Knowledge and practices of infection control among healthcare workers in a Tertiary Referral Center in North-Western Nigeria.

BACKGROUND: Healthcare acquired infections (HCAIs) otherwise call nosocomial infection is associated with increased morbidity and mortality among hospitalized patients and predisposes healthcare workers (HCWs) to an increased risk of infections. The study explores the knowledge and practices of infection control among HCW in a tertiary referral center in North-Western Nigeria.
MATERIALS AND METHODS: This is a cross-sectional study. A self-administered structured questionnaire was distributed to the study group (of doctors and nurses). Data on knowledge and practice of infection control were obtained and analyzed. Study population were selected by convenience sampling.
RESULTS: A total of 200 responses were analyzed, 152 were nurses while 48 were doctors. The median age and years of working experience of the respondents were 35 years (interquartile range [IQR] 31-39) and 7 years (IQR 4-12), respectively. Most of the respondents 174/198 (87.9%) correctly identified hand washing as the most effective method to prevent HCAI, with nurses having better knowledge 139/152 (91%) (P = 0.001). Majority agreed that avoiding injury with sharps 172/200 (86%), use of barrier precaution 180/200 (90%) and hand hygiene 184/200 (92%) effectively prevent HCAI. Only 88/198 (44.4%), 122/198 (61.6%), and 84/198 (42.4%) of the respondents were aware of the risks of infection following exposure to human immunodeficiency virus, hepatitis B virus and hepatitis C virus-infected blood, respectively. About 52% of doctors and 76% of nurses (P = 0.002) always practice hand hygiene in between patient care.
CONCLUSION: Gaps have been identified in knowledge and practice of infection control among doctors' and nurses' in the study; hence, it will be beneficial for all HCW to receive formal and periodic refresher trainings.

Introduction

The need for infection control in healthcare facilities is born out of the need to prevent Healthcare associated infections (HCAIs). HCAI can be defined as an infection occurring in a patient during the process of care in a hospital or other healthcare facility which was not present or incubating at the time of admission.[1] It contributes to significant morbidity and mortality, longer duration of hospitalization, as well as increased cost of treatment in both developed and resource-poor countries. The prevalence in the developed world is reported to be 15% among hospitalized patients while it is as high as 37% for patients admitted into the Intensive Care Unit.[1] The prevalence in developing countries is somewhat higher with up to 19% prevalence of HCAI among hospitalized patients.[1] In the United States, the added expenditure as a result of HCAI is in excess of $4.5 billion,[23] while in the United Kingdom, a mortality rate of 13% and a prolongation of hospital stay by a factor of 2.5 was reported.[4] Even with the paucity of data in sub-Saharan Africa, HCAI remain a major cause of preventable morbidity and mortality in developing countries where infection rates are relatively higher due to poor infection control practices and overcrowding of hospitals.[5]

Abuse and misuse of antibiotics has further enabled multi-drug-resistant organisms to flourish which can be transmitted as HCAIs.[6] To curtail this menace, it has become necessary to implement infection control measures so as to reduce morbidity and mortality that comes with the HCAIs. Standard guidelines with various components from evidence-based care have been outlined to ensure global standard among healthcare workers (HCWs) for effective infection control.[123456789]

Many studies have shown disparity in knowledge of infection control based on a cadre of HCW and their years of experience (YOE).[1011] Studies have also found differences in terms of actual knowledge of infection transmission and control, its interpretation and application by HCW.[101213]

Similarly, several studies have shown the benefits of effective infection control measures span wide from improving morbidity and mortality, prevention of disease transmission to enhancing a cost effective healthcare.[14151617]

Simple practical procedures that are part of the components of standard precautions against HCAI have been found to be effective in reducing the HCAIs. Simple hand hygiene when performed well can reduce the prevalence of HCAI substantially.[19] Improved compliance in hand hygiene with standard alcohol-based rub can reduce the rate of nosocomial infections by as much as 40%.[18] Perception of HCW about hand hygiene when improved through appropriate education and enlightenment has been shown to improve compliance to hand hygiene among medical personnel.[19]

The prevention of HCAI perhaps requires a multi-targeted approach. When properly conducted, it can also affect other aspects of medical practice. A study from Indonesia found a decrease of inappropriate use of antibiotics by about 22% after the implementation of a multifaceted infection control and antibiotic stewardship program.[20]

This study is aimed to assess the knowledge and practices of infection control among HCWs at a Tertiary Institution with a view to improving on what is currently obtained.

