Challenges of Compliance with Infection Prevention and Control Standard Procedures among Healthcare Workers: A Hospital-Based Cross-Sectional Study

Introduction: This hospital-based cross-sectional study aimed to assess the compliance of 214 healthcare workers (HCWs) with Infective Prevention and Control (IPC) standard procedures. The study addresses the critical issue of IPC compliance among HCWs, as it plays a pivotal role in reducing the risk of infectious disease transmission within healthcare settings.

Methodology: Analytical cross-sectional study was conducted at St. Francis Referral Hospital, involved 251 Health care workers from difference department including Internal Medicine, Surgery, Emergency. The Compliance with Standard Precautions scale (CSPS) tool developed by WHO was used. Descriptive and regression analysis was done. A P-value of less than 0.05 indicated statistical significance.

Results: Overall average compliance with IPCSPs was 54% where by only 24.7% (62/251) of healthcare workers had a good compliance. The majority of HCWs (85.3%) reported highest compliance on proper disposal of used sharp items into sharp boxes and low compliance rate (11.6%) was on the disposal of the sharp box. Statistically significant were found between IPCSPs and number of years of working experience, level of education, profession, IPC training and IPC meeting attendance.

Conclusion: This cross-sectional study has shed light on the critical challenges faced by healthcare workers in complying with IPCSPs. Findings revealed a concerning compliance with IPCSPs which is below the WHO standard and national level standard as well. In light of these findings, it is recommended that we should enhance IPC training program, IPC awareness campaign and more implementational research.

The 1970s witnessed a significant spread of hepatitis among healthcare workers (HCWs) due to exposure to blood-borne pathogens. In response, Infection Prevention and Control Standard Precautions (IPCSPs) were established, initially known as universal precautions. These precautions are essential for preventing the transmission of infectious agents and apply to all patients and healthcare workers in all healthcare settings [1, 2]. IPC is crucial for global health systems, impacting the safety of both patients and health providers. It plays a vital role in containing antimicrobial resistance (AMR), preventing Healthcare-Associated Infections (HAIs), and managing outbreaks of highly contagious diseases. The United States Centers for Disease Control and Prevention (CDC) proposed IPCSPs in 1996, expanding on universal precautions to include all potential sources of infection [3- 5]. HAIs pose a significant public health issue worldwide, contributing to morbidity, mortality, increased hospital stays, healthcare costs, and the rise of AMR where by Low and middle-income countries (LMICs) bear the highest burden. While the economic burden of HAIs is well-documented in developed countries, limited data is available for LMICs. In Africa, HCWs' attitudes and behaviors have been identified as contributors to HAI transmission. The emergence of diseases like Ebola and COVID-19 emphasizes the need to strengthen IPC for resilient health systems [6,7]. Sub-Saharan African countries struggle with high HAI rates due to inadequate IPCSP compliance. Factors like insufficient training, lack of protective equipment, and workload hinder compliance [8) . In Tanzania, efforts have been made to improve IPC for healthcare workers in healthcare settings since 2004, with revised national IPC documents introduced in July 2018, aligning with World Health Organization (WHO) recommendations [9]. These updated guidelines are designed to enhance HCWs' compliance with IPCSPs, ultimately breaking the cycle of infection transmission and safeguarding HCWs, patients, and the community from HAIs and associated consequences, including AMR, prolonged hospital stays, increased costs and tragically, deaths [8]. Despite these efforts, adherence to IPCSPs remains a significant challenge in many countries, particularly in the developing world [1,10]. This lack of adherence exposes patients to heightened risks of contracting HAIs, whether through direct contact with contaminated hands of HCWs, exposure to contaminated equipment, or during healthcare procedures [11]. Consequently, this study aimed to comprehensively assess the challenge of compliance with IPCSPs among healthcare workers at Saint Francis Reginal Referral Hospital, with the ultimate goal of informing targeted interventions to strengthen infection prevention and control measures.

Study design 

This was analytical cross-sectional study, which included 251 healthcare workers regardless of their discipline, conducted between July and September 2023. 

Study Area

This study was conducted at St. Francis Regional Referral Hospital at Ifakara, Morogoro region. The hospital has 371 beds and has departments of Surgery, Internal Medicine, Gynaecology and Obstetrics, Paediatrics, Ophthalmology, Chronic diseases, Orthopedics, Community Health and Intensive care. Additionally, there were Outpatients’ Department and wards for Tuberculosis, Dental Medicine, Physiotherapy, Occupational therapy, Psychiatry, Rehabilitation, Radiology and a laboratory for the production of infusions. 

