Health-Care Workers’ Compliance with Infection Prevention Guidelines and Associated Factors in Hadiya Zone, Southern Ethiopia: Hospital Based Cross Sectional Study

Background

Health care acquired infection (HAI) is an infection occurring in a patient in a hospital or other health care facility in whom the infection was not present or incubating at the time of admission. This includes infections acquired in the health care facilities but appearing after discharge, and also occupational infections among staff of the facilities [1]. The most common pathogens that cause Nosocomial infections are staphylococcus aureus, Pseudomonas aeruginosa, and E. coli which are transmitted through different modes like contaminated hands of health care workers and contaminated instruments [2]. HAIs remain as the most frequent adverse event in any health care delivery system and affect millions of people each year, leading to significant morbidity and mortality [3]. Nosocomial (hospital-acquired) infections are a significant problem throughout the world and are increasing at alarming rate [4]. The Institute of Medicine reported that adverse events affect approximately 2 million patients each year in the United States, resulting in 90,000 deaths and an estimated $4.5–5.7 billion per year in additional costs for patient care [5]. Between 2002 and 2009 HAI prevalence increased by 11.7 % in a network of major Canadian hospitals [6]. Data from American hospitals demonstrated that HAIs alone account for an estimated 1.7million infections within a year. The same data also revealed 98,987 HAIs associated deaths; of these, 36.3% were for pneumonia, 31% for blood stream infections, 13.2% for urinary tract infections, 8.3% for surgical site infections, and 11.2% for infections of other sites [7]. Although a well- established data were not available regarding the burden of HAIs in Africa, a systematic review done in the region showed that its magnitude would be much higher than in the developed nations [8]. Percutaneous exposures to blood and body fluids through contaminated needle pricks and other sharps are an important occupational hazard for morbidity and mortality from infections with blood-borne pathogens among health care workers. It is estimated that 2.5% of Human Immuno deficiency Virus (HIV) cases and 40% of Hepatitis B virus (HBV) and Hepatitis B virus (HCV) cases among HCWs worldwide are the result of this form of exposure [9]. Sex of health care workers, infection risk perception, training on standard precautions, accessibility of personal protective equipment and management are considered as major factors influencing compliance to infection prevention guidelines [2]. Nosocomial infection rates range from as low as 1% in a few countries in Europe and the Americas to more than 40% in parts of Asia, Latin America and sub- Saharan [10]. In many developing countries, however, the risk of needle stick injuries and accidental exposure to blood or body fluids is even higher [11]. Study conducted in Ethiopia revealed that significant numbers of healthcare workers (65.9%) were exposed to blood and body fluids, of which 29% were because of needle-stick injury [9]. Preventing and controlling infection in health care facilities involves two levels of approach, standard precautions and transmission- based precautions. Standard precautions are taken to reduce the risk of transmitting blood-borne microorganisms and other pathogens from both recognized and unrecognized sources. These precautions are used as a minimum, in the care of all patients in health care facilities and settings, regardless of their diagnoses or presumed infection status [12]. Infection prevention guidelines guide health care workers (HCWs) to practice regular hand hygiene , use personal protective equipment (PPE) like gloves, masks, eye protection, face shield and gowns when contact with mucus membranes , blood and body fluids of patients is anticipated. The guidelines also recommend correct disposal of sharps and other clinical waste [2]. In Ethiopia, the protection of patients and healthcare workers form infections inside the health care facilities has been given particular attention by the Federal Ministry of Health. Indeed, the Ministry is scaling-up its activities related to infection prevention and using all opportunities to strengthen ongoing activities. As in many of its program, the Ministry has been utilizing available evidence to establish optimal infection prevention practices in health facilities [3]. Despite a significant improvement in facility of health institutions and in the number and kind of health task forces in Ethiopia particularly in the last two decades, local reports showed that there is still high burden of HAIs [13]. On the other hand very limited evidences are available with regard to the level of compliance of healthcare workers with infection prevention guidelines and its associated factors in the country in general and in the study area in particular. There is also no study conducted before in the study area regarding compliance of health care workers with infection prevention guidelines. Therefore, this study was aimed at assessing health care workers’ compliance with infection prevention guidelines and associated factors in Hospitals of Hadiya zone, Southern Ethiopia.

