CHAPTER ONE
INTRODUCTION
Infection is one of the most important problems in health care services worldwide. It constitutes one of the most important causes of morbidity and mortality associated with clinical, diagnostic and therapeutic procedures. Health care workers are at a high risk of needle stick injuries and blood-borne pathogens as they perform their clinical activities in a hospital. They are exposed to blood-borne infections by pathogens, such as human immunodeficiency virus (HIV), hepatitis B and hepatitis C viruses, from sharp injuries and contacts with blood and other body fluids. According to a World Health Organization (WHO) estimate, in year 2002, sharp injuries resulted in 16 000 hepatitis C virus, 66 000 hepatitis B virus and 1000 HIV infections in health care workers worldwide. Recapping, disassembly, and inappropriate disposal increase the risk of needle stick injury. The incidence rate of these causative factors is higher in developing countries for the higher rate of injection with previously used syringes. Developing countries where the prevalence of HIV infected patients is very high, record the highest needle stick injuries too. Needle stick injuries were also reported as the most common occupational health hazard in a Nigerian teaching hospital. Interventional measures have been proposed to minimize exposure of health care workers and patients to infection with the implementation of universal precautions as one of the strategies. In 1983, the US Centre for Disease Control and Prevention (CDC) published a document that recommended blood and body fluid precautions when a patient was known or suspected to be infected with blood borne pathogens. In 1987, the CDC recommended that regardless of patient’s infection status, the precautions must be consistently used. This extension of blood and body fluid precautions to all patients is referred to as “universal blood and body fluid precautions” or simply “universal precautions.”These precautions include set of precautions devised to prevent transmission of all known blood-borne pathogens including HIV, hepatitis B virus, and hepatitis C virus to/from health care personnel when providing first aid or other health care services. This applies to blood and other body fluids containing visible blood and also to vaginal secretions and semen. In 1996, the CDC included the universal precautions in a new prevention concept the so-called “safety precautions.” The “safety precautions,” which are devised to be used for the care of all patients in hospitals regardless of their diagnosis or presumed infection status, now replace the “universal precautions.” The fact that “safety precautions” are recommended for the care delivery to all patients, regardless of their presumed infection state, is important when handling equipment and devices that are contaminated or suspected of contamination, and in situations of contact risk with blood, body fluids, secretions and excretions except sweat, without considering the presence or absence of visible blood and skin with solution of continuity and mucous tissues. Safety precautions include hand washing; use of barriers (e.g., gloves, gown, cap, mask); care with devices, equipment and clothing used during care; environmental control (e.g., surface processing protocols, health service waste handling); adequate discarding of sharp instruments including needles; and patient’s accommodation in accord to requirement levels as an infection transmission source. Another important measure is adequate professional immunization, as this guarantees anticipated protection against immune-preventable diseases. The level of practice of universal precautions by health care workers may differ from one type of health care worker to another. The differences in knowledge of universal precaution by health care workers may be influenced by their different type of training. Various studies carried out among different categories of health care workers found that exposure to blood or other body fluids was approximately 9.3%.A similar study conducted in Ibadan found a higher exposure rate of 25.1%. Several factors ranging from personal to organizational causes were responsible for non-adherence to the basic principles of universal precautions among health care providers. Universal precaution awareness education has not been pronounced among health care workers, particularly in developing countries. According to the most recent guideline published by the Healthcare Infection Control Practices Advisory Committee (HICPAC) in 2007, it has been recommended to apply safety precautions (SPs) for all people during healthcare irrespective of their disease status. These SPs include but not limited to hand hygiene, use of personal protective equipment, and instrument processing. In many studies, compliance with safety precautions among healthcare professionals was reported to be inadequate with regard to eye protection, avoidance of needle recapping, glove use when required, and washing hands before and after patient contact, use of face masks, and avoidance of a used needle that is disassembled from a syringe and in implementation of precautions for all patients. According to the literature, major reported factors that affect compliance with safety precautions include but not limited to lack of understanding and knowledge among healthcare workers on Safety Precautions, shortage of time to implement the precautions (work overload), limited resources, lack of proper training, uncomfortable equipment, skin irritation, forgetfulness, distance from the necessary facilities, and insufficient support from management in creating a facilitating work environment. Moreover, certain socio-demographic variables such as age, sex, job category, marital status, working site in the hospital and work experience were found to be associated with compliance with safety precautions. Interventions tried in other countries to increase the compliance of healthcare workers with Safety Precautions include but not limited to in-service training on Safety Precautions beyond ordinary level, pre-service training by inclusion of Safety Precautions in educational curricula, and availability of personal protective equipment. We, therefore, conducted this study to assess the knowledge, and compliance with safety precautions among health facilities in OrukAnam L.G.A, AkwaIbom State.
