intervention to the population of birth to 3-year-old infants and toddlers. More than half (n = 8) of the studies included a team of HCWs, which suggests that the task and responsibility of carrying out IPC measures was well distributed amongst different individuals within the relevant healthcare settings. However, caregivers, who are integral to early intervention services (Owens, 2016), were only included in one study (Buser, Fisher, Shea, & Coffin, 2013). The selected studies focused significantly more on IPC measures than on PPE. This has a bearing on the nature of challenges reported in the selected studies in relation to early intervention.

In this scoping review, the main results of the literature search (steps 1–5) included challenges and suggestions to implementing IPC measures within early intervention by different HCWs. During the consultation exercise, practitioners related all of the literature search findings to their professional experience and shared additional challenges and suggestions relating to infection control used within ECI, with relevance to the South African context. The combined results of the literature review and consultation phase revealed three core themes, namely challenges to establishing IPC measures within early intervention, challenges to conducting ECI when utilising IPC measures and overcoming the challenges. The results of the literature search and consultation are concurrently presented and discussed below. The identity of stakeholders in the consultation phase has been anonymised by the code P (pilot study), F1 (FGD 1) or F2 (FGD 2) followed by the p (participant) number; for example Pp1 refers to Participant 1 in the pilot study.

The literature search highlighted several challenges to establishing IPC measures within early intervention. During the consultation, practitioners reflected on these findings in relation to the ECI services they provide in South Africa. The challenges included five major barriers to implementing IPC measures.

Participants in the consultation described five central challenges to conducting ECI when utilising IPC measures (see Figure 3). These challenges were additional to those found in the literature search and demonstrate the value of conducting a consultation with local stakeholders to determine the applicability of research findings for SLTs in South Africa.

The importance of hand hygiene was emphasised by all 14 studies in the scoping review. The study by Lorenzini, Costa and Silva (2013) declared hand hygiene to be the most effective and least expensive method for preventing and controlling HAIs. Then, two frequently reported recommendations were improved ‘supplies and infrastructure’ and ‘education and training’ for HCWs and caregivers. Salem and Youssef (2017) reported that without basic supplies and infrastructure, it is not possible for staff members to meet IPC standards or provide an acceptable level of care.

During the consultation, practitioners agreed with these recommendations and provided three additional suggestions to improve IPC practices within ECI. Firstly, practitioners discussed the difficulty of disinfecting intervention material. Cleaning strategies were mentioned such as using ‘different boxes’ (F2P3) to indicate the sanitised and unsanitised toys, quarantining therapy material which could not be sanitised such as the ‘sand’ (F1p4) in sensory boxes and placing pictures in ‘plastic sleeves’ (F1p6) so that they could be cleaned more easily. An alternative strategy was to avoid disinfection altogether by asking caregivers to bring therapy material from ‘home’ (F1p1) or to make toys using ‘recyclable materials’ (F1p1) which could easily be disposed of or given to patients after a single use.

Secondly, practitioners reiterated the difficulty of young children not understanding or following IPC instructions. One practitioner suggested having ‘regular hand sanitising times’ (Pp4), especially with children who frequently touch objects and surfaces. Thirdly, the close contact nature of ECI was discussed. Practitioners stated that their approach to ECI had shifted to become more ‘parent-led’ (F2p2) in an attempt to maintain their social distance from the children. This required SLTs to train caregivers on ECI strategies and explain why IPC measures were in place. These modifications were useful in transferring ECI techniques to the patients’ homes and empowering caregivers to take more responsibility for infection control. Parent-led intervention or parent coaching is, of course, the recommended practice to follow in the communication intervention of young children (Dathan Rush, 2021).

The resilience of practitioners in navigating solutions during unprecedented times is commendable, especially considering the lack of standard IPC protocols for ECI. Overall, there was a clear need for ECI-targeted IPC guidelines which take into consideration both the characteristics of the population (e.g. young children with special needs) and the settings in which services are provided (e.g. nonmedical and low-resource settings). The predicament remains of ECI strategies compromising the effectiveness of IPC measures. Understanding the challenges to implementing IPC measures within ECI can be seen as the first step to overcoming them.