Healthcare workers' compliance and factors for infection prevention and control precautions at Debre Tabor Referral Hospital, Ethiopia

¹Department of Environmental Health Science, College of Health Sciences, Debre Tabor University, Debre Tabor, Ethiopia, ²Department of Internal Medicine, School of Medicine, College of Health Sciences, Debre Tabor University, Debre Tabor, Ethiopia

^&Corresponding author
Alebachew Amsalu, Department of Environmental Health Science, College of Health Sciences, Debre Tabor University, Debre Tabor, Ethiopia

Introduction    

Healthcare-acquired infections (HAIs) are infections that begin 48 hours or more after being admitted to the hospital or within 30 days of receiving health care [1]. HAIs are a worldwide issue, particularly in low- and middle-income countries, where the prevalence ranges from 5.7% to 19.1% [2] and death occurs in approximately 10% of affected patients [3]. In Ethiopia, the overall prevalence of HAIs was 16.96%, with surgical site infection (39.66%), urinary tract infection (27.69%), bloodstream infection (19.9%), dual infections (surgical site and urinary tract infection) (14.01%), and respiratory tract infection (13.51%) being the most common [4].

A comprehensive implementation of IPCP could potentially prevent up to 55-70% of HAIs [5]. IPCP are scientific approaches and practical solutions aimed at preventing infection-related harm to patients and health care workers (HCWs). Continuous running water supply, infection prevention guidelines, and IPCP training were all significantly associated with higher chances of safe infection prevention practice [6].

In Ethiopia, infection prevention practices range from 52.2% to 39.4%, and the likelihood of safe infection prevention practice is higher among HCWs who have good knowledge and a positive attitude toward infection prevention [7]. Building infection prevention and control capacity in low- and middle-income countries is feasible if there is sufficient and consistent evidence on strategies for specific needs interventions [8]. The current study investigated HCWs' compliance with IPCP measures and identified associated factors at Debre Tabor Referral Hospital (DTRH), which can be used to improve preventive measures in healthcare settings.

Methods     

Study area: Debre Tabor Referral Hospital was designed to serve 1.5 million people per year, but it now serves 2.5 million people per year. It has five wards (surgery, medicine, pediatrics, obstetrics and gynecology, and intensive care), two large operating wards, and a small operating ward. Currently, the DTRH has a total of 409 employees (140 nurses, 27 midwives, 26 general practitioners, 28 pharmacists, 5 radiographs, 17 laboratory technicians, 6 medical laboratories, 6 anesthesiologists, 4 health informatics, an environmental health officer, 12 experts, 36 other technicians and 101 administrative staff.

Study design and period: institutional based cross-sectional study was conducted in DTRH from October 14 to November 4, 2021.

Sources population: all regularly employed HCWs working at the DTRH and providing direct patient care (nurses, physicians, anesthesiologists, midwives, and laboratory technicians/technicians during the study period).

Study population: regularly employed HCWs working at DTRH and provide direct patient care during the study period.

Inclusion criteria: healthcare workers regularly employed and provide direct patient care during the data collection period.

Exclusion criteria: healthcare workers who were seriously ill, on annual and maternity leave during data collection.

Sampling and sample size determination: the census method was used.

Measurement of variables: compliance with IPCP of HCWs is the outcome variable. The 22 items on a three-point Likert scale (1 = seldom, 2 = sometimes, and 3 = always) were used to measure compliance with IPCP of HCWs. Participants who scored 66 points (22 items multiplied by 3 points) were considered "compliant" for IPCP [9]. The independent variables of study are sociodemographic factors (age, sex, marital status, job category, work experience) and assigned place), knowledge about IPCP (knowledgeable: when the participants correctly answers the knowledge assessment question = mean (equal to or greater than 5), less knowledgeable: when the participants correctly answers the knowledge assessment question is less than five [9] and institutional factors (workplace infection prevention guidelines, continuous water sources availability, alcohol swabs always present in wards, soap for handwashing always present in wards, availability of personal protective equipment (PPE), support administrative and training on safety practices).

