KNOWLEDGE, ATTITUDE, AND PRACTICE OF STANDARD PRECAUTIONS AMONG HEALTH-

CARE WORKERS IN ABEOKUTA SOUTH, OGUN STATE

ABSTRACT

Standard precautions aim to safeguard healthcare workers against potential exposure to infected blood and bod-
ily fluids by implementing fundamental infection prevention principles. These principles encompass various
measures, such as practicing proper hand hygiene, utilizing suitable personal protective equipment (such as
gloves, masks, face shields, and gowns), preventing needlestick injuries and other sharp instrument accidents,
adhering to respiratory hygiene and cough etiquette, maintaining a clean environment, employing appropriate
linen handling procedures, ensuring proper waste disposal, and handling patient care equipment appropriately.
Additionally, standard precautions also serve to protect patients by minimizing the risk of healthcare personnel
transmitting infections through their hands or equipment during the provision of healthcare services. This re -
search aims to assess the knowledge, attitude, and practice of standard precautions (SP) among healthcare work-
ers (HCWs) in Abeokuta South, Ogun State. A total of 250 HCWs were surveyed using a structured question-
naire. The results revealed that majority of the respondents were females (65.6%) aged between 21-25 years
(65.6%), single (95.6%), and of Christian faith (98.4%). Additionally, 61.2% were medical students, and 33.2%
were on ward posting. In terms of knowledge, 92% of respondents knew that SP protects HCWs and prevents
infection spread, while 87.2% agreed that SP is indicated while attending to all patients. However, only 14.8%
were aware of hospital policies enhancing compliance to SP. Regarding attitude, 38.2% agreed that SP protects
healthcare workers and patients, and 68.8% strongly agreed that curriculum should include SP training. Prac-
tice-wise, 74.8% knew that syringes cannot be reused, but only 24.2% practiced proper hand hygiene after glove
removal. The reserach highlights the need for improved education and policy implementation to enhance SP
compliance among HCWs. Measures such as regular training, availability of PPE, and supportive supervision
should be implemented to ensure adherence to SP guidelines, thereby reducing healthcare-associated infections.

CHAPTER ONE
1
 GENERAL INTRODUCTION

1.0 Introduction

In the healthcare setting, the implementation of standard precautions is crucial for preventing the transmission

of infectious diseases between healthcare workers (HCWs) and patients. Standard precautions encompass a set

of infection control practices that aim to protect both HCWs and patients from potential exposure to bloodborne

pathogens and other infectious agents. Adherence to standard precautions requires a combination of knowledge,

attitude, and practice among HCWs. Abeokuta South, located in Ogun State, Nigeria, is home to several health -

care facilities providing services to a large population. Infection control measures, particularly the adherence to

standard precautions, are critical to reducing the risk of healthcare-associated infections and promoting patient

safety. However, the successful implementation of standard precautions relies on the knowledge, attitude, and

practice of HCWs. Understanding the current knowledge, attitude, and practice of standard precautions among

HCWs in Abeokuta South is essential for identifying gaps and designing effective interventions to improve

compliance. This chapter provides an overview of the research topic, the rationale for the study, the research ob-

jectives, and the organization of the thesis.

1.1 Background Information

Effective infection control practices are crucial in healthcare settings to prevent the transmission of infectious

diseases. Healthcare workers, who are at the forefront of patient care, play a vital role in implementing these

practices. Standard precautions, recommended by the World Health Organization (WHO), are a set of guidelines

that integrate various infection control measures to protect both HCWs and patients from potential exposure to

bloodborne pathogens and other infectious agents. Standard precautions are basic level of infection control pre-

cautions which are to be used as a minimum in the care of all patients. Health care workers including clinical

medical and nursing students are exposed to blood and other body fluids in the course of daily interaction with
2
patients1. These are potential sources of infections. Common infections healthcare workers are prone to in a

healthcare setting may include Hepatitis B virus, Hepatitis C virus and Human immunodeficiency virus infec -

tions2. Standard precautions are meant to reduce the risk of blood borne and other pathogens, from both recog-

nized and unrecognized sources. Exposure to blood can result from percutaneous injury (needle stick or other

sharps) and mucocutaneous injury (splash of blood or other body fluids into the eyes, nose or mouth) or blood

contact with non-intact skin3.

Standard precautions are designed to protect healthcare workers from being exposed to potentially infected

blood and body fluids by applying the fundamental principles of infection prevention 4. These principles include:

hand hygiene, use of appropriate personal protective equipment (like gloves, mask, face shield, gown), preven-

tion of needle stick and injuries from other sharp instruments, respiratory hygiene and cough etiquette, environ-

mental cleaning, use of linens, proper waste disposal and patient care equipment 5. Standard precautions are also

intended to protect the patient by ensuring that health care personnel do not transmit infections to patients

through their hands or equipment during health care 6. The successful implementation of standard precautions re-

lies on several factors, including the knowledge, attitude, and practice of HCWs. Knowledge refers to the under-

standing and awareness of the guidelines, protocols, and best practices related to standard precautions. It in-

volves knowing the correct procedures for hand hygiene, the use of personal protective equipment (PPE), safe

handling and disposal of sharps, and other preventive measures.

In the healthcare setting, the risk of infectious diseases transmission is a significant concern for both patients

and healthcare workers (HCWs). Standard precautions are a set of guidelines developed by the World Health

Organization (WHO) to prevent the transmission of infections in healthcare facilities. Adherence to standard

precautions is crucial in reducing the risk of infection for both HCWs and patients. However, the effectiveness

of these precautions relies on the knowledge, attitude, and practices of HCWs. This research aims to assess the

3
knowledge, attitude, and practice of standard precautions among HCWs in Abeokuta South, Ogun State.

1.2 Problem Statement

Non-compliance with standard precautions among healthcare workers (HCWs) poses significant risks and nega-

tive implications for both HCWs and patients. Inadequate adherence to these precautions can lead to the trans-

mission of infectious diseases, increased healthcare-associated infections (HAIs), prolonged hospital stays, in-

creased healthcare costs, and even mortality. The burden of these negative outcomes in the health sector cannot

be underestimated. One of the negative implications of non-compliance with standard precautions is the in-

creased risk of healthcare-associated infections. HAIs contribute to patient morbidity and mortality, prolong

hospital stays, and impose a substantial economic burden on healthcare systems. These infections can be caused

by various pathogens, including multidrug-resistant organisms, and can lead to severe complications, particu-

larly in immunocompromised patients. Furthermore, the inadequate implementation of standard precautions can

result in outbreaks of infectious diseases within healthcare facilities. Such outbreaks not only affect patients but

also impact the HCWs themselves, leading to absenteeism due to illness and further straining the healthcare sys-

tem's capacity to deliver quality care.

Strict enforcement of standard precautions is therefore necessary to address these challenges and ensure patient

and HCW safety. Adherence to these precautions can significantly reduce the risk of HAIs, protect HCWs from

occupational exposure to infectious agents, and maintain a safe healthcare environment. When implemented ef-

fectively, standard precautions contribute to improved patient outcomes, reduced healthcare costs, and enhanced

public health. Existing practices in healthcare often reveal gaps in the knowledge, attitude, and practice of stan -

dard precautions among HCWs. Studies have reported instances of improper hand hygiene, inconsistent use of

personal protective equipment (PPE), inappropriate handling and disposal of sharps, and suboptimal adherence

to safe injection practices. These practices increase the risk of cross-contamination and transmission of infec-

4
tious agents between HCWs, patients, and the community.

This research aims to address the problem of non-compliance with standard precautions among HCWs in

Abeokuta South, Ogun State. By assessing the knowledge, attitude, and practice of standard precautions, the

study will identify specific areas of concern and gaps in compliance. The findings will provide valuable insights

for designing targeted interventions, educational programs, and policies to enhance adherence to standard pre-

cautions in healthcare facilities.

1.3 Research Objectives

The general objective of this research is to assess the knowledge, attitude, and practice of standard precautions

among HCWs in Abeokuta South, Ogun State. The specific objectives include:

1. To evaluate the level of knowledge regarding standard precautions among HCWs.

2. To assess the attitudes of HCWs towards the implementation of standard precautions.

3. To determine the extent to which HCWs adhere to standard precautions in their daily practice.

4. To identify factors influencing the knowledge, attitude, and practice of standard precautions among

HCWs.

5. To provide recommendations for improving the implementation of standard precautions in healthcare fa-

cilities in Abeokuta South.

1.4 Significance of the Study

The findings of this research will have significant implications for healthcare workers (HCWs) in Abeokuta

South, Ogun State. Assessing the knowledge, attitude, and practice of standard precautions among HCWs will

5
aid in the identification of gaps and areas that require improvement. This information can be used to develop

targeted interventions and educational programs to enhance HCWs' understanding of infection control practices

and promote their adherence to standard precautions. Improved knowledge and practice of standard precautions

will not only protect HCWs from occupational hazards and reduce the risk of healthcare-associated infections

but also enhance their confidence and job satisfaction. When HCWs feel safe and supported in their workplace,

it can positively impact their overall well-being and contribute to better patient care.