1.2. STATEMENT OF PROBLEM
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. 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. The prevalence in developing countries is somewhat higher with up to 19% prevalence of HCAI among hospitalized patients. In the United States, the added expenditure as a result of HCAI is in excess of $4.5 billion, while in the United Kingdom, a mortality rate of 13% and a prolongation of hospital stay by a factor of 2.5 was reported. 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.Abuse and misuse of antibiotics has further enabled multi-drug-resistant organisms to flourish which can be transmitted as HCAIs. 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. Safety guidelines with various components from evidence-based care have been outlined to ensure global safety among healthcare workers (HCWs) for effective infection control.Many studies have shown disparity in knowledge of infection control based on a cadre of HCW and their years of experience (YOE). Studies have also found differences in terms of actual knowledge of infection transmission and control, its interpretation and application by HCW.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.
Simple practical procedures that are part of the components of safety 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. Improved compliance in hand hygiene with safety alcohol-based rub can reduce the rate of nosocomial infections by as much as 40%.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.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.
1.3 AIMS AND OBJECTIVES OF THE STUDY
The general objective is to assess the knowledge and compliance with safety precautions among health facilities in Nigeria. Other general objectives of the study include the following;
1.4. RESEARCH QUESTIONS
1.5. RESEARCH HYPOTHESES
HO:There is no significant impact of knowledge and compliance on safety precaution among health care workers in health facilities in Nigeria.
H1:There is a significant impact of knowledge and compliance on safety precaution among health care workers in health facilities in Nigeria.
HO: There is no significant relationship between knowledge and compliance with safety precautions among health facilities in Nigeria.
H1:There is a significant relationship between knowledge and compliance with safety precautions among health facilities in Nigeria.
1.6. SIGNIFICANCE OF THE STUDY
On the whole, available data show that needle stick injuries and blood borne pathogens are serious threats to patients, health care workers and to the host community. The rising prevalence of morbidity and mortality as a result of nosocomial and blood borne infections such as HIV/AIDS, HBV and HCV among others is as a result of lack of awareness, wrong attitude towards and non-compliance with the definitions and recommendations of safety precautions. Compliance with safety precautions has been shown to reduce risk of exposure to blood and body fluids. Due to this, surveillance of health care workers compliance to safety precautions is an important element of occupational and nosocomial infection control as it enables assessment of risks from occupation exposure to infection.
This study will expose the level of awareness, attitude and practice of safety precautions among the health care workers in health care facilities in Nigeria and hence could be used as a baseline for intervention. It will also identify gaps which would be recommended for correction through interventions. This study could be used to monitor trends of events concerning knowledge, attitude and practice of safety precautions among health care workers in health care facilities in Nigeria, by reviewing from time to time, the incidence of needle stick injuries and the morbidity and mortality pattern. It will also identify gaps in the standard precaution practices among these HCWs and the results from the study will be used for the planning of health education intervention programme. It will also provide reference material for the academic society as well as further research.
1.7. SCOPE OF THE STUDY
The study is restricted to the knowledge and compliance with safety precautions among health facilities in Nigeria using OrukAnam LGA in AkwaIbom state as a case study.
LIMITATION OF THE STUDY
Financial constraint- Insufficient fund tends to impede the efficiency of the researcher in sourcing for the relevant materials, literature or information and in the process of data collection (internet, questionnaire and interview).
Time constraint- The researcher will simultaneously engage in this study with other academic work. This consequently will cut down on the time devoted for the research work.
1.8. OPERATIONAL DEFINITION OF TERMS
Knowledge: The Oxford Advanced Learners Dictionary (2001) defines knowledge as the information, understanding and skills that one gains through education or experience. It also defines knowledge as the state of knowing about a particular fact or situation. In this study, knowledge refers to the awareness of basic principles of safety precautions.
Practice: Practice is the usual or expected way of doing something in a particular organization or situation (Oxford 2001). In this study, practice refers to the extent that health care workers implement recommended strategies of safety precautions.
Safety precautions: The Centers for Disease Control and Prevention defines safety precautions as a group of infection prevention practices that apply to all patients, regardless of suspected or confirmed infection status, in any setting in which healthcare is delivered. It is based on the assumption that every person is infected or colonized with an organism that could be transmitted in the healthcare setting and thus health care workers need to apply infection control practices during the delivery of health care. The same definition/assumption applies in this study.
Occupational exposure: Occupational exposure is defined by the Occupational Safety and Health Administration (OSHA) of US Department of Labour as reasonably anticipated skin, eye, mucous membrane, or parental contact with blood or other potentially infectious materials that may result from the performance of an employee's duties. The same definition applies in this study.
Blood-borne infections: OSHA defines blood-borne infections as infections from pathogenic microorganisms that are present in human blood and can cause disease in humans. These pathogens include, but are not limited to, HBV and HIV. In this study, blood-borne infections are infections from pathogenic microorganisms that are present in human blood, are capable of causing disease in human, and are predominantly transmitted via blood and blood contact.
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