Data collection procedures and quality assurance: data were collected using pre-tested, structured, and self-administered questionnaires. This questionnaire was developed based the guidelines for the prevention and control of environmental infections [10]. The data were collected by trained nurses and was carried out under the supervision of environmental health experts. Data quality was ensured in the data collection, coding, entry and analysis process.

Data processing and analysis: the collected data were entered into EpiData (version 3.1) software and exported to SPSS (version 23) software for cleaning and analysis. The results were presented using figure and tables as variables in terms of frequency and percentage. A bivariable and multivariable logistic regression analysis were calculated to identify predictors of compliance with IPCP. The odds ratio with a 95% confidence interval (CI) was used to determine the strength of the association. Enter variables with p values less than or equal to 0.2 in multivariable logistic regression analysis. A 95% CI at p value = 0.05 is declared statistically significant.

Results     

Sociodemographic characteristics: the response rate in this study was 96% and half (50.5%) of the respondents were female HCWs. Majority of the respondents were in the range of 26-30 age group and married (59.6%). Among the HCWs participated, 70.2%, and 54.3% were nursing professionals and with five or more years of work experience, respectively (Table 1).

Level of compliance with standard precautions (SPs): the proportion of HCWs who were compliance with IPCP was 10.6%. Compliance with IPCP of anesthesiologists (25%) was most compliant followed by laboratory technicians (13.3%) (Figure 1). The HCWs always wash their hands before touching a patient, after being exposed to body fluids, between patient contacts, and touching patients' surroundings were 37%, 78.4%, 15.4%, and 16.3%, respectively (Table 2). From participated HCWs, 71.6%, 32.7%, 20.7%, were always clean and disinfect equipment´s and environmental surfaces, considered all patients as potentially infectious, and wear water proof apron when there was possibility of body fluid exposure, respectively. In addition to this 16.8% of HCWs was seldom place used sharps in a puncture-resistant containers at point of use and 69.2% was always segregated infectious medical wastes into yellow color-coded bin (Table 3).

Knowledge of HCWs about IPCP: in the current study, 76% of HCWs were knowledgeable on disinfection prevents HAIs and 66.3% of HCWs were knowledgeable on masks and goggles are necessary if the procedures and patient care activities are likely to cause blood flashing or exposure to deep body fluid. In addition, 76.4% HCWs was aware that used needles should be placed in a puncture resistant container (Table 4).

Factors associated with compliant with IPCP: multiple logistic regression analysis revealed that HCWs with the availability of PPE (AOR = 21.20, 95%, CI = [2.46-11.37]), receiving training on IPCP (AOR = 17.60, 95%, CI = [3.58-8.65]), and more than or equal to five years of work experience (AOR = 7.82, 95%, CI = [1.61-12.07]), were statistically significant predictors of compliance with IPCP (Table 5). Institutional factors for instance 70.2%, 71.2%, and 68.3% of HCWs were with no training on IPCP, no soap and no persistent water supply, respectively (Figure 2).

Ethical consideration: ethical clearance was obtained from the Research Review committee of Debre Tabor University. Participants were assured and convinced of confidentiality concerning all information acquired. In addition, verbal consent was obtained from each participant and director of DTRH.

Discussion     

Compliance with IPCP is a cost-effective strategy for preventing HAIs in resource-constrained developing countries like Ethiopia. The current study investigated HCWs' compliance with IPCP as well as personal and institutional factors that influence it. HCWs´ compliance with IPCP was 10.6% in this study, which is comparable to the study in northern Ethiopia (12%) [11], but much lower than studies in Southern Ethiopia (56.5%) [12]. Regarding their profession and compliant, anesthetists were the most compliant (25%) and physicians were the lowest (5.9%). A similar study in Southeast Ethiopia showed that nurses were the most compliant professionals (57%) and anesthetists and laboratory professionals were the least in total of 8.9% [13]. Knowledge and work experiences of HCWs´ might be the reason for discrepancy.