Study Population

This study was conducted among healthcare workers present at St. Francis Reginal Referral Hospital during the study period.

Inclusion criteria 

All HCWs was included, regardless of their cadre (clinicians, nurses, laboratory personnel, pharmacists, medical attendants, physiotherapist, radiographers, mortuary attendants and cleaners) 

Exclusion Criteria 

Health care workers who are under supervisions (medical students, interns or volunteers) were not involved in the study.

Sampling Procedure 

Simple random sampling was used where by each healthcare workers had equal chance to participate in this study as far as he or she meet the inclusion criteria.

Sample size estimation 

OpenEpi computation statistical software was adopted in calculation of sample size, thus came up with the sample size of 248 healthcare workers with confidence level 95%, Margin of error 5% and population proportion 50% 

Data Collection

Questionnaires of adherence with Standard Precautions Scale was designed based on the SPs guidelines that were published by WHO will be used in this study (5,7). This was used to assess the extent to which HCWs comply with SPs and had 20 items to be responded by a four-point Likert scale (never, seldom, sometimes and always). A score of 1 was given to an “always” response in positively worded statements and the “never” option in negatively worded statements, while 0 for the other responses, giving a total possible score range of 0 to 20. Scores above 16 was signify better adherence with SPs. Compliance rates (CR) was considered as the average compliance with the 20 items in percentage. Healthcare workers were expected to comply with National Guidelines for Recognition of Implementation Status of Quality Improvement Initiatives in Health Facilities and National IPC guidelines and standards fully; hence, a compliance rate of 80% was the desired level of compliances and was used as dichotomous variable, compliance score of 80% and above was categorized as high compliance and compliance score of below 80% as low compliance [12]. This was examining the adherence to PPE, disposal of sharps and waste products, decontamination and prevention of cross-infection between patients. Other parts of questionnaire were social demographic characteristics, working experiences and challenges of compliance with IPC standards precautions. Finally, Data collection were done by self-filling of questionnaire.

Variables

Dependent variable: Compliance to IPCSPs such as; hand washing, waste management, decontamination and use of PPEs. Compliance of 80% and above was considered as desired level of IPC compliances. This is according to Tanzania standard based management and recognition for quality of services in Tanzania guidelines, hence compliance was considered as dichotomous variable where by compliance score of 80% and above was categorized as high compliance and compliance score of below 80% as low compliance 

Independent variables: challenges of compliance with IPCSPs: social demographic factors, Healthcare workers factors, Health facility factors and Health system factors.

Data Management and Analysis

Data were collected by research assistance, entered and checked daily by principal investigator for completeness and entered in Excell, then exported to SPSS for analysis. Descriptive statistics was done on the calculation of median, interquartile range and frequency for Continuous variables. Categorical variables were summarized in form of proportions, frequency tables and p-values computed for categorical variables using Chi-square test and Fisher’s exact test. Also, frequency distribution was compared using the Chi-square test where those with p value < 0>

Demographic characteristics of the study respondents 

A total of 251 participants were recruited in this study. The mean age of participants was 31.64 ± 8.96 years where the predominantly age group was 21-30 (64.9%). Majority of the respondent were: male (54.6%), nurses (45.4%) and Diploma (45.82%).

Table 1:below shows the demographic characteristics of the study participants.

Infection prevention and Control (IPC) experience of the study respondent

Table 2 below shows the working experience of the respondents where by majority had been working in healthcare services delivery in less than 6 years (72.1%). In addition, majority of healthcare workers (68.5%) had experienced blood / body fluid exposure while 54.6% had not been vaccinated against hepatitis B. On IPC experiences, 54.2%, 26.3% and 22.8% had not received IPC training, received a rarely motivation in their working unit, and attend a weekly IPC meeting at their working unit for the past one year of working respectively. 21.1% did not receive any IPC supportive supervision for the past one year.