The Ministry of Health in Ogun State will greatly benefit from the findings of this study. The findings will

hopefully provide information on the current status of adherence to standard precautions among HCWs in

Abeokuta South. This information can be used by policymakers and public health officials to develop evidence-

based strategies and policies to improve infection control practices in healthcare facilities. The study's findings

can guide the formulation of guidelines, protocols, and training programs that promote standardized, safe, and

effective healthcare practices.

This research will add to the existing body of knowledge in the field of infection control and standard precau-

tions. Hence, this research will also serve as a reference for future studies and can guide the development of tar -

geted interventions and policies in similar healthcare settings.

1.5 Scope and Limitations

This study will focus on healthcare workers in Abeokuta South, Ogun State, Nigeria. The research will include

various healthcare settings, such as hospitals, clinics, and primary healthcare centers. The study's limitations

may include self-reporting bias, as participants might overstate their adherence to standard precautions due to

social desirability bias. The research will also be limited by the sample size and the cross-sectional nature of the

study, which may restrict the generalizability of the findings.

6
 CHAPTER TWO

LITERATURE REVIEW

2.0 INTRODUCTION

Literature review is an insightful analysis and evaluation of each research source as it relates to the objectives of

the current study10.A review of related literature helps identify what other researchers have done and reported

on the research problem. It also helps identify areas of controversy or disagreement and discover gaps in exist-

ing knowledge in the problem area. This chapter presents a review of literature on the knowledge, attitude and

practice of standard precautions among health care providers including medical and nursing students from the

global, regional, and national and district perspectives.

The review explored reports on the knowledge, attitude and practice of standard precautions among health care

providers especially the medical and nursing students in order to identify information, ideas and methods that

are relevant to the present study. It identified findings and views from previous studies in order to provide intel -

lectual context for positioning the study in relation to those other studies. It helped in widening the researcher’s

knowledge base, increase his depth of knowledge regarding standard precautions, and justify the significance of

the study.

2.2.0REVIEW OF LITERATURE

The researchers looked at various reports and studies conducted in different countries as well as in Nigeria re-

lated to the research topic. The focus of the review was on the knowledge Attitude, and practice of standard

precautions among health care workers in Abeokuta south Ogun state.

The following keywords were used as the topic of the review:

7
 Standard precautions

 Knowledge of standard precautions

 Attitude towards standard precautions

 Practice of standard precautions

2.1.1STANDARD PRECAUTIONS

Historical Background

The CDC (Centre for Disease Control and prevention) first published a document in 1983 entitled ’Guidelines

for Isolation Precautions in Hospital, which contained a section on precautions for blood and body fluids. The

section recommended preventive measures to be taken when a patient is known or suspected to be infected with

blood-borne pathogens11 .In 1987, CDC published ‘Recommendations for Prevention of HIV Transmission in

Healthcare Settings’.

In contrast to the 1983 guidelines, the Recommendations suggested that precautions be consistently used for all

patients regardless oftheir blood-borne infection status. This extension became known as the Universal Precau -

tions and it was defined by CDC (1996) as a set of precautions designed to prevent the transmission of HIV,

HBV and other blood-borne pathogens when providing first aid or health care. Under the universal precautions,

blood and certain body fluids of all patients were considered potentially infectious for HIV, HBV and other

blood-borne pathogens. Thus, universal precautions replaced and eliminated the need for the isolation category

"blood and body fluid precautions" in the 1983 CDC Guidelines for Isolation Precautions in Hospitals. Univer-

sal precautions was applicable to blood, other body fluids containing visible blood, semen, vaginal secretions,

tissues, and the cerebrospinal, synovial, pleural, peritoneal, pericardial, and amniotic fluids. However, the uni-

versal precautions did not apply to faeces, nasal secretions, sputum, sweat, tears, urine, and vomitus unless they
8
contained visible blood. It did not also apply to saliva except when visibly contaminated with blood or in the

dental setting where blood contamination of saliva is predictable 12. Universal precautions recommended the use

of protective barriers such as gloves, gowns, aprons, masks, or protective eyewear, which can reduce the risk of

exposure of the health care worker's skin or mucous membranes to potentially infective materials. It recom-

mended that all health care workers take precautions to prevent injuries caused by needles, scalpels, and other

sharp instruments or devices.

However, additional precautions were needed for diseases transmitted by air and droplet contacts in order to

protect health care workers from occupationally acquired pulmonarytuberculosis, severe acute respiratory syn-

drome (SARS), and, recently, human influenza. These additional precautions included airborne, droplets and

contact precautions. Airborne precautions would reduce the transmission of diseases spread by air. Airborne

transmission occurs when droplet nuclei less than 5 micron in size are disseminated in the air for long periods.

Diseases spread by this mode include active pulmonary tuberculosis, measles, chickenpox and haemorrhagic

fever. Droplet precautions control the transmission of pneumonias, pertussis, diphtheria, influenza type B,

mumps, and meningitis. Droplets transmission occurs when there is adequate contact between the mucous mem-

brane of the nose and mouth or conjunctivae of a susceptible person and large droplets greater than 5 microns 13.

Percutaneous exposures are the most common routes of exposure to blood-borne pathogens in health care set-

tings. Globally, injections are one of the most common health care procedures and they are often abused. Injec-

tion safety practices could significantly reduce occupational risks due to blood-borne pathogens in health care

settings. For example, wearing gloves as a protective barrier can reduce the incidence of contamination of the

hands but it cannot prevent penetrating injuries caused by needles or other sharp instruments. The CDC (1999)

reported that out of 191 health care workers reported to national surveillance in the United States, 55 had re-

ported occupational exposure to HIV, with a baseline negative and subsequent documented seroconversion. Of

9
the 55 health care workers, 47 sustained percutaneous injuries, five had mucocutaneous exposure, and two had

both percutaneous and mucocutaneous exposures.

In a study conducted by CDC (1997), injections with safety devices reduced injuries by 23%, while the re-use

of injection equipment accounted for an estimated 5% of new HIV infections14

In 1996, CDC published new guidelines, called Standard Precautions, for isolation precautions in hospitals. The

standard precautions synthesize the major features of body substance isolation and universal precautions to pre-

vent transmission of a variety of organisms. Standard precautions were developed for use in hospitals and may

not necessarily be indicated in other settings where universal precautions are used, such as childcare settings

and schools.

Standard precautions is based on the principle that all blood, body fluids, secretions, excretions except sweat,

non-intact skin, and mucous membranes may contain transmissible infectious agents. Standard precautions in-

cludes a group of infection prevention practices that apply to all patients regardless of whether they have sus -

pected or confirmed infection status in any setting in which healthcare is delivered. These practices include

hand hygiene, use of gloves, gown, mask, eye protection or face shield (depending on the anticipated exposure),

and safe injection practices. In addition, equipment or items in the patient’s environment likely to have been

contaminated with infectious body fluids must be handled in a manner to prevent the transmission of infectious

agents15

The application of standard precautions during patient care is determined by the nature of the health care

worker-patient interaction and the extent of anticipated blood, body fluid, or pathogen exposure. For some inter-

actions, e.g. Performingvenepuncture, only gloves may be needed, but for others, e.g. intubations, use of

gloves, gown, and face shield or mask and goggles is necessary.

10
Identification of patients infected with blood-borne pathogens cannot be reliably made through medical history

and physical examination, and it is not feasible or cost-effective to test all patients for all pathogens prior to giv -

ing care. Standard precautions are therefore recommended for use on all patients regardless of diagnosis and

treatment setting. Decision regarding the level of precautions to use will depend on the natureof the procedure

and not on the actual or assumed serological status of the patient. It is not safe to take precautions only with

people from so-called “high-risk groups” because many people belonging to such groups may not necessarily be

infected while many infected people may not even be from the high-risk groups.

2.1.2 COMPONENTS OF THE STANDARD PRECAUTIONS

The infection control problems that emerge during outbreak investigations often indicate the need for new rec -

ommendations or reinforcement of existing infection control recommendations to protect patients. Because such

recommendations are considered a standard of care and may not be included in other guidelines, they are usu-

ally added to the standard precautions. Three such areas of practice that have been added are respiratory hy -

giene/cough etiquette, safe injection practices and use of masks for the insertion of catheters or injection of ma -

terial into spinal or epidural spaces via lumbar puncture (e.g. milligram, spinal or epidural anaesthesia) 16

The transmission of SARS-CoV in emergency departments by patients and their family members during the

widespread of SARS outbreaks in 2003 highlighted the need for vigilance and prompt implementation of infec -

tion control measures at the first point of encounter within a healthcare setting (e.g. reception and triage areas in

emergency departments, outpatient clinics, and physician offices). The strategy proposed has been termed respi-

ratory hygiene/cough etiquette and itis intendedto be incorporated into infection control practices as a new com -

11
ponent of standard precautions. The strategy is targeted at patients and accompanying family members and

friends with undiagnosed transmissible respiratory infections, and applies to any person with signs of illness in-

cluding cough, congestion, rhinorrhoea, or increased production of respiratory secretions when entering a

healthcare facility. The elements of respiratory hygiene/cough etiquette include:

 Education of healthcare facility staff, patients and visitors;

 Posted signs in language(s) appropriate to the population served, with instructions to patients and ac-

companying family members or friends;

 source control measures (e.g. covering the mouth/nose with a tissue when coughing and prompt dis-

posal of used tissues, using surgical masks on the coughing person when tolerated and appropriate);

 hand hygiene after contact with respiratory secretions and;

 Spatial separation, ideally more than three feet, of persons with respiratory infections in common wait-

ing areas when possible.