Materials and Methods

Study site

This study was conducted at a Tertiary Referral Center in North-Western Nigeria. The hospital has a total bed capacity of 550 and provides tertiary level care across various surgical and medical sub-specialties, with the full support of well-equipped laboratories. The hospital serves as a referral center for the North-Western states in Nigeria and its neighboring countries including Niger Republic. The hospital has an infection control committee that holds a mandatory workshop for all staffs on a quarterly basis.

Study design

The study was a descriptive cross-sectional survey conducted among doctors and nurses involved with direct patient care over 1-month period. Data were obtained through a pretested, structured, self-administered questionnaire, which was distributed to the respondents by a team of trained research assistants. The research assistants explained the purpose of the study to respondents and obtained their consent before the questionnaire was filled anonymously by the respondents and returned within 1 h or when not possible, at the end of the day’s work. The questionnaire was pretested on a random sample of 15 who were not included in the main study. Following pretesting, some questions and responses were revised for clarity or deleted as appropriate. Questions used in the questionnaire were developed after reviewing published literature for relevant items.[2122232425] The validity of the questionnaire was confirmed by a Cronbach’s alpha internal consistency coefficient of 0.7958.

Demographic details including age, sex, cadre, YOE, and station of the respondent were collected. Other aspects of the questionnaire content comprised of 12 main questions related to knowledge regarding hand hygiene (3 questions), standard precautions (3 questions), needlestick injury (NSI), and postexposure prophylaxis (4 questions). One-point was given to a correct answer while 0 was given to an incorrect answer in the knowledge section, while practice was measured by a set of 4 positive questions each on hand hygiene and standard precaution using a five-point Likert’s scale (i.e., always, most of the time, sometimes, rarely, never). Scores of 5, 4, 3, 2, and 1 were given for any, always, most of the time, sometimes, rarely and never responses, respectively. The KAP scores for each study participant were thereafter used to calculate percentage KAP scores. In assessing the knowledge and practice, a score of 0–69% was considered poor, and ≥70% was considered good for knowledge and practice, respectively.

Study population and sampling method

The study population were doctors and nurses who were on duty in the various wards of the hospital at the time of the study. Those who were off duty were excluded. Other medical and nonmedical personnel were also excluded. Study participants were recruited by convenience sampling.

Statistical analysis

The responses were recorded in Microsoft Excel software and later transferred to STATA version 10, developed by StataCorp and analyzed. Means, medians, standard deviations, and proportion were determined as appropriate. Differences between the two groups were compared using Chi-square (χ2) test and Student’s t-test. Differences in median percentage knowledge and practice score between doctors and nurses were ascertained by Mann–Whitney U-test. Correlation between percent knowledge and practice score was ascertained by Spearman rho correlation. A P ≤ 0.05 was taken as statistically significant.

Ethics

Ethical approval was obtained from the Ethics Committee of the Hospital.

Informed consent was obtained from the respondents prior to the administration of questionnaire after the research assistants explained the purpose of the study to respondents.

The study was carried out according to Helsinki declaration.

Results

A total of 225 questionnaires were distributed out of which 200 were retrieved, 25 did not respond giving a response rate of 88.9%. Of the 200 responders, 152 were nurses while 48 were doctors. The study population has a median age of 35 years (interquartile range [IQR] 31–39) and median YOE of 7 years (IQR 4–12) [Table 1].

Table 1

Demographic details of the respondents

	Nurses (152)	Doctors (48)	Total (200)
Median age (years)	35 (IQR: 31.25-40)	34 (IQR: 30.25-36)	35 (IQR: 31-39)
Males	45	39	84
Females	107	9	116
Median experience (years)	7 (IQR: 5.25-12)	6 (IQR: 4-7)	7(IQR: 4-12)
Medical wards	66	19	85
Surgical wards	86	29	115

IQR=Interquartile range

The median overall percent knowledge and practice scores were 70% and 65%, respectively. On examining the knowledge of the respondents [Table 2], nurses were more knowledgeable of the fact that hand hygiene is the most effective method to prevent healthcare acquired infection (HCAI)(P = 0.001). When asked about standard precautions, majority agreed that avoiding recapping needles, use of barrier precaution and hand hygiene effectively prevent HCAI [Table 2]. Despite the nurses having better knowledge on hepatitis B virus (HBV) sero-conversion compared to doctors, knowledge on percentage estimated risk of acquiring infection with the human immunodeficiency virus (HIV), HBV or hepatitis C virus (HCV) following exposure to blood and other body fluid was generally poor [Table 2].