Institutional based cross-sectional study was conducted from May to June 2017 Study participants: The source population of the study was all health care workers in public Hospitals of Hadiya zone. The study population was all health care workers assigned in clinical services in public Hospitals of Hadiya zone. All health care workers who were assigned to clinical services during the study period and have regular program for direct patient care were included in the study and those health care workers who were assigned to clinical services but absent during study period and those with less than six months working experience were excluded from the study. Sample size determination and Sampling technique: Sample size was determined using Epi info version 7 for single population proportion by considering 12% of health care workers’ compliance with IP guidelines, obtained from similar previous study in Gondar [14]. Confidence level of 95 % and 0.04 margin of error were taken in the calculation. Considering 10 % none response rate, the determined sample size was 279. The required number of sample was allocated proportionally among the three hospitals found in Hadiya Zone. The sample was allocated depending on the number of health care workers in 2009 E.C. The sample assigned to each hospital was proportionally allocated to each category of health care workers. The sampling units, the health care workers, were selected by using simple random sampling technique.

Results

A total of 274 health care workers returned completely filled questionnaire which had a response rate of 98.2% out of 279 health care workers. Based on the finding minimum, mean and maximum ages in years of the respondents were 19, 26.68 and 57 respectively with SD of 4.18. The median work experience of the HCWs was 3 years with minimum work experience of 0.5 year and maximum work experience of 40 years. Out of the total respondents 147(53.6%) were males. Concerning Respondent's marital status, majority 170(62.0%) was single. Professionally, most frequent 135(49.3%) were nurses. Around one third 76(27.7%) were working in outpatient department (Table 1).

Compliance level (N and %), N =274 seldom Sometimes Always Wash hands before touching a patient 68(24.8%) 110(40.1%) 96(35.0%) Wash hands before clean or aseptic procedures 37(13.5%) 94(34.3%) 143(52.2%) Wash hands after body fluid exposure 15(5.5%) 54(19.7%) 205(74.8%) Wash hands after touching a patient 40(14.6%) 118(43.1%) 116(42.3%) Wash hands immediately after removal of gloves 60(21.9%) 115(42.0%) 99(36.1%) Wash hands between patient contact 67(24.5%) 122(44.5%) 85(31.0%) Wash hands after touching patient surroundings 54(19.7%) 117(42.7%) 103(37.6%) I provide care considering all patients as potentially infectious 27(9.9%) 105(38.3%) 142(51.8%) I protect myself against body fluids of all patients regardless of their diagnosis 12(4.4%) 86(31.4%) 176(64.2%) I wear clean gloves whenever there is a possibility of exposure to any body fluids 10(3.6%) 72(26.3%) 192(70.1%) I change gloves between contacts with different patients 18(6.6%) 61(22.3%) 195(71.2%) I avoid wearing my gown out of hospital compounds 19(6.9%) 35(12.8%) 220(80.3%) I wear a waterproof apron whenever there is a possibility of body fluid 96(35.0%) 70(25.5%) 108(39.4%) I wear eye goggles whenever there is a possibility of body fluid splashing 111(40.5%) 59(21.5%) 104(38.0%)

Hand hygine

Figure 2: Observed Compliance level with hand hygiene among health care workers in Hospitals of Hadiya zone, Southern Ethiopia, July, 2017 (N=51). Use of PPE: From the observed participants almost all (98%) worn gowns during procedures when contact with blood or body fluids is anticipated and during After handling Before preparing contaminated objects i.e., used medication instruments procedures which are likely to generate splashes or sprays of blood or other body fluids but only about half (54.9%) used Mouth, nose and eye protection (figure 3).

120.0%

100.0%

80.0%

60.0%

40.0%

20.0%

0.0% Gloves are worn when

Gowns are worn during procedures when contact with blood or body fluids contact with blood or body fluids Mouth, nose and eye protection is used when a procedure is likely to generate splashes Use of PPE Figure 3: Observed Compliance level with use of PPE among health care workers in Hospitals of Hadiya zone, Southern Ethiopia, July, 2017 (N=51).

From the observed 51 health care workers, 45(88.2%) decontaminated Used instruments immediately after use by soaking in 0.5% chlorine for 10 minutes and then washed in soapy water, then rinsed in clean water and dried before sending them for high level disinfection or sterilization.

90.2% of the observed participants did not recap or bend needles after use and both needle and syringe are immediately disposed of into a puncture resistant container and 76.5% segregated Solid waste at point of use according to category (Table 3).

