|Year : 2012 | Volume
| Issue : 2 | Page : 68-73
Perception and practice regarding infection control measures amongst healthcare workers in district government hospitals of Mangalore, India
Yamini1, Animesh Jain2, Chetan Mandelia1, S Jayaram3
1 Kasturba Medical College Mangalore, Karnataka, India
2 Department of Community Medicine, Kasturba Medical College, Manipal University, Mangalore, Karnataka, India
3 Department of Community Medicine, AJ Institute of Medical Sciences, Mangalore, Karnataka, India
|Date of Web Publication||27-Sep-2012|
Department of Community Medicine, Kasturba Medical College (Manipal University), Light House Hill Road, Mangalore - 575 001, Karnataka
Introduction: Healthcare workers must know the various measures for their own protection. They should improve organization of work, implement standard precautions and dispose biomedical waste properly to prevent occupational exposure. This study aimed at assessing the perception and practice of infection control measures amongst the healthcare workers in Mangalore. Materials and Methods: This cross-sectional study was conducted by using a pretested semi-structured proforma, by interview cum observational technique. One hundred and twenty healthcare workers (70 hospital staff including nurses and technicians at the two Government District Hospitals and 50 final-year MBBS students) were selected using convenient sampling and their perception and practice regarding infection control measures were studied. Results: Of the 120 participants, the majority (85.8%) was aware of disposing used needles and syringes in puncture-resistant containers but only 55.7% were actually practicing it. Three-fourths (75.8%) of the participants were aware about not recapping the needles after use but on observation, only 35.4% were practicing this. All healthcare workers were aware about the indication for using masks and gloves while handling patients, while only 77.1% were using them. We also found that only 61.8% washed their hands after attending every patient, 94.3% cleaned the area with a sterile swab before giving injections and only 35.7% of the labs/ wards/ operation theatres had three colored bags. Few (11.7%) of the workers have already been exposed to infectious blood samples and some (19.2%) are still not immunized against Hepatitis B. Conclusion: There is a need for improvement in the perception and practice of infection control measures among healthcare workers for both self and patient's protection. They should also get themselves immunized against Hepatitis B and report accidental exposure to infectious samples to the infection control committee.
Keywords: Healthcare workers, infection control, hospital-acquired infections, prevention
|How to cite this article:|
Yamini, Jain A, Mandelia C, Jayaram S. Perception and practice regarding infection control measures amongst healthcare workers in district government hospitals of Mangalore, India. Int J Health Allied Sci 2012;1:68-73
|How to cite this URL:|
Yamini, Jain A, Mandelia C, Jayaram S. Perception and practice regarding infection control measures amongst healthcare workers in district government hospitals of Mangalore, India. Int J Health Allied Sci [serial online] 2012 [cited 2014 Sep 30];1:68-73. Available from: http://www.ijhas.in/text.asp?2012/1/2/68/101668
| Introduction|| |
Hospital-acquired infection (HAI) is an infection occurring in a patient in a hospital or other healthcare facility in whom the infection was not present or incubating at the time of admission. This includes infections acquired in the hospital but appearing after discharge, and also occupational infections among staff of the facility.  A very high frequency of these infections is noted from Southeast Asian countries.  The major mode of transmission of these hospital-acquired infections is by pathogens transferred from one patient to another through healthcare workers (HCWs) who do not follow standard precautions.  Inadequate knowledge among healthcare workers leads to this poor compliance with hand washing. 
Exposures to blood are frequent during various procedures in the hospital. Both the patients and the healthcare professionals are at a major risk of infection with blood-borne viruses including HIV due to this. The World Health organization (WHO) Report estimates that 2.5% of HIV and 40% of HBV is a result of occupational exposure.  Needle-stick injuries are the commonest form of HIV exposure in healthcare settings.  This is much more important in developing countries where there is a paucity of standard reporting protocols and underreporting is high as over one-third incidents go underreported, so the number of individuals affected is much higher than reported. 
A huge amount of biomedical waste is produced during the various procedures of healthcare, which has a high potential for infection.  HCWs must know the various measures for their own protection. They should comply with infection control measures, improve organization of work, implement standard precautions and dispose biomedical waste properly to prevent occupational exposure. If, despite prevention, an injury occurs, immediate reporting should be done and measures taken in order to decrease the risk of HIV and Hepatitis B transmission. 