Table 2

Knowledge and practice of the respondents regarding infection control practices (only correct responses are shown in the table)

	Doctors n=48 (%)	Nurses n=152 (%)	Crude OR (95% CI)	P
Knowledge
Hand hygiene is the most effective method to prevent HCAI	35 (73)	139 (91)	3.97 (1.64-9.59)	0.001
Use of sterile gloves is the most effective method to prevent HCAI	25 (52)	52 (34)	0.48 (0.25-0.92)	0.027
Wearing gloves eliminates the need to wash hands	42 (88)	126 (83)	0.69 (0.27-1.80)	0.448
Component of universal precaution
Avoid injury with sharp	44 (91)	128 (84)	0.48 (0.16-1.47)	0.194
Barrier precaution	46 (96)	134 (88)	0.32 (0.07-1.45)	0.122
Hand hygiene	44 (91)	140 (92)	1.06 (0.33-3.46)	0.922
Risk of transmission of bloodborne pathogens
Percentage estimate of HIV transmission risk	26 (54)	62 (41)	0.58 (0.30-1.12)	0.104
Percentage estimate for HBV transmission risk	22 (46)	100 (66)	2.27 (1.176-4.394)	0.013
Percentage estimate for HCV transmission risk	15 (31)	69 (45)	1.82 (0.918-3.642)	0.08
Post exposure prophylaxis should begin within 72 h	27 (56)	88 (58)	1.07 (0.556-2.059)	0.84
Practice
Hand wash before and after glove use	37 (77)	140 (92)	3.468 (1.418-8.487)	0.004
Hand wash on contact with excretion and secretion of patients	48 (100)	149 (98)	0.000	0.33
Hand wash before and after any invasive procedure	43 (90)	143 (94)	1.848 (0.588-5.807)	0.29
Hand wash in between patient care	25 (52)	115 (76)	2.859 (1.453-5.626)	0.002
Wear cap and mask before invasive procedure	24 (50)	84 (55)	1.235 (0.645-2.366)	0.524
Wear long-sleeved gown before invasive procedure	22 (46)	69 (45)	0.98 (0.512-1.885)	0.958
Use sterile gloves before invasive procedure	40 (83)	141 (93)	2.564 (0.966-6.804)	0.05
Wear goggles before invasive procedure	29 (60)	109 (72)	1.66 (0.843-3.271)	0.14
Recap needles after use	15 (31.3)	27 (17.8)	2.10 (1.005-4.405)	0.05

OR=Odds ratio, CI=Confidence interval, HCAI=Healthcare acquired infection, HIV=Human immunodeficiency virus, HBV=Hepatitis B virus, HCV=Hepatitis C virus

As regards to practice of hand hygiene, 77% of doctors’ versus 92% of nurses’ (P = 0.004) and 52% of doctors’ versus 76% of nurses (P = 0.002) always practice hand hygiene before and after glove use and in between patient care, respectively. When asked about recapping needles, none of the respondents reported not recapping his/her needle after use, however, 31.3% versus 17.3% of doctors and nurses, respectively, said they recap needles most of the time.

Results of logistic regression analysis [Table 3] indicated that knowledge of infection control was greater among respondents stationed in surgical wards (odds ratio = 3.414 [1.822–6.395]) compared to those in medical wards.

Table 3

Factors influencing levels of good knowledge and practice of the respondents (n=200)

Variables	Crude OR (95% CI)
	Knowledge	Practices
Gender
Female	1.0 (reference)	1.0 (reference)
Male	0.708 (0.395-1.272)	0.804 (0.451-1.434)
YOE (years)
<10	1.0 (reference)	1.0 (reference)
>10	1.423 (0.748-2.702)	1.183 (0.6113-2.290)
Cadre
Nurses	1.0 (reference)	1.0 (reference)
Doctors	1.092 (0.561-2.124)	1.770 (0.916-3.416)
Station
Medical wards	1.0 (reference)	1.0 (reference)
Surgical wards	3.414 (1.822-6.395)	1.103 (0.619-1.967)

OR=Odds ratio, CI=Confidence interval, YOE=Years of experience

There was no statistically significant difference in both knowledge and practice between male and female respondent, nurses and doctors or those with years of working experience of ≥10 years and ≤10 years. There was a weak negative correlation between overall percent knowledge score and overall percent practice score (r = −0.004, P < 0.001).