Covering sneezes and coughs and placing masks on coughing patients are proven means of source containment

that prevent infected persons from dispersing respiratory secretions into the air7. Masking may be difficult in

some settings, e.g. Paediatrics, in which case emphasis by necessity may be on cough etiquette. Physical prox-

imity of less than 3 feet has been associated with an increased risk for transmission of infections via the droplet

route, e.g. N. meningitides and group A Streptococcus, and therefore supports the practice of distancing infected

persons from others who are not infected. The measures stated above should be effective in decreasing the risk

of transmission of pathogens contained in large respiratory droplets, e.g. Influenza virus, adenovirus, Bordetel-

lapertussis and Mycoplasmapneumonia.

Healthcare personnel are advised to observe droplet precautions, i.e. wear a mask, and hand hygiene when ex-

amining and caring for patients with signs and symptoms of a respiratory infection. Healthcare personnel who

12
have a respiratory infection are advised to avoid direct contact with patients, especially with high-risk patients.

If this is not possible, then a mask should be worn while providing patient care.

2.1.3ELEMENTS OF THE STANDARD PRECAUTIONS

Health care workers should assume that every person is potentially infected or colonized with an organism that

could be transmitted in the healthcare setting and, therefore, should apply the following infection control prac-

tices while delivering health care15.

Hand Hygiene

This has been cited frequently as the most important practice in reducing the transmission of infectious agents

in health care settings and it is an essential element of the standard precautions. Hand hygiene includes hand

washing with both plain or antiseptic-containing soap and water and the use of alcohol based products (gels,

foams or rinses), which do not require the use of water16. Hand hygiene involves:

 Avoiding unnecessary touching of surfaces that are close to the patient to prevent contamination of

clean hands by environmental surfaces and transmission of pathogens from contaminated hands to surfaces;

 Hand washing with either a non-antimicrobial soap and water or an antimicrobial soap and water when

hands are visibly dirty, contaminated with proteinaceous material, or visibly soiled with blood or body fluids;

 Decontaminating hands in the clinical situations described above if hands are not visibly soiled, or after

removing visible material with non-antimicrobial soap and water. The preferred method of hand decontamina-

tion is the use of an alcohol-based hand rub, but, alternatively, hands may be washed with an antimicrobial soap

and water. However, frequent use of alcohol-based hand rub immediately following hand washing with non-an-

timicrobial soap may increase the frequency of dermatitis.

Hand hygiene should be performed:

13
 Before having direct contact with patients;

 After having contact with blood, body fluids, excretions, mucous membranes, non-intact skin, or wound

dressings;

 After contact with a patient's intact skin, e.g., when taking pulse or blood pressure or lifting a patient;

 If hands will be moving from a contaminated-body site to a clean-body site during patient care;

 After contact with inanimate objects (including medical equipment) in the immediate vicinity of the pa -

tient and;

 After removing gloves. Hand washing with non-antimicrobial soap and water or with antimicrobial

soap and water is recommended if contact with spores, e.g. Clostridium difficile or Bacillus anthracis, is likely

to have occurred.

The physical action of washing and rinsing hands under such circumstances is recommended because alcohols,

chlorhexidine, iodophors, and other antiseptic agents have poor activity against spores. Artificial fingernails or

extenders should not be worn if duties include direct contact with patients at high risk for infection and 14 asso-

ciated adverse outcomes, e.g. those in intensive care units (ICUs) or operating rooms 16. Organizational policy

should be developed on the wearing of non-natural nails by healthcare personnel who have direct contact with

patients outside of the groups specified above.

Personal Protective Equipment

Personal Protective Equipment refers to a variety of barriers used alone or in combination to protect mucous

membrane airways, skin and clothing from contact with infectious agents. The selection of PPE depends on the

nature of patient interaction and/or the likely mode(s) of transmission 16. The following principles of use should

be observed:

14
 PPE should be worn when the nature of the anticipated patient interaction indicates that contact with

blood or body fluids may occur.

 Prevent contamination of clothing and skin during the process of removing PPE.

 PPE should be removed and discarded before leaving the patient's room or cubicle.

The following PPE are recommended for implementing standard precautions:

Gloves

Under standard precautions, gloves should be worn when it can be reasonably anticipated that contact with

blood or other potentially infectious materials, mucous membranes, non-intact skin, or potentially contaminated

intact skin, e.g. of a patient incontinent of stool or urine, could occur. Gloves with fit and durability appropriate

to the task should be used.

Disposable medical examination gloves should be worn for providing direct patient care such as wound dress -

ing, phlebotomy, setting intravenous infusion, etc. For cleaning the environment or medical equipment, dispos-

able medical examination gloves or re-usable utility gloves should be worn. Gloves should be removed after

contact with a patient and/or the surrounding environment (including medical equipment) using proper tech-

niques to prevent hand contamination. The same pair of gloves should not be worn for the care of more than one

patient and gloves should not be re-used, because this practice has been associated with the transmission of

pathogens. Gloves should be changed during patient care if the hands will move from a contaminated body site,

e.g. perineal area, to a clean body site, e.g. face16

Gowns

Gowns should be appropriate for protecting the skin and preventing soiling or contamination of clothing during

15
procedures and patient care when contact with blood, body fluids, secretions, or excretions is anticipated. A

gown should be worn for direct patient contact if the patient has uncontained secretions or excretions and it

should be removed and hand hygiene performed before leaving the patient’s environment. Gowns should not be

re-used even for repeated contacts with the same patient. Routine donning of gowns upon entrance into a high-

risk unit, e.g. intensive care unit, is not indicated16

Masks and Goggles

PPE should be used to protect the mucous membranes of the eyes, nose and mouth during procedures and pa-

tient care activities that are likely to generate splashes or sprays of blood, body fluids, secretions and excretions.

Select masks, goggles, face shields, and combinations of each according to the need anticipated by the task to

be performed.

A face shield that fully covers the front and sides of the face or a mask and goggles (in addition to gloves and

gown) should be worn during aerosol-generating procedures, e.g. bronchoscopy, suctioning of the respiratory

tract (if not using in-line suction catheters), and endotracheal intubation in patients who are not suspected of be-

ing infected with an agent for which respiratory protection is otherwise recommended, e.g. M. tuberculosis,

SARS or haemorrhagic fever viruses.

Respiratory Hygiene/Cough Etiquette

Healthcare personnel should be educated on the importance of source control measures in containing respiratory

secretions to prevent droplet and fomite transmission of respiratory pathogens, especially during seasonal out-

breaks of viral respiratory tract infections in communities, e.g. influenza, adenovirus, parainfluenza virus. The

following measures should be implemented to contain respiratory secretions in patients and accompanying indi -

16
viduals who have signs and symptoms of a respiratory infection, beginning at the point of initial encounter in a

healthcare setting, e.g. triage, reception, and waiting areas in emergency departments, outpatient clinics, and

physician offices:

 Post signs at entrances and in strategic places, e.g. elevators and cafeterias, within ambulatory and in-

patient settings with instructions to patients and other persons with symptoms of a respiratory infection to cover

their mouth/nose when coughing or sneezing, use and dispose of tissues, and perform hand hygiene after hands

have been in contact with respiratory secretions.

 Provide tissues and no-touch receptacles, e.g. foot pedal operated lid or open and plastic-lined waste

basket, for disposal of tissues.

 Provide resources and instructions for performing hand hygiene in or near waiting areas in ambulatory

and in-patient settings; provide conveniently located dispensers of alcohol-based hand rubs and, where sinks are

available, supplies for hand washing.

 During periods of increased prevalence of respiratory infections in the community, e.g. as indicated by

increased school absenteeism, increased number of patients seeking care for a respiratory infection, offer masks

to coughing patients and other symptomatic persons, e.g. persons who accompany ill patients, upon entry into

the facility or medical office and encourage them to maintain special separation, ideally a distance of at least 3

feet from others in common waiting areas. Some facilities may find it logistically easier to institute this recom -

mendation year round as a standard of practice16.