The aim of this study is to study the perception and practice regarding infection-control measures among nurses, technicians in Government District Hospitals of Mangalore in Karnataka state and final-year MBBS students of an institution.
| Materials and Methods|| |
This cross-sectional study was conducted in the Government District Hospitals- Hospital 1 and 2 affiliated with College 1, in the month of February 2009. Study participants were Nursing/Technical Professionals and Final-Year MBBS students. Non-random sampling (convenient sampling) was used to select participants.
An anonymous, structured, self-administered questionnaire, printed in English was pre-tested and used as the data collection instrument. The questionnaire was divided into three sections: Section one had questions on knowledge of infection control measures and section two had questions on the attitude of healthcare workers in the context of taking particular steps to prevent hospital-acquired infections. Section three had questions on practice of various ways to prevent hospital-acquired infections. The investigator kept this part of the proforma and filled it after observing the work of the healthcare workers in the wards/labs.
Apart from demographic variables, the experience in direct patient care (in years) was taken.
The first part of the proforma judged the knowledge of health care workers on the correct method of disposal of used syringes and needles, their recapping after use, disposal of biomedical waste, methods of instrument decontamination, collection of blood samples, use of protective barriers while handling TB and HIV patients and in various procedures, appropriate hand washing.
The second part of the proforma judged the attitude of healthcare workers in the incident of a needle-stick injury, about hepatitis B immunization, and necessity of the awareness about various infection-control measures. It also had questions on accidental exposure to infected blood samples, provision in hospitals for reporting this and any working infection control committee in the hospital.
The third part of the proforma had questions on the practice of various activities that prevent HAIs. One question each was on the way of disposal of used syringes and recapping after every use, washing of hands after every patient, cleaning the area with a sterile swab before giving injections, use of masks and gloves while handling patients and colored bags being present in labs, wards and operation theatres.
Data collection and analysis
The permission to conduct the study was taken from the Medical Superintendent of both the hospitals. The study was presented to and approved by the departmental review board of Community Medicine. The participants were approached in the hospitals. After obtaining the written informed consent, data was collected by a self-administered questionnaire for assessing the perception whereas practices of nurses and technicians with respect to infection control were observed. The questionnaires were distributed to the nurses, technicians and medical students and adequate time was given to complete and return these. Observations were recorded on a pre-tested semi-structured proforma.
The collected data was entered and analyzed using Statistical Package for Social Sciences (SPSS) Version 11.5, and Chi-square test and P value were used to see association.
| Results|| |
Of the total 140 hospital staff and 125 final-year medical students posted in the government hospitals, a total of 120 (70 hospital staff including nurses and technicians and 50 final-year MBBS students) took part in this study.
A large number (70.8%) of respondents (n = 120 including 100% nurses (n = 64) were females while the rest 29.2% (66.6% (n = 6) technicians and 62% students (n = 50) were males. Almost all (82.9%) hospital (n = 70) staff were from Mangalore city itself whereas 80% students (n = 70) were from places like Delhi, Uttar Pradesh, etc.
[Table 1] shows that the majority (67.5%) of participants (40.6% nurses, 83.3% technicians and 100% medical students, n = 120) were in the age group of 20-30 years. All the nurses had completed either BSc (Nursing) or Diploma or GNB, the technicians had done BSc in Medical Laboratory Technology (MLT) and the students were enrolled in MBBS. Three-fifths (60%) of the hospital staff (n = 70) had a working experience of more than five years.
Majority of the healthcare workers (85.8%, n = 120) were aware of the fact that used syringes and needles are to be disposed in a puncture-resistant container. This included 91.4% hospital staff (n = 70) and 78% medical students (n = 50). Most of them (75.8%, n = 120) also knew that the used needles and syringes are not to be recapped after use. This included 77.1% hospital staff (n = 70) and 74% medical students (n = 50) as shown in [Table 2].
