A RESEARCH REPORT ON FACTORS ASSOCIATED WITH COMPLIANCE TO STANDARD INFECTION CONTROL PRECAUTIONS AMONG HEALTH WORKERS IN AL-SHABBAH CHILDREN HOSPITAL, JUBA

OPERATIONAL DEFINITIONS

ABSTRACT

Background: Healthcare workers are at greater risk of occupational exposure to splashes, sharps, and needle stick injuries (SSNIs), that in turn result into nosocomial or hospital acquired infections. Although they had previously been associated with patients, health care workers too have been affected, and unlike patients, health workers also face increased risk of needle stick injuries (NSI). Following NSIs, around 20 types of pathogens can be transferred through blood, which is always worrying due to the potential risk of transmission of Blood Borne Pathogens (BBPs). Therefore, infection control on the part of health workers themselves and not just patients has in the recent past been emphasized, with healthcare workers being front line of protecting themselves and clients from infection. The specific aspects that can prevent infections when practices are referred to as standard infection control precautions. Nonetheless, for them to be effective in preventing infections and occupational injuries among health workers, they have to be optimally complied to.

Objective: The purpose of this study was to assess the factors associated with compliance to standard infection control precautions among health workers in Al-Shabbah children hospital, Juba, South Sudan.

Methods: A descriptive cross sectional research design was used to study health workers working at Al-Shabbah hospital, Juba – South Sudan. Al- Shabbah hospital was purposively sampled and consecutive sampling was used to sample them. This study used structured interviews to collect quantitative data while a self-designed, structured self-administered questionnaire was used to capture it. Data Processing and analysis was done using Statistical Package for the Social Sciences (SPSS) version 20.0.

Results: It was found out that slightly more than half of the health workers who were interviewed at Al Shabbah hospital were compliant to infection control precautions 30(51%). Two institutional characteristics had a statistically significant relationship with compliance to infection control precautions. They are; availability of infection control equipment at the health facility (X² = 12.646, P = 0.000), and the nature of patients handled at health facility (X² = 9.061, P = 0.003). Only one individual characteristic had a statistically significant relationship with compliance to infection control precautions. It was the frequency of using gloves (X² = 7.667, P = 0.022).

Conclusion: The level of compliance to standard infection control precautions among health workers in Al-Shabbah children hospital, Juba, South Sudan is 51%. Thus, about 5 of every 10 health workers at Al-Shabbah children hospital, Juba comply with the infection control precautions during their routine health care service provision. That level of compliance to infection control precautions is affected mainly by institutional characteristics and to a less extent by individual characteristics.

CHAPTER ONE: INTRODUCTION

1.0 Introduction

According to estimates by the International Labor Organization (ILO), 2.3 million workers die every year from work-related injuries and diseases (ILO, 2018). There are even those who suffer from non-fatal work-related diseases, numbering up to 160 million workers and those who suffer from non-fatal injuries, numbering up to 313 million per year. The ILO estimates that more than 4 per cent of the world’s annual GDP is lost as a consequence of work-related injuries and diseases. This is even more pronounced when it comes to developing countries in which work-related deaths, injuries and diseases take a particularly heavy toll given that large numbers of people in those countries are engaged in hazardous activities including agriculture, construction, logging, fishing and mining (ILO, 2018).

It is cognizance of the health dangers associated with work places, that the area of occupational safety and health was embedded in the “health”, “labor” and “institutions” Sustainable Development Goals (SDGs). Target 3.9 of the health SDG aims at substantially reducing the number of deaths and illnesses from hazardous chemicals and air, water, and soil pollution and contamination by 2030. In addition, Target 8.8 of the labor SDG also aims at protecting labor rights and promoting safe and secure working environments of all workers, and the “institutions” SDG, target 16.6 aims at developing effective, accountable and transparent institutions at all levels. The cross cutting nature of Occupational Safety and Health (OSH) in the SDGs implies that addressing OSH gaps can turn the vicious circle described above into a virtuous circle of healthier lives and increased productivity at the work place. But to do so, there are populations of workers that must be given utmost attention, given their elevated risk of work related injuries and diseases, among which are health care workers.

1.1 Background of the study

Healthcare workers are at greater risk of occupational exposure to splashes, sharps, and needle stick injuries (SSNIs) (Ongete, 2018), that in turn result into nosocomial or hospital acquired infections. Nosocomial infections, or Hospital-Acquired Infections (HAI), are among the most significant causes of morbidity and mortality in healthcare settings throughout the world (Allegranzi, 2011). Prevention of HAIs is central to providing high quality and safe healthcare, even in settings with limited resources (Murni, 2015). Such infections have been discovered to be recurrent problems, identified chiefly in intensive care facilities, surgical, and medical wards (Camille, 2018). Although they had previously been associated with patients, health care workers too have been affected, and unlike patients, health workers also face increased risk of needle stick injuries (NSI).