Patient Placement

The potential for transmitting infectious agents should be included in patient placement decisions. Patients who

pose a risk for transmission to others, e.g. uncontained secretions excretions or wound drainage and infants with

suspected viral respiratory or gastrointestinal infections, should be placed in a single-patient room when avail-

17
able. Patient placement should be based on the following principles:

 Route(s) of transmission of the known or suspected infectious agent

 Risk factors for transmission in the infected patient

 Risk factors for adverse outcomes resulting from a hospital acquired infection (HAI) in other patients in

the area or room being considered for patient placement

 Availability of single-patient rooms

 Patient options for room sharing, e.g., cohort patients with the same infection16

Patient Care Equipment and Instruments/Devices

Policies and procedures should be established for containing, transporting, and handling patient care equipment

and instruments/devices that may be contaminated with blood or body fluids. Organic materials should be re-

moved from critical and semi-critical instruments/devices using recommended cleaning agents before high-level

disinfection and sterilization to enable effective disinfection and sterilization process 16.

PPE should be used according to the level of anticipated contamination when handling patient care equipment

and instruments/devices that are visibly soiled or may have been in contact with blood or body fluids 16

Care of the Environment

Policies and procedures should be established for routine and targeted cleaning of environmental surfaces as in-

dicated by the level of patient contact and degree of soiling. Surfaces that are likely to be contaminated with

pathogens should be cleaned and disinfected more frequently, including those surfaces that are close to the pa-

tient (e.g. bed rails, over bed tables) and frequently touched in the patient care environment (e.g. door knobs,

surfaces in and surrounding toilets in patient rooms), compared to other surfaces (e.g. horizontal surfaces in

waiting rooms). The efficacy of in-use disinfectants should be reviewed when evidence of continuing trans-

18
mission of an infectious agent (e.g. rotavirus, C. difficile, norovirus) may indicate resistance to the in-use prod -

uct and change to a more effective disinfectant as indicated. In facilities that provide health care to paediatric

patients or have waiting areas with child play toys, e.g. obstetrics/gynaecology offices and clinics, policies and

procedures should be established for cleaning and disinfecting toys at regular intervals.

Use the following principles in developing such policy and procedures:

 Select play toys that can be easily cleaned and disinfected.

 Do not permit use of stuffed furry toys if they will be shared.

 Clean and disinfect large stationary toys (e.g. climbing equipment) at least once a week and whenever

visibly soiled.

 If toys are likely to be mouthed, rinse with water after disinfection or wash in a dishwasher.

 When a toy requires cleaning and disinfection, do so immediately or store in a designated labelled con-

tainer separate from toys that are clean and ready for use. Multi-use electronic equipment should be included

in policies and procedures for preventing contamination and for cleaning and disinfection, especially those

items that are used by patients, those used during delivery of patient care, and mobile devices that are moved in

and out of patientrooms frequently16.

Textiles and Laundry

Used textiles and fabrics should be handled with minimum agitation to avoid contamination of air, sur-

faces and persons. If laundry chutes are used, ensure that they are properly designed, maintained, and used in a

manner to minimize dispersion of aerosols from contaminated laundry16.

Safe Injection Practices

The following recommendations apply to the use of needles, cannulas that replace needles, and, where applica-

19
ble, intravenous delivery systems.

 Use aseptic technique to avoid contamination of sterile injection equipment.

 Do not administer medications from a syringe to multiple patients, even if the needle or cannula on the

syringe is changed. Needles, cannula, and syringes are sterile, single-use items; they should neither be re-used

for another patient nor allowed to contact a medication or solution that might be used for another patient.

 Fluid infusion and administration sets, i.e. intravenous bags, tubing and connectors, should be used for

one patient only and disposed appropriately after use. Consider a syringe or needle/cannula contaminated once

it has been used to enter or connect to a patient’s intravenous infusion bag or administration set.

 Use single-dose vials for parenteral medications whenever possible.

 Do not administer medications from single-dose vials or ampoules to multiple patients and do not com-

bine leftover contents for later use.

 If you must use multidose vials, both the needle or cannula and syringe used to access the multidose vial

must be sterile.

 Do not keep multidose vials in the immediate patient treatment area; store in accordance with the manu-

facturer's recommendations and discard if sterility is compromised or questionable.

 Do not use bags or bottles of intravenous solution as a common source of supply for multiple patients16.

2.1.4Transmission-based Precautions

Transmission-based precautions are for patients documented or suspected to be infected with highly transmissi-

ble or epidemiologically important pathogens, for which additional precautions beyond the standard precautions

are needed to interrupt transmission in hospitals.

There are three types of transmission-based precautions: air-borne precautions, droplet precautions, and contact

precautions. They may be combined for diseases that have multiple routes of transmission and when used either
20
singularly or in combination, they should be used in addition to the standard precautions. Transmission-based

precautions remain in effect for a limited period, i.e. while the risk of transmission persists or for the duration of

the illness, then they are discontinued. The duration for most infectious diseases reflects known patterns of per-

sistence and shedding of infectious agents associated with the natural history of the infectious process and treat -

ment16.

Air-borne precautions are to reduce the risk of air transmission of infectious agents. Air transmission occurs

through the dissemination of either air-borne droplet nuclei (small particleresidues {5 µm or smaller} of evapo-

rated droplets that may remain suspended in the air for long periods) or dust particles containing the infectious

agent. Microorganisms carried in this manner can be dispersed widely by air currents and may become inhaled

by or deposited on a susceptible host within the same room or over a longer distance from the source patient,

depending on environmental factors. Therefore, special air handling and ventilation are required to prevent air

transmission. Air-borne precautions apply to patients known or suspected to be infected with epidemiologically

important pathogens that can be transmitted by air, such as M. tuberculosis, measles, chickenpox, and dissemi-

nated herpes zoster. In acute care hospital and long-term setting, it involves placement of the patient in an air-

borne infection isolation room (AIIR). AIIR is a single-patient room that is equipped with special air handling

and ventilation capacity that meet the required standards, i.e. Monitored negative pressure relative to the sur-

rounding area, twelve air exchanges per hour for new construction and renovation and six air exchanges per

hour for existing facilities, and air exhausted directly to the outside. In the event of an outbreak or exposure in-

volving large number of patients who require air-borne precautions, it also involves placing together (cohorting)

patients who are presumed to have the same infection (based on clinical presentation and diagnosis when

known) in areas of the facility that are away from other patients, especially patients who are at increased risk for

infection (e.g. immunocompromised patients).

21
Again, air-borne precautions can be applied in this setting using temporary portable solutions, e.g. exhaust fan,

to create a negative pressure environment in the converted area of the facility and discharging air directly to the

outside, away from people and air intakes16.

2.1.5 Common Infections Transmissible Through Occupational Exposure

Three common infectious pathogens known to be transmissible through occupational exposure are HBV, HCV

and HIV. The risk of transmission of these pathogens to health care workers depends on the prevalence of the

disease in the patient population as well as the nature and frequency of exposures.

Transmission of HBV, HCV and HIV can occur through occupational exposure due to percutaneous injury (nee-

dle stick or other sharps injury), mucocutaneous exposure (splash of blood or other body fluids into the eye,

mouth or nose), or blood contact with non-intact skin. However, percutaneous injury, precisely needle stick in-

jury, is the most common form of occupational exposure and the most likely to result in infection. Among 35

million health care workers worldwide, about 3 million experience percutaneous exposure to blood-borne

pathogens each year; 2 million to HBV, 0.9 million to HCV and 750,000 to HIV.

These injuries may result in 15,000 HCV, 70,000 HBV and 1000 HIV infections and more than 90% of these in-

fections occur in developing countries14

Hepatitis B Virus (HBV) Infection

HBV infection is a major infectious hazard for health care workers, and 5-10% of HBVinfected workers be-

come chronically infected. Persons with chronic HBV infection are at risk for chronic liver disease (i.e. chronic

active hepatitis, cirrhosis and primary hepatocellular carcinoma) and are potentially infectious throughout their

lifetime17. The risk of HBV infection is primarily related to the degree of contact with blood in the workplace

and to the hepatitis B antigen (HBeAg) status of the source person. The risk of acquiring HBV infection from

22
occupational exposure depends on the frequency of percutaneous and per mucosalexposures to blood or body

fluids containing blood18. Although percutaneous injuries are among the most efficient modes of HBV transmis-

sion, percutaneous exposures probably account for only a minority of HBV infections among HCWs.

In several investigations of nosocomial hepatitis B outbreaks, most infected HCWs could not recall an overt

percutaneous injury19.However, in some studies, up to one-third of infected HCWs recalled caring for a patient

who was HBsAg-positive20. In addition, HBV has been demonstrated to survive in dried blood at room tempera-

ture on environmental surface for at least one week. Thus, HBV infections that occur in HCWs with no history

of non-occupational exposure or occupational percutaneous injury might have resulted from direct or indirect

blood or body fluid exposures that inoculated HBV into cutaneous scratches, abrasions, burns, other lesions, or

mucosal surfaces21, 22.

Blood contains the highest HBV titres of all body fluids and it is the most important medium of transmission in

the healthcare setting. HBsAg is also found in several other body fluids, including breast milk, bile, cere-

brospinal fluid, faeces, nasopharyngeal washings, saliva, semen, sweat and synovial fluids 23.However, the con-

centration of HBsAg in the body fluid can be 100-1000 folds higher than the concentration of infectious HBV

particles. Therefore, most body fluids are not efficient vehicles of transmission because they contain low quanti-

ties of infectious HBV, despite the presence of HBsAg. Because of the high risk of HBV infection among

HCWs, routine preexposure vaccination of HCWs against hepatitis B and the use of standard precautions to

prevent exposure to blood and other potentially infectious body fluids have been recommended since 1980s 24.