[Table 2] also shows that the majority (94.1%) of the respondents were aware of the use of gloves for large open wound dressing. More than two-thirds (68.3%) of healthcare workers (that included 71.4% hospital staff and 64% students) said gloves should be worn during collection of blood samples. However, for giving injections only a little over half (54.1%) of our respondents were in favor of wearing gloves. All the respondents were aware of the fact that masks should be used while handling tuberculosis patients and gloves should be used while handling HIV patients. Some (25%) respondents also thought that masks should also be used while handling HIV patients.
Almost half (58.3%, n = 120) of the healthcare workers (54.2% hospital staff (n = 70) and 64% medical students (n = 50)) were aware of the six steps of hand washing.
On being asked about the procedure to be followed in the event of a needle-stick injury, 88.3% healthcare workers were aware of the appropriate sequence of events to be followed and its notification to the appropriate authority immediately. Some (11.7%) healthcare workers (N = 120, including 18.6% hospital staff (n = 70) and 2% students (n = 50)) were already exposed to infectious blood samples. Awareness regarding the Infection Control Committee working in their hospital was poor as only 41.7% (N = 120) were aware of the presence of such a committee.
Most of the (88.3%) respondents were of the opinion that healthcare workers should be immunized against Hepatitis B (Chi square=7.474, P value = 0.024 significant) whereas only 80.8% healthcare workers (n = 120) were immunized against Hepatitis B infection.
Among the hospital staff, 70% (n = 70) have not undergone any training program for infection control; 88.3% respondents (N = 120) were aware that infection-control measures need to be taken for both patients' and self-protection. These included 88.6% hospital staff (n = 70) and 88% medical students (n = 50).
Observations with respect to infection-control practices of healthcare workers.
The observation was carried out among the hospital staff only as medical students are not engaged in routine care and procedures in the ward. On observing the work of hospital staff (n = 70), it was observed that 55.7% respondents disposed the used syringes and needles in the correct way and 68.6% did not recap the needles after use; 61.4% hospital staff washed their hands after every patient, 94.3% cleaned the injection area with a clean swab and 77.1% used masks and gloves while handling patients. Thirty percent threw the infected waste in a red/yellow bag.
| Discussion|| |
As needle-stick injuries are a major source of hospital-acquired infections, proper disposal of needles is mandatory so that this preventable source of infection is no more a major cause of nosocomial infections. Three-fourths (75.8%) of HCWs in this study were aware that the needles are not to be recapped after use. This result was similar to a study done in Turkey where 73% HCWs did not recap the needles after use. 
With regards to following standard precautions the respondents in this study were similar in knowledge to those in a study done by Suchitra et al.,  where nurses felt that standard precautions were protective (72%) and compulsory (60%). In spite of the recommendations of the Center for Diseases Control (CDC) that the most important factor in reducing the number of cases of blood-borne viral infections like Hepatitis B (HBV), Hepatitis C (HCV) and Human Immunodeficiency Virus (HIV) infections amongst healthcare workers is the adoption of standard precautions such as the wearing of gloves, protective goggles/visor, mask and protective aprons, most health workers did not attach much importance to these essentials.  Our results were similar to studies done by researchers elsewhere. ,,
In our hospital setting, all HCWs agreed that they will wear gloves while handling HIV patients whereas in a study done in London, only 11% nurses said that they would take these extra protective measures only if the patient had full-blown symptoms. 
Studies indicate that healthcare workers' hands are the main source of HAI transmission, and therefore, hand washing by caregivers is the most important procedure in preventing HAIs. ,, Although standard precautions and guidelines have been established to decrease the transmission of HAIs, adherence to such policies is uncommon. , We found a similar result in our hospitals with regards to awareness of the six steps of hand washing and practice of washing hands before and after every patient: compliance to these being poor in our subjects. Similar results have been observed in a study done in Baltimore, nurses scored significantly higher on knowledge but significantly lower on self-reported practices. Also, neither level of knowledge nor positive opinion about the value of hand-washing was associated with an increase in hand-washing practices. 