Needle Stick Injuries (NSIs) are common and to an extent inevitable among health-care workers (HCWs) during execution of their patient care services (Goel, 2017). Nowadays, NSIs are a serious work-related hazard and a potential risk of transmission of infections (Desalegn, 2015). Following NSIs, around 20 types of pathogens can be transferred through blood, which is always worrying due to the potential risk of transmission of Blood Borne Pathogens (BBPs) (Baghcheghi, 2011). Hepatitis B virus, Hepatitis C Virus, and HIV infection are commonest HAIs, mostly transmitted by healthcare workers who fail to practice infection prevention measures (Melaku, 2018). Worldwide, around 40% of HCWs suffer from hepatitis B and C virus infection and 2.5% are affected by human immunodeficiency virus (HIV) caused by NSIs (Gheshlagh, 2018). These injuries not only raise the possibility of negative health consequences, but also lead to psychological distress, fear, tension, and anxiety in HCWs which results in increasing absence from work and have a direct negative effect on the health care services (Ghanei, 2015). On the other hand, medical treatment, blood work, and missed days at work for these injured individuals impose a high cost on the health care system (Geravandi, 2016).

Therefore, infection control on the part of health workers themselves and not just patients has in the recent past been emphasized, with healthcare workers being front line of protecting themselves and clients from infection (Rosenthal, 2015; Kamunge, 2013; Rasslan, 2012). Infection prevention is a process of placing a barrier between susceptible host and the microorganisms (Tietjen, 2011) and a major component of safe and high-quality service delivery at the facility level (Melaku, 2018). The specific aspects that can prevent infections when practices are referred to as standard infection control precautions.

Standard precautions (formally universal precautions) were designed by the Centers for Disease Control and Prevention (CDC) in 1987 to help prevent the transmission of infection with blood-borne microorganisms in healthcare facilities (Amoran and Onwube, 2013). These recommendations were developed to protect healthcare workers, patients and visitors even in the absence of symptoms. This was specifically for infections such as Human Immunodeficiency Virus (HIV) or Hepatitis B virus (HBV). The main aspects of universal precautions and body substance isolation were subsequently merged into a unit of recommendations, namely the Standard Precautions by the CDC’s Hospital Infection Control Practices Advisory Committee (HICPAC) in 1995 (Amoran and Onwube, 2013). The use of these measures is aimed at minimising the spread of healthcare-associated infections (HAIs) in the handling of all body substances, such as blood, secretions and excretions. In addition, the application of this type of precaution is influenced by a risk assessment (CDC, 2017). The Standard precautions are made up of hand hygiene, personal protective equipment, and respiratory hygiene and cough etiquette, the safe use and disposal of sharps, environmental cleaning, handling and laundering soiled linens and reprocessing of reusable patient care equipment (Saito, 2017; FGPS Challenge, 2009).

Nonetheless, for them to be effective in preventing infections and occupational injuries among health workers, they have to be optimally complied to. Compliance in this case refers to the consistent practice of each of the infection control precautions at each opportunity. However, although global rates of compliance to infection control precautions are poorly documented, evidence shows that compliance is largely sub optimal (less than 80%).  It has been suggested that the adherence rate amongst healthcare workers (HCWs) is less than 50% (Hessels et al., 2016; Pyrek, 2017). In countries like Hong Kong and Brazil, it has been reported that compliance to infection control guidelines is 57.4 and 69.4% respectively among nurses (Lam, 2014; Pereira, Lam, Chan, Malaguti‐Toffano, & Gir, 2015). In Africa, compliance has been reported to be less than 60% (Melaku, 2018).

1.2 Statement of the Problem

At Al-Shabbah hospital, there is evidence to attest to the fact that health workers at that hospital are not as compliant to infection control precautions as they should be during their routine duties. Despite being a national children’s referral hospital, Al-Shabbah hospital has in the past five years (2014 – 2018) had numerous cases of health worker occupation injuries and illnesses due to nosocomial infections. In the year 2014, there were five cases of nosocomial infections among health care workers at the hospital, which then increased to seven in the year 2015 (Hospital records, 2016). In the year 2017, there were eight cases of nosocomial infections, while in 2018, there were twelve cases, the commonest being Hepatitis B , Hepatitis C and even HIV/AIDS  In addition to that, there have also been reports of cases of needle stick injuries among health care workers at the same hospital, ranging from 3 to 5 annually.  Further still, although anecdotally reported, it is said that health workers at that facility also wash their hands half of the time at each given opportunity.