Hepatitis C Virus (HCV) Infection

Hepatitis C virus is one of the hepatitis agents known to be transmitted through blood and blood products. HCV

has been implicated as a major cause of chronic liver disease and hepatocellular carcinoma worldwide, but the

risk of occupational transmission of HCV is low.

23
The average incidence of anti-HCV seroconversion after accidental percutaneous exposure from an HCV posi-

tive source is 1.8% (range 0–7%) 25. One study showed that transmission occurred only from hollow-bore nee-

dles26 .Transmission in HCWs rarely occurs from mucous membrane exposures to blood; no transmission in

HCWs has been documented from intact or non-intact skin exposures to blood. A prevalence of 6% HCV infec-

tion has been reported among healthy blood donors in a Nigerian population in Jos27. The highest prevalence of

12.3% of hepatitis C antibody so far reported among volunteer blood donors in Nigeria was in a study con-

ducted at the University of Benin Teaching Hospital28. The disease prevalence in a population is one of the de-

terminants of the risk of infection transmission among HCWs. There is therefore a need to pay attention to HCV

infection among HCWs in Nigeria.

Human Immunodeficiency Virus

The seroprevalence of HIV varies widely from country to country and from one region to another within the

same country. Sub-Saharan Africa (SSA) has the highest HIV seroprevalence in the world. The 2005 sero-sen -

tinel survey conducted in Nigeria reported an overall HIV seroprevalence 29. This high prevalence in the country

poses an occupational risk to HCWs. The average risk of HIV transmission after percutaneous exposure to HIV

infected blood has been estimated to be approximately 0.3% 30and after a mucous membrane exposure approxi-

mately 0.09%31. Cases of HIV transmission after non-intact skin exposure have been documented 17. Various

studies suggest that several factors may influence the risk of HIV transmission after occupational exposure. In a

retrospective study of HCWs whohad percutaneous exposure to HIV, the risk for HIV infection was foundto be

increased with exposure to a larger quantity of blood from the source person. A needle that was visibly contami-

nated with the patient’s blood was placed directly in a vein or artery 32.

2.1.6 Post-exposure Management

Exposure prevention by adhering to standard precautions remains the primary strategy for the prevention of in-
24
fections due to occupational exposure. Nevertheless, occupational exposure sometimes occurs; therefore, appro-

priate post-exposure management is important for workplace safety. Health care facilities should make available

a system that includes written protocols for prompt reporting, evaluation, counselling, and treatment as well as

follow-up of occupational exposures that might place HCWs at risk for acquiring infections. Again, HCWs

should be educated on the risk for and prevention of infections, including the need to be vaccinated against hep -

atitis B33, 34.

Post-exposure Prophylaxis for HIV

Post-exposure prophylaxis is an important part of post-exposure management. PEP for HIV involves initiation

of antiretroviral regimen as soon as possible preferably within hours rather than days of exposure. The recom-

mended PEP regimen involves the use of two or three antiretroviral agents, depending on the level of risk for

HIV transmission represented by the exposure. If PEP is offered and taken and the source is later determined to

be HIV negative, PEP should be discontinued. However, concerns have been expressed regarding HIV negative

sources being in window period for conversion35

Post-exposure Prophylaxis for HBV Infection

Post-exposure prophylaxis for HBV infection involves the combination of hepatitis B immune globulin (HBIG)

and hepatitis B vaccine. For perinatal exposure to an HBsAG, HBeAg positive mother, a regimen combining

HBIG and initiation of the hepatitis B vaccine series at birth is 85–95% effective in preventing HBV infection.

In the occupational setting, multiple doses of HBIG initiated within one week followingpercutaneous exposure

to HBsAg positive blood will provide an estimated 75% protection from HBV infection 36. Ensure access to clin-

icians who can provide post-exposure care during all working hours including nights and weekends. HBIG,

25
hepatitis vaccine, and antiretroviral drugs for HIV post-exposure prophylaxis should be made available for

timely administration (either by providing access on-site or by creating linkages with other facilities or

providers). Persons responsible for providing post-exposure management should be familiar with the evaluation,

treatment protocols, and facility plan for accessing HBIG, hepatitis B vaccine and antiretroviral drugs for HIV

PEP.

All HCWs should be educated to report occupational exposures immediately after they occur, particularly be-

cause HBIG, hepatitis B vaccine and HIV PEP are most likely to be effective if administered as soon as possible

after exposure. HCWs that are at risk of occupational exposure to infective organisms should be familiar with

the principles of post-exposure management as part of their job orientation and ongoing job training.36

2.1.7 Immunization

Because of their contact with patients or infective materials from patients, many HCWs are at risk of exposure

and possible transmission of some vaccine-preventable diseases. Maintenance of immunity is therefore an es -

sential part of prevention and infection control programs for HCWs. Optimal use of immunizing agents safe-

guards the health of workers and protects patients from becoming infected through exposure to infected work -

ers. Consistent immunization program could substantially reduce both the number of susceptible HCWs in hos-

pitals and attendant risk of transmitting vaccine-preventable diseases to other workers and patients. Any medical

facility that provides direct patient care is encouraged to formulate a comprehensive immunization policy for all

health care workers17

On the basis of documented nosocomial transmission, HCWs are considered to be at significant risk of acquir-

ing or transmitting hepatitis B, influenza, measles, mumps, rubella, and varicella, all of which are vaccine-pre-

ventable and for which immunization is strongly recommended17.

26
2.2 KNOWLEDGE OF STANDARD PRECAUTIONS

Knowledge refers to a recall of information and it is a pre-requisite to appropriate behavioural change. It is the

most important tool for effecting behaviour change 37. The linkage between knowledge and behaviour has been

stated in the cognitive behaviour theory, which states that behaviour is mediated through cognition and that

knowledge is necessary but not sufficient to produce behaviour change 38. This section reviews available litera-

ture on the knowledge of health care providers of standard precautions.

A study to assess health care workers' perception of nosocomial infections and compliance to standard precau -

tions in teaching hospital in southeast Nigeria was carried out.It was cross-sectional study done in 2014 at Fed-

eral University of Agriculture, Abeokuta Teaching Hospital FUNAAB, Enugu. Out of 629, most were females

(64.4%), nurses (46.1%) and within 20–59 years agerange. One hundred and twelve (17.8%) have had at least

one nosocomial infection since employment. Although many received training on SP (62%), only 20.3% were

aware of hospital policy that enhances compliance. Regular access to PPE (56.1%) and hand hygiene (62.8%)

were reported. Most (64.5%) reported total absence of control measures for respiratory infections. Presence of

an epidemic, hospital policies and managing an infectious patient encourage compliance with SP while emer-

gency situations and non-availability of PPE were major constraints.Nosocomial infections occurred most

among orderlies (33.3%) and least among doctors (14%). Those who received training on SP and use of PPE

were less likely to develop nosocomial infections. Standard precautions training and regular provision of

PPEare recommended39.

In another study carried out in FUNAAB to determine the knowledge and practice of universal precautions in

27
tertiary health facility, it was observed that the level of knowledge and compliance with precaution by health

workers in FUNAAB Enugu is low. Low level of training and unequal training exposure among the various oc-

cupations contributes to this.

Two hundred and forty six health workers participated in the study, consisting of 150 females and 96 males. The

male to female ratio was 1: 1.6. Majority of the respondents were between ages 20-49 years. One hundred and

twenty four (50.4%) of the respondents were aware of universal precaution, while 88 (35.8%) knew the correct

definition of universal precaution. Thirty four (13.8%) had received training on universal precaution however

no ward attendant was trained. On multiple regression (P = 0.049) and training (P = 0.006) were the variables

that were predictive of correct definition of universal precaution. Hands gloves were used by 86.6% of the re-

spondents, 32.9% did not re-sheath needles and 43.9% practiced appropriate hand washing.40

A study to assess the knowledge and compliance with universal precautions and their perceived risk of infection

at the workplace in Ibadan, showed poor knowledge of and compliance with standard precautions. Some 77.5%

of the respondents were aware but only 24% had the correct knowledge of the universal precautions. Knowl-

edge was highest (36.9%) among surgical and medical residents; it was 10.8% among laboratory medicine resi-

dents and 15.4% among interns. Significantly, senior registrars had better knowledge than junior doctors 41.

In another study on knowledge, attitude and practices among health care workers (nurses and paramedical staff)

in Sharourah, Kingdom of Saudi Arabia, 21% of nurses and 30% of paramedics were unaware that HIV and

hepatitis C can be transmitted through needle stick injury. Some 74% of the respondents had a history of needle

stick injury, of which only 7% reported the injuries to a doctor for post-exposure prophylaxis. Some 27% used

gloves for phlebotomy procedure always and 29% felt that needles could be recapped after use. Only 61% of

the respondents were aware of the universal precautions42.