A few healthcare workers, including medical students were already exposed to needle-stick injury, however, the proportion of injuries was lesser than that in a study done in a German University.  The exposure to needle-stick injury could be because of lack of the necessary protection, insufficient education and not having information about various blood-borne viral diseases.  Nevertheless, it is reassuring to note that the majority of the hospital staff and medical students were aware of the appropriate sequence of events to be followed and its notification to the appropriate authority in the event of a needle-stick injury. In Germany, only 38.8% employees and 18.8% medical students reported to proper authorities after the incidence of first needle-stick injury.  In another study done in Korea  only 30% medical students had reported to the infection control team and their reasons of not reporting were that they thought exposure was not dangerous (64.7%), did not know the system of reporting (10.2%), and were very busy (6.0%). In our setup, it was found that a good percentage of HCWs reported to the appropriate authorities but a few incidents that went underreported should also have been reported. The reasons for underreporting in our setup could be forgetfulness, presumption or belief among HCWs that the patient was not infectious, workload pressure and lack of time. Failure to report diminishes the chances of the healthcare worker to receive counseling, risk assessment, and potentially beneficial prophylactic treatment, and the right to collect workers' compensation in case of development of an infection.
As needle-stick injuries are a potential source of Hepatitis B infection, it is mandatory for all the HCWs to be immunized against Hepatitis B before they join their hospital duties. In our setup, four-fifths (80.8%) of healthcare workers were immunized against Hepatitis B infection. Various studies have reported varying proportion of immunization amongst medical and nursing students. ,, In another study done in Turkey, 72.3% nurses had been vaccinated against Hepatitis B. The possible reasons for not getting immunized could be lack of opportunity or cost of the vaccine. In Italy,  widespread use of the hepatitis B inoculation has seen figures for HBV infection in healthcare workers fall from 48% to 18% in 10 years.
It has been found in various studies  that a yearly education program on nosocomial infections and its prevention helps in the retention of knowledge, attitudes and practices among the various categories of HCWs. This also helps in better adherence to barrier protection such as hand washing, use of gloves and hand disinfection. Among our hospital staff, 70% have not undergone any training program for infection control. Lewis et al. achieved a similar response in their study where not many participants agreed that taking courses in infection control would help improve infection control in hospitals. Most respondents were aware that the infection control measures need to be applied for both patients' and self-protection.
| Conclusion|| |
Overall, healthcare workers in this study had a good knowledge of the preventive measures against hospital-acquired infections. They were aware of the standard precautions, immunizations and barrier methods of protection but the practice of these measures was found to be poor. An occupational health awareness programme at the beginning of the pre-clinical training for making individuals aware of occupational risks, immunization policies and the importance of standard safety precautions would help in reducing the incidence of nosocomial infections.
| Acknowledgments|| |
We would like to acknowledge Rosy Chadha, Vasu Vashishtha, Aniruddh Soni, Jaimini Dey and Poornima Narayan Nambiar for their help in data collection and data entry. The Dean, KMC Mangalore is acknowledged for his support and encouragement. We thank the medical superintendents of the government hospitals for having accorded us permission to conduct this study. We are also grateful to the participants of this study for their participation and co-operation. Institution where the work was carried out: Kasturba Medical College, Manipal University, Mangalore, Karnataka.