The above evidence is symbolic of possible gaps in compliance to infection control precautions among health workers at Al-Shabbah hospital given that with utmost compliance, there would no cases of nosocomial infections or needle stick injuries among those health workers, as those precautions can ably prevent such occurrences if complied with (Centres for Disease Control (CDC), 2017). Surprisingly, in the context of Al-Shabbah hospital, the level of compliance to infection control precautions among health care workers thereat is not known, and so are the factors associated with compliance to those precautions. There is therefore a research gap in the respect, which if not filled, compliance to those infection control precautions might continue being intermittent, which will increase incidences of nosocomial infections among health work force, and ultimately affect health care service delivery.

1.3 Objectives of the study

1.3.1 General objective

To assess the Factors associated with compliance to standard infection control precautions among health workers in Al-Shabbah Children Hospital, Juba, South Sudan

1.3.2 Specific objective

1. To assess the level of compliance to standard infection control precautions among health workers in Al-Shabbah children hospital, Juba, South Sudan
2. To analyse the institutional factors associated level of compliance to standard infection control precautions among health workers in Al-Shabbah children hospital, Juba, South Sudan
3. To establish the individual factors associated level of compliance to standard infection control precautions among health workers in Al-Shabbah children hospital, Juba, South Sudan

1.4 Research questions

1. What is the level of compliance to standard infection control precautions among health workers in Al-Shabbah children hospital, Juba, South Sudan?
2. What are the institutional factors associated level of compliance to standard infection control precautions among health workers in Al-Shabbah children hospital, Juba, South Sudan?
3. To establish the individual factors associated level of compliance to standard infection control precautions among health workers in Al-Shabbah children hospital, Juba, South Sudan

1.5 Justification of the study

Occupational health and safety is one of the prioritized health targets in the currently operational sustainable development goals, and although that is the case, achievement of the OHS SGD targets will require focus on the most prone work forces, among which are health care workers. To further augment the achievement of that target(s), there will be need to determine the extent which those populations comply with safety guidelines within their workplaces and any determinants of the same. That will be especially important in developing countries like South Sudan where the health systems are in the development stages as well. That however calls for studies to uncover the two aspects (compliance and its associated factors), which are currently few, especially in countries like South Sudan. Even though many studies have been conducted in other countries (Sahiledengle, 2018; Morka, 2015; Sharm, 2014; Unekea, 2014; Alice, 2013; Sarani, 2014; Jain, 2012; McGaw, 2012), very few are available in the South Sudan context. It was therefore justifiable to conduct this study to assess the factors associated with compliance to standard infection control precautions among health workers in Al-Shabbah children hospital, which is one of the referral hospitals in South Sudan.

1.6 Significance of the study

Health care providers, planners and evaluators should not ignore this high morbidity and life threatening infection levels. On top of these, unless appropriate infection prevention is compiled to, health care facilities can be the source of infection and epidemic disease for not only the health care workers but the community at large. It is thus of significance that, a study of the determinants of compliance to standard infection control precautions among health care workers at Al-Shabbah children’s hospital – Juba is done.

Significance to the health workers

The findings of this study will show the health workers at the study site, which area(s) of infection control they are observing most, and which they are less compliant with; this might enable them to know the gaps they have to specifically work on, their occupational health and safety.

Significance to policy/regulation review and or development

Findings and recommendations of the study will be useful for ensuring that barriers to compliance are minimized at hospital settings. Recommendations emerging from this study will be useful for improving occupational health and safety in hospitals. The health care workers will be the ultimate beneficiary of interventions that will be based on findings from the study

The findings of this study will reveal the actual performance of infection prevention and control practice and the factors that influence compliance with infection prevention standard precautions among nurses. This will be a good basis for designing and implementation of effective interventions for sustaining the observed positive behaviours and sealing the identified performance gaps among the nurses working at Al-Shabbah children’s hospital.

Significance to generating new knowledge

This study might improve knowledge and practice on issues pertaining to occupational health and safety in Juba where little is known about this public health aspect. It will also contribute towards nursing research in Uganda and it will develop knowledge. This study will lead to health improvement of the health care personnel. As a result the quality of health care will be improved because a healthy nursing community will result in improved patient care.

This study will also act as an information source and as well as a guideline for other researches. This could be used to validate infection control guidelines to design and improve new approaches to comply with the changing needs of the patients.

1.6 Scope of the study

1.6.1 Geographical scope

Al-Shabbah is government owned national children referral hospital located in Juba, the capital of South Sudan. The hospital has a bed capacity of 150, and health care work force of about 72 health care personnel.  The hospital provides services ranging from general medicine, nutrition, laboratory services, emergency services and intensive care as well.

1.6.2 Content scope

This study was delimited to assessing compliance to infection control precautions among health care workers, which in this study included; compliance to hand hygiene practices, PPE use and needle recapping

1.7  Conceptual framework

Figure 1 below shows the variables that were included in the study content scope, which were three in number, two being independent and one being dependent. The independent variables were; Institutional factors and Individual factors. The dependent variable was compliance to Infection control precautions including; Hand hygiene guidelines, PPE use, and Needle recapping

                Independent variables

C