Another study carried out on health care workers from a tertiary hospital and two state government-owned sec-
28
ondary health care hospitals in Ibadan, Nigeria, showed that only the tertiary hospital had a safety policy. Identi-

fied barriers to infection control included lack of equipment, inadequate reporting system, and inadequate fund-

ing for the workers. The same study showed that 89.1% of the HCWs were routinely in contact with body fluids

and blood at work and 82.5% reported ever having an accidental splash with body fluids, with blood being the

reported fluid in 69.3% and urine in 50.0% of cases. Laboratory personnel were at greatest risk for contact, fol -

lowed by surgeons. Needle pricks occurred in 59.8% of cases while medication vials were responsible for

22.2%. Sharp injuries were commonest among surgeons. Up to 90.8% of the workers had ever heard about stan-

dard precautions but inadequate fund and equipment hindered them from practicing it43.

A study in Iran investigated knowledge of and practices towards universal precautions among 540 health care

workers and medical students in two university hospitals in Mazandaran Province, Islamic Republic of Iran.

Only 65.8% and 90.0% staff in the two hospitals and 53.5% of medical students had heard about universal pre-

cautions. Overall, there was a low understanding of precautions, except concerning disposal of sharps, contact

with vaginal fluid, use of mask and gown or cleaning spilled blood. Health workers had difficulty distinguishing

between deep body fluids and body secretions that are not considered infectious. Good practices were reported

regarding hand-washing, disposal of needles, and glove, mask and gown usage.

2.3 ATTITUDE TOWARDS STANDARD PRECAUTIONS

Allport (1935) defined an attitude as a mental or neural state of readiness, organized through experience, exert -

ing a directive or dynamic influence on the individual’s response to all objects and situations to which it is re -

lated. A simpler definition of attitude is a mind-set or a tendency to act in a particular way due to both an indi -

vidual’s experience and temperament.

Health care workers may have similar training but their behaviour may vary according to their perception of

risk. Some of the reasons health care workers gave for not complying with universal precautions are habit, lack
29
of time, interference with procedures, discomfort with protective equipment, lack of supplies, carelessness,

concern for costs, unexpected body fluid contact, and the possibility inciting fear in patients.

In a study carried out to determine the level of awareness and practice of Standard precautions SP, among labo-

ratory workers at two tertiary public health facilities in Nigeria.Study participants were 130, mean age: 28.2

years (SD±6.6), number of years in hospital employment: 3.7 years (SD±2.4) and the male to female ratio was

1.8:1. Many (41.5%) were unaware and 25.4% do not observe SP. Participants attest to availability of various

safety devices and equipment including hand gloves (86.2%), disinfectants (84.6%), HBV immunisation

(46.2%) and post exposure prophylaxis (PEP) for HIV and HBV (79.6%).

Attitude to safety is unsatisfactory as 60.0% eat and drink in the laboratory, 50.8% recap needles and 56.9% use

sharps box. Even though 83.1% are willing to take PEP, only 1.5% will present self-following laboratory injury.

This study shows the deficit in the awareness of SP among laboratory personnel and demonstrates that attitude

and practice of safety rules are unsatisfactory. Training and re-training on SP is therefore desired. Counselling to

induce a positive attitudinal change on HBV immunisation and PEP is similarly necessary 44.

A study was conducted in Ile-Ife, Nigeria, on the knowledge and practice of universal precautions among quali-

fying medical and nursing students. Out of 129 students consisting of 103 medical students and 26 nursing stu -

dents, 83 (64.3%) were familiar with the concept of universal precautions. There was a higher level of knowl-

edge among nursing students (77%) than among medical students (61%). Knowledge of what constitutes the

universal precautions was low among the students. Only 38.8% had good knowledge of the precautionary mea-

sures. Prevalence of needle stick injury was high (41.8% of total population) among the study population;

39.8% among medical students and 50% among nursing students45. This high prevalence of needle stick injury

is an evidence of poor adherence to standard precautions.

2.4 PRACTICE OF STANDARD PRECAUTIONS

30
 Practice is the actual application or use of an idea, belief, or method, as opposed to theories relating to it 46. The

universal precautions have been in place since 1987, but there has been extensive documentation of suboptimal

adherence especially in the developing countries. However, non-compliance among health care workers may

vary according to workplace setting, whether rural or urban.

A study conducted among health care workers in rural north India, showed low compliance with eye protective

wears. A high proportion of health care workers were not complying with needle recapping precautions. The

study also showed that compliance with standard precautions was associated with being on the job for a longer

period, knowledge of blood borne pathogen transmission and strong commitment to workplace safety. The

study suggested that interventions to improve compliance to standard precautions among health care workers in

rural north India should address knowledge and understanding as well as safety measures by the employee’s or-

ganizations47.

A related study conducted among health care workers in public and private health care facilities in Abeokuta

metropolis in Nigeria showed that about one-third of all respondents always recapped used needles. Use of re-

capped needles was highest among doctors but less among trained nurses. Less than two-thirds (63%) of the re -

spondents always used personal protective equipment, but more than half (56.5%) had never worn goggles dur -

ing deliveries and surgeries. Almost all (94.5%) of the health care workers observed hand washing after han-

dling patients48.

Odusanya in 2003 conducted a study on awareness and compliance with universal precautions amongst health

workers at an emergency medical service in Lagos, Nigeria, and found that the group of health workers had

good knowledge about exposure risks at work but did not translate their knowledge into safe work practices.

Only 42% of the respondents complied with the universal precautions49.

In another study done in 2011 to determine the Knowledge and practice of standard precautions among health
31
care workers in the Federal Medical Centre, Asaba, Delta State, Nigeria. A total of 167 respondents participated

in this study. The mean age of the HCWs was 36.9 ± 6.8 years made up of 47 (28.1%) doctors, 100 (59.9%)

nurses and 20 (12.0%) laboratory workers. There were more females (65.3%) than males (34.7%) in the study.

One hundred and thirty seven (82.0%) respondents had heard about standard precautions. Only 63 (37.7%) of

them had correct knowledge of it. There was fair practice and adherence to the standard precautions by those

who knew of it.Findings from this study emphasised the need for intensive enlightenment programme to edu-

cate health care workers on various aspects of standard precautions and infection control programmes and poli -

cies50.

32
 CHAPTER THREE

METHODOLOGY

3.1 Study Area

Abeokuta, the capital of Ogun State in southwestern Nigeria, pulsates with history and commerce [1]. Founded

in 1830, it served as a refuge for the Egba people fleeing war [2]. The city's name, translating to "under the

rock" in Yoruba, reflects its location amidst a cluster of rocky outcrops, with the iconic Olumo Rock a major

landmark [2]. Abeokuta thrives as an agricultural hub, with its markets overflowing with rice, yams, and palm

produce [3]. It also serves as the headquarters for the Ogun-Oshun River Basin Development Authority, a vital

institution for regional development [3]. Abeokuta South is a local government area within the larger city of

Abeokuta, the capital of Ogun State, Nigeria [1]. This area holds historical significance as the traditional seat of

the Egba people since the 1800s [2]. It's a bustling center within the city, likely brimming with cultural and

commercial activity.

3.2Study Population

The study population consists of clinical medical students and nursing students of the the Federal University of

Agriculture, Abeokuta (FUNAAB). Established in 1988, FUNAAB is a leading federal university focused on

agricultural research and training [2]. It offers a wide range of undergraduate and postgraduate programs in vari-

ous disciplines related to agriculture, including sciences, management, and engineering [2]. The university is

known for its beautiful campus and its commitment to innovation and entrepreneurship in the agricultural sector

[2].

3.3 Inclusion Criteria

33
All clinical medical and nursing students in the Federal University of Agriculture, Abeokuta selected for the

study and present at the time of recruitment for the study.

3.4 Exclusion Criteria

Those who do not give informed consent. Students who were selected but were ill or absent at the time of the

sampling.

3.5 Study Design

The study will be a cross-sectional descriptive study to determine the knowledge, attitude and practice of stan-

dard precautions among medical and nursing students in FUNAAB.

3.6 Sample Size Estimation

From the literature review, the prevalence rate is 82%

Using N= Z²P (1-P)/D²

Where N= Sample size required for study

Z = confidence level, set at 95% = 1.96

P = prevalence from previous study = 0.82

D = Margin of error tolerated, taken as 5%, (standard value of 0.05)

N = 1.96² x 0.82 (1-0.82)

0.05²

N= 226.8 ≈ 227

34
10% inclusion criteria= 23

Total sample size= 227 + 23 = 250

3.7 Sampling technique

The technique used simple random sampling.

3.8 Study Instrument

The study instrument was a self-administered questionnaire eliciting the knowledge, attitude and practice of

standard precautions among medical and nursing students of FUNAAB. The questions were mostly close-

ended.

3.9 Data Collection

The data was collected by the primary researchers and some research assistants.

3.10 Plan for Data management

Statistical calculations, tables and charts was be used to analyse and interpret data collected.