| References|| |
|1.||Benenson AS. Control of communicable diseases manual. 16th ed. Washington: American Public Health Association; 1995. |
|2.||Mayon-White RT, Ducel G, Kereselidze T, Tikomirov E. An international survey of the prevalence of hospital-acquired infection. J Hosp Infect 1988;11(Supplement A):43-8. |
|3.||Horn WA, Larson EL, McGinley KJ, Leyden JJ. Microbial flora on the hands of health care personnel: Differences in composition and antibacterial resistance. Infect Control Hosp Epidemiol 1988;9:189-93. |
|4.||Meengs MR, Giles BK, Chisholm CD, Cordell WH, Nelson DR. Handwashing frequency in an emergency department. J Emerg Nurs 1994;20:183-8. |
|5.||Tetali S, Choudhury PL. Occupational exposure to sharps and splash: Risk among health care providers in three tertiary care hospitals in South India. Indian J Occup Environ Med 2006;10:35-40. |
|6.||Ippolito G, Puro V, De Carli G. The risk of occupational human immunodeficiency virus infection in health care workers. Arch Intern Med 1993;153:1451-8. |
|7.||Sharma S, Chauhan SV. Assessment of bio-medical waste management in three apex Government hospitals of Agra. J Environ Biol 2008;29:159-62. |
|8.||Neill TM, Abbott AV, Radecki SE. Risk of needlesticks and occupational exposures among residents and medical students. Arch Intern Med 1992;152:1451-6. |
|9.||Talas MS. Occupational exposure to blood and body fluids among Turkish nursing students during clinical practice training: Frequency of needlestick/sharp injuries and hepatitis B immunization. J Clin Nurs 2008;18:1394-403. |
|10.||Suchitra JB, Devi NL. Impact of education on knowledge, attitudes and practices among various categories of health care workers on nosocomial infections. Ind J Med Microbiol 2007;25:181-7. |
|11.||Smooth EC. Practical precautions for avoiding sharp injuries and blood exposure. Plast Reconstr Surg 1998;101:528-34. |
|12.||Netsing S, Nielsin TL, Nielsen JO. Noncompliance with universal precautions and associated risk of mucocutaneous blood exposure among Danish physicians. Infect Cont Hosp Epidemiol 1997;18:692-8. |
|13.||Knight VM, Bodsworth NJ. Perceptions and practice of universal blood and body and fluid precautions by registered nurses at a major Sydney teaching hospital. J Adv Nurs 1998;27:746-51. |
|14.||Erbay B, Korkmaz M, Öztoprak N, Colgan A, Akýncý E. Evaluation of injuries related to blood and body fluids for health care workers in Ankara Education and Research Hospital. [Numune Ankara Numune Eðitim ve Araþtýrma Hastanesi Çalýþanlarýnýn Kan ve Vücut sývýlarýyla iliþkili yaralanmalarýnýn deðerlendirilmesi]. 6th International Symposium [VI Ulusal Viral Hepatit simpozyumu kitabý], 2002;42-3. |
|15.||Leliopoulou C, Waterman H, Chakrabarty S. Nurses failure to appreciate the risks of infection due to needle stick accidents: A hospital based survey. J Hosp Infect 1999;42:53-9. |
|16.||Sharir R, Teitler N, Lavi I, Raz R. High-level handwashing compliance in a community teaching hospital: A challenge that can be met! J Hosp Infect 2001;49:55-8. |
|17.||Kampf G, Kramer A. Epidemiologic background of hand hygiene and evaluation of the most important agents for scrubs and rubs. Clin Microbiol Rev 2004;17:863-93. |
|18.||Kim PW, Roghmann MC, Perencevich EN, Harris AD. Rates of hand disinfection associated with glove use, patient isolation, and changes between exposure to various body sites. Am J Infect Control 2003;31:97-103. |
|19.||Whitby M, McLaws ML, Ross MW. Why healthcare workers don't wash their hands: A behavioral explanation. Infect Control Hosp Epidemiol 2006;27:484-92. |
|20.||Alvaran MS, Butz A, Larson E. Opinions, knowledge, and self-reported practices related to infection control among nursing personnel in long-term care settings. Am J Infect Control 1994;22:367-70. |
|21.||Schmid K, Schwager C, Drexler H. Needlestick injuries and other occupational exposures to body fluids amongst employees and medical students of a German university: Incidence and follow-up. J Hosp Infect 2007;65:124-30. |
|22.||Kosgeroglu N, Ayranci U, Vardareli E, Dincer S. Occupational exposure to hepatitis infection among Turkish nurses: Frequency of needle exposure, sharps injuries and vaccination. Epidemiol Infect 2003;132:27-33. |
|23.||Moon CS, Hwang JH, Lee CS, Park KH, Kim ES. Exposure to blood and body fluid among medical students in Korea. Am J Infect Control 2010;38:582-3. |
|24.||Bonanni XX. Impact the universal vaccination programmes on the epidemiology of hepatitis B: 10 years of experience in Italy. Vaccine 2003;21:85-7. |
|25.||Lewis KL, Thompson JM. Health care professionals' perceptions and knowledge of infection control practices in a community hospital. Health Care Manag (Frederick) 2009;28:230-9. |
[Table 1], [Table 2]