This low compliance might be due to lack of PPE, a lack of work experience, insufficient training for HCWs, and the study settings. However, when each specific domain of IPCP examined, better results were observed in some items. For instance, the overall hand hygiene of HCWs in this study was 33.6%, which is much higher than study in Northern Ethiopia, 16.5% [14] but lower than and the overall hand hygiene compliance of HCWs in Ethiopia (38%) [14]. These differences were most likely caused by persistent water and soap supply, and HCW knowledge of infection prevention and control.

Although skin provides some protection from exposure to potentially infectious substances, it is strongly recommended that health professionals use blood and body fluid precautions for further protection when they are providing health care [15]. Only 20.7% of HCWs always wore waterproof apron when there was possibility of body fluid exposure, which is lower than the study in Southeast Ethiopia (39%) [13]. The proportion of HCWs who always protect themselves from any bodily fluid exposure in this study was 43%, which was lower than the proportion in Ghana, which was 50% [16]. This discrepancy of might be due to HCWs´ knowledge and availability of PPE in the working institution. The segregation of healthcare waste as infectious and non-infectious by HCWs in this study was 69.3%, which is lower than the study in Uganda, which was 80%, but higher than the study in Kenya, which was 38.9% [17]. This variation might be due to receiving IPCP training and the availability of PPE at the workplace.

The overall knowledge of HCWs on IPCP in this study was 76%, which is higher than similar study in Southeast Ethiopia 53.7% [13], and Nigeria 16.6% [18]. But lower than 84.6% [19], taking IPCP training and gaining work experience could be the causes of this discrepancy. Work experience of more than or equal to five years, access to PPE, and receiving SP training are predictors of HCWs' compliance with SP in this study. Compliance with SP was likely to be higher by 21 times, 17.6 times, and 7.8 times for availability of PPE, receiving training, and work experience greater or equal to five years than their counterparts, respectively [20]. Other studies also mentioned knowledge 3.8 times [14], training 12.3 times and PPE availability 10.2 times [21] as of predictors for compliance with SP by HCWs. There are studies reported that there was no association between knowledge [17], and work experience [22], on compliance with SP by HCWs. These differences on predictors and values might be due to healthcare facilities IPC setup and study setting.

Limitations of the study

Participants were only drawn from hospital settings, the study's generalizability is limited to referral hospitals and not to smaller healthcare facilities in the town. Another limitation of this study was its cross-sectional design, which does not establish the definitive and effect of a relationship between the dependent and independent variables.

Conclusion     

HCWs' compliance with IPCP remains extremely low. Five years of work experience or more, availability of PPE, and receiving IPCP training were factors those are significantly associated with IPCP compliance. Updating infection prevention measures for HCWs through in-service training and the implementation of infection prevention measures (such as PPE provision) will improve IPCP compliance. Furthermore, follow-up actions and the implementation of infection prevention guidelines should be implemented to improve HCWs compliance with IPCP.

Competing interests     

The authors declare no competing interests.

Authors' contributions     

AA: participated in design, method, write up and manuscript preparations. HK: participated in method, data collection and analysis. Both authors have reviewed the manuscript and approved the final version for submission.

Tables and figures     

Table 1: socio-demographic characteristics of HCWs working at DTRH, Ethiopia, 2021 (n = 208)

Table 2: level of compliance with handwashing IPCP among HCWs working at DTRH, Ethiopia, 2021 (n = 208)

Table 3: level of compliance with IPCP among HCWs working at DTRH, Ethiopia, 2021 (n = 208)

Table 4: knowledge of HCWs on IPCP working at DTRH, Ethiopia, 2021 (n = 208)

Table 5: bivariate and multivariate analysis of factors associated with compliance with IPCP among HCWs working at DTRH, Ethiopia, 2021 (n = 208)

Figure 1: proportion of HCWs compliance with IPCP by profession at DTRH, Ethiopia, 2021 (n = 208)

Figure 2: institutional factors affecting HCWs' compliance with IPCP at DTRH, Ethiopia, 2021 (n = 208)

References