Table 2

Compliance with infection prevention and Control standard precaution (IPCSPs) 

The overall average compliance of the healthcare workers to IPCSPs at SFRH was 54% where by only 24.70% healthcare workers had good compliance to IPCSPs. The majority of healthcare workers experienced the highest compliance with proper disposal of used sharp items into sharp boxes (85.3%) while only 11.6% reported that the sharp box is only disposed when it is full. Healthcare workers reported suboptimal compliance to the following IPCSPs: 70.9% covered wound or lesion with waterproof dressing before patient contacts, 70.1% wear gloves to decontaminate used equipment with visible soil, 70.1% cleaned up spillage of blood or other body fluid immediately with disinfectants. For hand hygiene practice, only 64.5% of healthcare workers wash hands between patient contact while 52.2% did not use alcohol hand rub as an alternative when hands are visible soiled, and 18.7% used only water for hand washing.

Table 3: Shows compliance with IPC standard precaution of HCWs (N = 251) at SFRH with standard precaution (SP) based on the WHO Compliance with standard Precaution Scale (CSPS) 

Perceived challenge of compliance with Infection prevention and control standard precaution

The finding of this study showed statistically significant between the number of years of working experiences (p= 0.002) and compliance with IPCSPs where by healthcare workers with 1- 5 years working experience had a good compliance (69.35%) compared to those with more than 6 years of working experiences (10.58%). Additionally, the findings showed a statistically significant between the healthcare workers who received IPC training (p= 0.05) in previous 1 year and compliance with IPCSPs where by those who had never attend any IPC training experienced a poor compliance compared to those received the training. Furthermore, compliance with IPCSPs was found to be statistically significant with IPC meeting attendance (p= 0.02) where by those who never attend any meeting had a poor compliance compared with those attended weekly meeting. Lastly, compliance with IPCSPs were found to be statistically significant with level of education (p= 0.038) and professional (p= 0.024) where by diploma holders experienced a good compliance (45%) compared to other cadre and majority of them were nurses (53.23%). Age and sex were found to be non- statistically significant with the compliance of IPCSPs. 

Findings of this study highlight the low compliance with IPCSPs among healthcare workers per WHO standards and national standard as well [9, 12]. This study show that the overall average compliance with IPCSPs is 54% where by only 24.70

This cross-sectional study has shed light on the critical challenges faced by healthcare workers in complying with infection prevention and control (IPC) standard precautions. Our findings revealed a concerning compliance with IPCSPs which is below the WHO standard and national level standard as well. In light of these findings, it is recommended that we should enhance IPC Training by Implement comprehensive and regular IPC training programs for all healthcare workers, emphasizing the importance of adherence to standard precautions and proper use of PPE. In addition, Increasing IPC awareness by foster a culture of IPC awareness and safety within healthcare facilities. Encourage reporting of exposure incidents, provide easy access to PPE, and regularly review and update IPC protocols. Furthermore, Foster Research and Development by Invest in research to develop advanced IPC technologies and practices that can further minimize the risk of exposure to blood/body fluids and other infectious agents. Lastly, encourage the collaborative learning by facilitate the exchange of best practices and lessons learned among healthcare institutions to promote continuous improvement in IPC compliance. By addressing these recommendations, healthcare facilities can enhance IPC compliance, reduce the risk of exposure to bloodborne pathogens, and ultimately create safer environments for both healthcare workers and patients.

This cross-sectional study has shed light on the critical challenges faced by healthcare workers in complying with infection prevention and control (IPC) standard precautions. Our findings revealed a concerning compliance with IPCSPs which is below the WHO standard and national level standard as well. In light of these findings, it is recommended that we should enhance IPC Training by Implement comprehensive and regular IPC training programs for all healthcare workers, emphasizing the importance of adherence to standard precautions and proper use of PPE. In addition, Increasing IPC awareness by foster a culture of IPC awareness and safety within healthcare facilities. Encourage reporting of exposure incidents, provide easy access to PPE, and regularly review and update IPC protocols. Furthermore, Foster Research and Development by Invest in research to develop advanced IPC technologies and practices that can further minimize the risk of exposure to blood/body fluids and other infectious agents. Lastly, encourage the collaborative learning by facilitate the exchange of best practices and lessons learned among healthcare institutions to promote continuous improvement in IPC compliance. By addressing these recommendations, healthcare facilities can enhance IPC compliance, reduce the risk of exposure to bloodborne pathogens, and ultimately create safer environments for both healthcare workers and patients.

Acknowledgement

I would like to extend my sincerely gratitude to St. Francis University College of Health and Allied Sciences for their ethical approval, furthermore to St. Francis Referral Hospital and Research Mentorship Forum for making this happen.

Conflict of Interest

No any competing interest