Discussion

Nosocomial transmission of infections among healthcare givers and their patients usually results from breach in hospital infection control guidelines. To curtail this, there is need to educate healthcare givers on infection control measures, however, this can only be achieved by understanding the gaps in knowledge and practice of infection control among healthcare givers.

Our study confirms some gaps in knowledge regarding hand hygiene, with about half of the doctors agreeing with the use of sterile glove as the most effective method of preventing HCAI. The overall knowledge on the risk of transmission of bloodborne pathogens (HIV, HBV, HCV) and postexposure prophylaxis was poor. While the practice of hand hygiene is generally good, relatively fewer of the respondents reported washing their hands in between patient care, with nurses reporting a better practice. There was a weak negative correlation between good knowledge and good practice among the respondent.

The quarterly mandatory training embarked upon by the hospital infection control committee would likely explain the overall good knowledge and practice shown in this study. A similar pattern has been previously reported in Nigeria.[24] Studies elsewhere also showed that training improves knowledge and compliance with standard precaution.[192627] In another study among health workers in a Tertiary Hospital in North-Eastern Nigeria, training on standard precautions was predictive of correct knowledge of standard precaution.[22] The identified gaps in knowledge and practice of hand hygiene in this study despite regular training, is alarming. Ogoina et al.[11] reported the poor practice of hand hygiene despite good knowledge among HCW in two tertiary hospitals in Nigeria. Insufficient water supply among others has been shown to affect the practice of hand hygiene among HCW in Nigeria.[24] In Uganda, Sethi et al.[28] reported that up to 75% of HCW at Mulago general hospital disagreed with the fact that their hands, when unclean, can be a source of infections and less than half of the respondent reported having easy access to clean water in between patients. This knowledge and practice gap in hand hygiene needs to be bridged, as hand hygiene is the single most important means of preventing HCAI.[1]

The poor knowledge on the risk of transmission of bloodborne pathogens (HIV, HBV, HCV) suggest most of the respondents underestimate the risk of transmission and this may put HCW at risk of being infected with these pathogens following exposure. This may explain the poor compliance with the use of simple personal protective equipment such as gowns, caps and mask and goggles identified in this study, as most of the respondent would have underestimated the risk associated with invasive procedures. According to World Health Organization, globally 40% of HBV infections among HCWs are due to occupational exposure.[29] Most exposures are caused by blood or body-fluids especially due to NSIs which carry a substantial risk. Hence, this underscores the need to further educate HCW on the risk of acquiring infection following exposure to blood and other body fluid.

The relatively lower compliance to the observance of hand hygiene by medical doctors as shown in this study is in conformity with the observation in various other studies where doctors are generally shown to poorly comply with universal precaution compared to nurses.[23243031] In a related study, Bamigboye and Adesanya[32] observed a higher level of knowledge among nursing students 77%, compared to medical students, 61%, with only 18.9% of the students claiming that universal precautions featured during their classroom sessions. Therefore, they concluded that the exclusion of such important topics from the medical education curriculum as the possible reason for the poor practice of universal precaution observed among medical student in their study. In addition, Adinma et al.,[24] in their study suggested YOE as one of the factors responsible for poor compliance with universal precautions among doctors compared to nurses who have more YOE. This finding is at variance with Gershon et al.’s[33] observation of the better practice of universal precautions among younger health workers. In another study among medical students, females were shown to comply more with universal precaution as compared to their male counterparts.[34] However, in our study, we did not find any significant association between YOE or gender of HCW and good knowledge and practice of infection control respectively.

The finding of weak correlation between good knowledge and good practice suggests knowledge does not always translate into good practice. This has also been shown in a previous study in Nigeria.[11] Other confounding predictors of good infection control practice may probably have a role. Lack of resources, excess workload and time constraint have been reported as major factors influencing the poor practice of infection control in healthcare facilities in Nigeria,[112435] and other countries of the world.[2636]

This study was limited by the self-report method of assessment of practice of infection control because the level of compliance might have been more properly assessed by observation. Hence, studies directly observing infection control practices among HCW in Nigeria are recommended.

Suggestions and Conclusion

Even with regular infection control training in the hospital, gaps have been identified in knowledge and practice of infection control among doctors and nurses. This underscores the need for continued refresher training and measures to compel implementation of infection control in the hospital. With the recent emergence of Ebola virus disease in West Africa and other endemic transmissible viral hemorrhagic diseases like Lassa fever, it becomes imperative to adopt strict measures of infection control in hospitals in Nigeria.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.