3.11 Ethical Consideration

Ethical clearance was obtained from the health research ethics committee of the Federal University of Agricul-

ture, Abeokuta teaching hospital. Participation in the study was voluntary and based on informed consent. Re-

spondents’ anonymity and confidentiality was maintained.

3.12 Limitations of Study

1. Administering questionnaires to junior students as they stay in different campuses.

35
2. Reluctance to fill the questionnaire.

3. Only very few similar studies involving medical and nursing students have been done.

3.13 Overcoming the Limitations

1. Research assistants were trained from each class

2. The questionnaires were administered when respondents deemed convenient.

3. Similar studies with healthcare workers were used in literature review.

CHAPTER FOUR

RESULT
36
A total of 250 questionnaires were administered to 250 respondents. A total of 250 questionnaires were retrieved

given a response rate of 100%. The results from the study is as outlined below in the tables and charts

Table 1: socio demographic variables of the respondents

VARIABLES FREQUENCY PERCENT

AGE

16-20 48 19.2

21-25 164 65.6

26-30 34 13.6

>30 4 1.6

GENDER

Male 86 34.4

Female 164 65.6

RELIGION

Christianity 246 98.4

Islam 2 0.8

Others 2 0.8

MARITAL STATUS

Married 11 4.4

37
Single 239 95.6

COURSE OF STUDY

Medicine 153 61.2

Nursing 97 38.8

Table 2: Socio-demographics variables of Respondents contd.

VARIABLES FREQUENCY PERCENT

LEVEL OF STUDY

100 6 2.4

200 36 14.4

300 50 20.0

400 36 14.4
38
500 41 16.4

600 81 32.4

PRESENT UNIT OF POST-

INGS

ICU 6 2.4

Theatre 29 11.6

Ward 83 33.2

Lab 1 0.4

Casualty 3 1.2

Outpatient clinic 47 18.8

Community medicine/lectures 77 30.8

None 4 1.6

Tables 1 and 2 show that majority (65.6%) of respondents were females majority (65.6%) of the respondents

were aged between 21-25 years.

95.6% were single. Most (98.4%) were Christians. 61.2% were medical students while 38.8% were nursing stu-

dents. 33.2% of respondents were on ward posting.

39
Chart 1: Respondents Awareness of Standard Precautions

40
Table 3: Knowledge of Standard Precautions

VARIABLES FREQUENCY PERCENT

What are standard precautions

Protect health worker only 10 4.0

Protect health worker prevent infection spread 231 92.4

Don't know 9 3.6

When are standard precautions indicated

While attending to all patients 218 87.2

While attending to HIV patients 10 4.0

While attending to contagious blood infection 6 2.4

Infectious respiratory diseases 3 1.2

Gastrointestinal diseases 2 .8

Others 3 1.2

Don't know 8 3.2

In standard precautions, which body fluids are

guarded against

All except saliva 6 2.4

All except sweat 13 5.2

41
All except urine 1 .4

All except faeces 1 .4

All body fluids 217 86.8

None 12 4.8

Table 4.0 Knowledge of SP

Did you receive any education on the use of per- FREQUENCY PERCENT

sonal protective equipment

Yes 200 80.0

No 50 20.0

Are you of any hospital policy that enhances com-

pliance to SP

Yes 37 14.8

42
 No 213 85.2

86.6% have heard of SP, while 13.4% of the respondents had not heard of SP. 92% knows that SP protects

healthcare workers and prevent infection spread. 87.2% agree that SP is indicated while attending to all patients.

Majority (86.8%) of the respondents know that SP guard against all body fluids. 80% received education on the

use of personal protective equipment, while only 14.8% are aware of hospital policy that enhances compliance

to SP.

Table 5: Indications for Hand Hygiene

VARIABLES FREQUENCY PERCENT

Indications for hand hygiene

Before touching the patient 196 21.5%

Before exiting patient area 143 15.7%

After contact with fluids 196 21.5%

Prior to performing any aseptic proce-

193 21.2%
dure

After glove removal 173 19.0%

Others 10 1.1%

Table 6: Attitude towards Standard Precautions

VARIABLES FREQUENCY PERCENT

43
Advantages of Standard Precautions

Easy to practice 71 12.5%

Protects health workers and patients 216 38.2%

Not associated with stigma 72 12.7%

Reduce spread of communicable diseases 196 34.6%

Don’t know 11 1.9%

Curriculum should include training on

Standard Precautions

Strongly agree 172 68.8

Agree 59 23.6

Don’t know 3 1.2

None of the above 16 6.4

SP are useful in protecting against hazards

Strongly agree 147 58.8

Agree 77 30.8

Don’t know 5 2.0

Disagree 2 .8

44
Strongly disagree 3 1.2

None of the above 16 6.4

Table 7: Attitude towards standard precautions continued

VARIABLES FREQUENCY PERCENT

Standard precautions are not really necessary

Strongly agree 3 1.2

Agree 5 2.0

Don’t know 1 .4

Disagree 35 14.0

Strongly disagree 190 76.0

Standard precautions are meant only for the

theatre

Strongly agree 7 2.8

45
Agree 5 2.0

Don’t know 1 .4

Disagree 40 16.0

Strongly disagree 181 72.4

None of the above 16 6.4

Table 6 and 7 shows 38.2% of respondent who agreed that SP protects healthcare workers and patients against

infections. 68.8% strongly agreed that their curriculum should include training on SP. 58.8% strongly agreed

that SP are useful in protecting against hazards. 76% strongly disagreed that SP are not necessary. 72.4%

strongly disagreed that SP are meant only for the theatre.

Table 8: Practice of Standard Precautions

VARIABLES FREQUENCY PERCENT

Can a syringe be re-used to enter an injection vial if

the needle is changed

Yes 63 25.2

No 187 74.8

46
Do you regularly wear PPE when attending to pa-

tients

Yes 94 37.6

No 156 62.4

How do you dispose a used syringe and needle

Discard in a safety box without recapping 76 30.4

Recap before discharge 148 59.2

Disconnect and discharge and replace with new nee-

13 5.2
dle

Others 1 .4

Don't know 12 4.8

47
Table 9: Practice of Standard Precautions Continued

VARIABLES RESPONSES PERCENT

When do you was/decontaminate your hands

Before wearing a glove 112 14.8

After removal 183 24.2

Before touching a patient 135 17.9

Before leaving a patients care area 149 19.7

Prior to performing an aseptic procedure 163 21.6

Others 13 1.7

Which PPE do you regularly wear

If yes gloves 136 40.5

Face masks 102 30.4

Eye goggles 17 5.1

Gown 69 20.5

Others 12 3.6

Yes 79 31.9

I don’t know 140 56.5

48
Table 10.0 Practice of SP continued

Have you ever had your hand on surfaces exposed to FREQUENCY PERCENT

blood or bodily fluids

Yes 159 63.6

No 91 36.4

If yes, what did you do

Nothing 3 1.2

washed with water 9 3.6

washed with soap and water 81 32.4

49
 rinsed with disinfectants 50 20.0

used an alcohol based hand rub 16 6.4

Others 1 .4

none/no response 90 36.0

Tables 8,9 and 10 show 74.8% knew that syringes cannot be reused to enter an injection vial if the needle is re-

placed. 62.4% do not wear PPE regularly when attending to patients. 59.2% recap needle before they discard.

Only 24.2% practice proper hand hygiene after removal of gloves. And a total of 40.5% regularly make use of

gloves. 63.6% have had their hands exposed to blood or body fluids and only 32.4% of these washed with soap

and water.

Table 11.0 sources of information

VARIABLE RESPONSES

FREQUENCY PERCENT

Sources of Informa- lectures 184 62.6

tion
classmate 30 10.2

friend 25 8.5

media 38 12.9

50
 others 17 5.8

Table 11.0 shows 62.6% got to know of SP from lectures, 10.2% knew from fellow classmates, 12.9% knew

from the media.

Table 12.0 Enablers and Constraints to practice of SP

VARIABLE RESPONSES

51
 FREQUENCY PERCENT

if there is an epidemic 84 31.8

managing an infected
What makes you apply 146 55.3
person
SP
policies to punish non-
34 12.9
compliance

Conditions that impedes adherence to SP

emergency situation 107 36.

do not understand how

40 13.5
to observe SP

unavailable PPE 118 39.7

reduces my job effi-

32 10.8
ciency

52
do you have access to hand hygiene

always 94 37.6

sometimes 140 56.0

never 2 .8

others 9 3.6

Don't know 5 2.0

Chart 2..0 Proportion of respondents that have had infections due to non-use of SP

53
Table 13.0 Suggestions on measures to compliance

54
What measures are on ground in your department to FREQUENCY PERCENT

limit spread of respiratory tract infection

signs at entrances with instructions 84 33.6

provide receptacles for disposal of tissues 24 9.6

offer masks to coughing patients 26 10.4

triage patients 10 4.0

Others 22 8.8

Don't know 84 33.6

Measures to ensure compliance with SP

hand hygiene 180 22.4%

PPE 183 22.8%

disinfectants 167 20.8%

regular workers training 148 18.4%

supportive supervisor of workers 120 14.9%

others 6 0.7%

55
 CHAPTER FIVE

DISCUSSION, CONCLUSION AND RECOMMENDATIONS

5.1 Discussion of Findings

Knowledge of Standard Precautions

In this study, 250 medical and nursing students in FUNAAB were surveyed. Majority of the respondents were

within the age range of 21-25 years (65.6%), followed by those within 16-20 years (19.2%). Also 65.6% were

females, while the males were 34.4%. 95.6% were single while 4.4% were married. Majority of the respondents

were Christians (98.4%). 61.2% were medical student and 38.8% were nursing students. Majority (32.4%) of

medical students were in 600 level. While majority (20%) of nursing students were in 300 level.