Discussion

This study was conducted on 274 health-care workers to assess compliance level with Infection Prevention Guidelines and associated factors in Hospitals of Hadiya Zone, Southern Ethiopia. The findings of the study showed that the overall compliance of HCWs with infection prevention guidelines was 15.0% (95%CI: 11.0%, 19.0%). This finding is in line with the findings of study Gondar University Comprehensive Specialized Hospital, Northwest Ethiopia which showed overall compliance of 12% [14]. Even though the overall compliance of HCWs with infection prevention guidelines is very low, when specific components of the IP guidelines was analyzed better compliance was recorded in some of the items. A relatively higher proportion of HCWs were found to be always compliant with Wash hands after body fluid exposure (74.8%), wear clean gloves whenever there is a possibility of exposure to any body fluids (70.1%), changing gloves between contacts with different patients (71.2%), clean and disinfect equipment and environmental surfaces (72.6%) and placing used sharps in puncture-resistant container at point of use (79.2%). In contrary, relatively low compliance was recorded in Wash hands before touching a patient (35.0%), Wash hands between patient contact (31.0%), Wash hands immediately after removal of gloves (36.1%) and Wash hands after touching patient surroundings (37.6%) These findings were nearly similar to findings of study done in Gondar University Comprehensive Specialized Hospital, Northwest Ethiopia [14]. However, there is improvement in hand washing practice in this study as compared to study conducted in Mbagathi district hospital, Nairobi, Kenya in which only 5.6% Wash hands between patient contact and 3.3% of the participants wash hands before putting and after removing gloves [16]. This difference might be due to presence of regular training, accessibility of PPE and better management support on safety for the participants of current study. The current study revealed that female health care workers were about 3 times more compliant to infection prevention guidelines as compared to males. This result is in line with the findings of study done in Gondar University Comprehensive Specialized Hospital, Northwest Ethiopia, in which females were 2.2 folds more complaint as compared to males [14]. The compliance difference in sex might be due to the females’ natural ability to obey rules and regulations. In Ethiopia, females have more responsibility to care for family in that they might be more careful not to bring health problems to their family.

In this study, respondents who had positive attitude towards IP guidelines were 3 times more likely to had compliance with IP guidelines as those who had negative attitude. This result similar with the findings of study done in Gondar University Comprehensive Specialized Hospital, Northwest Ethiopia which showed that that HCWs who had higher perception of infection risk were about 3.5 times more likely to always comply with standard precautions than those who had lower perception of risk. The finding is also similar to study conducted in Mbagathi district hospital, Nairobi, Kenya [14, 16]. But it is in contrary to study conducted at Ronald Ross General Hospital Mufulira District, Zambia which showed low level of compliance was not due to negative attitude [17]. This difference might be due to the cultural differences in the two countries and the difference in up-to- date knowledge and skill regarding infection prevention guidelines among Health care workers. This study showed that the odds of having compliance to IP guide lines was about 3 times higher on those health care workers who had access to IP guidelines as those who had no access to IP guidelines. This result is in consistency with the findings of study done in Gondar University Comprehensive Specialized Hospital, Northwest Ethiopia, in which HCWs who had access to PPE were 3 times more complaint as those who had no access [14]. The finding is also similar to study conducted in Ronald Ross General Hospital Mufulira District, Zambia [17]. Health care workers who had training on IP guidelines were 2.3 times more likely to comply with IP guidelines as compared to those who had no training. This finding is in line with the findings of study done in Gondar University Comprehensive Specialized Hospital, Northwest Ethiopia and study conducted in Ronald Ross General Hospital Mufulira District, Zambia [14, 17].

Limitation of the study

This study has the following limitations: As being cross-sectional in the design, this study lacks to show temporal relationship between cause and effect. Moreover, out of the 274 participated health care workers, only 51 were observed on their infection prevention practices. This could have biased the results since some of the participants who were not observed could have had some unusual IP practices.

Conclusion

In this study the overall compliance level of the health care workers to infection prevention guide lines was very low. Being female, attitude towards infection prevention guidelines, accessibility of personal protective equipments and training on infection guidelines were factors significantly associated with compliance with infection prevention guidelines. Continuous training on infection prevention guidelines should be given to health care workers, especially for males. Accessibility of infection prevention materials and equipments in the hospitals should get due attention.

Consent for Publication

“Not applicable” in this section.

Funding

The study was fully funded by Hosanna College of Health Sciences. The college also provided experts for supervisory, advisory and facilitation activities during the study period.

Availability of Data and Materials

The authors do not have full mandate to share the data since they are the property of the funding institution.

Competing Interests

The authors declare that they have no competing interests.

Acknowledgements

We would like to forward our great thanks to Hossana college of Health Science for giving us this golden opportunity to develop this research proposal. We would also like to thank Wachemo University Nigist Ellen Mohammed Memorial General hospital, Shone and Homecho district hospitals for providing relevant information for this research activity. Lastly, our gratitude goes to all individuals who participated in giving us all the relevant information for this research process.

Authors’ Contributions

TY conceived the research idea, conducted the data collection, data analysis and data interpretation, and wrote and reviewed the paper. GK conducted the data collection, data analysis and data interpretation, and reviewed the paper. TL and EG approved the proposal, participated in data analysis and revised subsequent draft of the paper. All authors read and approved the final paper.