56
In our study, only 14.8% of respondents were aware of hospital policies that enhance the compliance to standard

precautions. 52.4% have received training on infection control. In a similar study in south-east Nigeria, 62% re-

spondents received training on universal precautions and only 20.3% of respondents were aware of hospital

policies that enhance compliance to standard precautions 39. This is likely due to inadequate orientation of the

students and staff of the hospitals. Another study conducted in Ibadan showed poor knowledge of standard pre-

cautions. In a study among healthcare workers in Saudi Arabia, only 61% were aware of universal precautions 42.

In another study carried out on healthcare workers in a tertiary hospital and two state secondary health care fa -

cilities in Ibadan showed that 90.8% of the workers have heard of standard precautions 43. In a similar study in

Iran 53.5% of medical students have heard about universal precautions. In our study, 86.4% of respondents

have heard of standard precautions. A study done among healthcare workers in Asaba reported that 82% of the

respondents had heard of standard precautions50. This shows adequate awareness of standard awareness of stan-

dard precautions among the study groups.

Attitude towards Standard Precautions

A study done among medical students in Saudi Arabia showed that 68.1% identified the place of PPE in com-

plete elimination of the risk of acquiring infections 51. In our study, 58.8% strongly agreed that SPs are useful in

protecting against hazards in workplaces and 76% strongly disagreed that SPs are not really necessary in hospi-

tals. This same study in Saudi Arabia showed that 61.4% disagreed and strongly disagreed that current curricu-

lum provides them with enough information on SP. 80% agreed and strongly agreed about their need to receive

training and orientations on SP 51. In our own study, 68.8% strongly agreed that the curriculum should include

training on SP.

57
Practice of Standard Precautions

In our study, it was discovered that out of 250 respondents, 94 (37.6%) regularly wear PPEs while attending to

patients, while 156 (62.4%) do not, with reasons from 121 (48.4%) being that there is no regular access to PPE.

In a similar study done among healthcare workers in public and private health care facilities in Abeokuta, Nige-

ria showed that less than two- thirds (63%) use PPE 48. The reason for this may not be farfetched as there is a

problem of unavailability and inadequate supply of PPE in most Nigerian hospitals.In our study, it was also dis -

covered that 136 (40.5%) wear gloves, 102 (30.4%) face masks, 17 (5.1%) eye goggles and 69 (20.5%) gowns.

Among those who wear gloves, 112 (14.8%) decontaminate their hands before wearing gloves. 183 (24.2%) de -

contaminate their hands after removal of gloves. In a study done among healthcare workers in northern Nigeria,

70.1% wear gloves but only 2.1% practice hand washing before wearing gloves and 10.7% wash their hands af-

ter wearing gloves8. This shows that the knowledge about proper hand hygiene is not sufficient.

It was also noted among the healthcare workers in Abeokuta that 94.5% observed hand washing 48. In our study

it was discovered that after hand exposure to contaminants, 3 (1.2%) do nothing, 9 (3.6%) wash with water, 81

(32.4%) wash with soap and water, 50 (20%) rinse with disinfectant, 16 (6.4%) use an alcohol based hand rub.

The reason for the improved turn out may be because of an epidemic or during the management of an infected

patient. It could also be for the sake of personal hygiene.

Our study showed that 76 (30.4%) discard used syringes in a safety box without recapping, 148 (59.2%) recap

before discarding, 13 (5.2%) re-use syringe with a new needle. In a similar study done among laboratory work-

ers at two tertiary public health facilities in Nigeria, 50.8% recap before discarding while 56.9% do not recap

before discarding44. In another study done among medical students in Saudi Arabia, 17.9% disagreed to the re-

58
capping of needle before disposal while 32.7% disagreed to the bending of needle before disposal 51. The out-

come is as a result of inadequate training received by students and health workers on proper methods of observ -

ing standard precaution.

Enablers, constraints and measures on compliance to SP

A study done in south eastern Nigeria revealed 64.5% respondents reported total absence of control measures

for respiratory infections39. In our study, 33.6% reported signs at entrances been used as a measure for control of

respiratory tract infections. Presence of an epidemic, hospital policies and managing an infectious patient en-

courage compliance with SP, while emergency situations and non-availability of PPE are major constraints.

5.2 Conclusion

This research focused on the Knowledge Attitude and practice of standard precautions among health care work-

ers in Abeokuta south Ogun state. Our study shows areas of commendation as well as areas which need im-

provement. Knowledge of SP was good and reflected a similarity with students and healthcare

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 APPENDIX

Research Questionnaire: Knowledge, Attitude, and Practice of Standard Precautions among Health Care

Workers in Abeokuta South, Ogun State

Instructions:

Thank you for participating in this research study. Your input is valuable for understanding the knowledge, atti-

tude, and practice of standard precautions among healthcare workers in Abeokuta South, Ogun State. Please

read each question carefully and provide your response based on your experiences and understanding. Your re-

sponses will be kept confidential and used for research purposes only.

Section A: Socio-Demographic Information

1. Age: Please select the appropriate age range:
 16-20

 21-25

 26-30

 >30
2. Gender: Please indicate your gender:
 Male

 Female
3. Religion: Please select your religious affiliation:
 Christianity
66
  Islam

 Others (Please specify: _______)

4. Marital Status: Please indicate your marital status:
 Married

 Single
5. Course of Study: Please select your course of study:
 Medicine

 Nursing

 Others (Please specify: _______)

6. Level of Study: Please select your current level of study:
 100

 200

 300

 400

 500

 600
7. Present Unit of Postings: Please select your present unit of postings:
 ICU

 Theatre

 Ward

 Lab

 Casualty

 Outpatient Clinic
67
  Community Medicine/Lectures

 None
Section B: Knowledge of Standard Precautions
1. What are standard precautions?
 Protect health worker only

 Protect health worker and prevent infection spread

 Don't know
2. When are standard precautions indicated? (Select all that apply)
 While attending to all patients

 While attending to HIV patients

 While attending to contagious blood infection

 Infectious respiratory diseases

 Gastrointestinal diseases

 Others (Please specify: _______)

 Don't know
3. In standard precautions, which body fluids are guarded against?
 All except saliva

 All except sweat

 All except urine

 All except feces

 All body fluids

 None
4. Did you receive any education on the use of personal protective equipment?
68
  Yes

 No
5. Are you aware of any hospital policy that enhances compliance to standard precautions?
 Yes

 No
Section C: Attitude towards Standard Precautions
1. Do you agree that standard precautions protect healthcare workers and patients against infections?
 Strongly agree

 Agree

 Not associated with stigma

 Reduce spread of communicable diseases

 Don’t know
2. Should the curriculum include training on standard precautions?
 Strongly agree

 Agree

 Don’t know

 None of the above

3. Do you think standard precautions are useful in protecting against hazards?
 Strongly agree

 Agree

 Don’t know

 Disagree

 Strongly disagree

69
  None of the above
4. Do you agree that standard precautions are necessary?
 Strongly agree

 Agree

 Don’t know

 Disagree

 Strongly disagree
5. Do you think standard precautions are meant only for the theatre?
 Strongly agree

 Agree

 Don’t know

 Disagree

 Strongly disagree

 None of the above

Section D: Practice of Standard Precautions
1. Can a syringe be re-used to enter an injection vial if the needle is changed?
 Yes

 No
2. Do you regularly wear PPE when attending to patients?
 Yes

 No
3. How do you dispose of a used syringe and needle?
 Discard in a safety box without recapping
-[ ] Recap the needle and discard in a safety box

70
  Discard in regular waste bin

 Don't know
4. How do you handle sharps (e.g., needles, blades) after use?
 Recap and discard in a safety box

 Discard in regular waste bin

 Don't know
5. Do you wash your hands regularly before and after patient contact?
 Yes

 No
6. How do you handle contaminated linen (e.g., bedsheets, gowns)?
 Place in regular laundry bin

 Place in a separate bin for contaminated linen

 Don't know
7. Have you ever been exposed to a bloodborne pathogen during patient care?
 Yes

 No
8. Have you received any training on standard precautions within the past year?
 Yes

 No
Thank you for your participation! Your responses are greatly appreciated.
ShareTell me more.Can you provide more information about the purpose of this research study?

71