Awareness and attitude of health care workers in a teaching hospital in southwestern Nigeria towards nosocomial infections

Despite advances in health care system, Nosocomial infections (NIs) still remain a preventable disease threatening public health. This study assessed awareness and attitude of health care workers in LAUTECH teaching Hospital Osogbo towards Nosocomial infections. Descriptive cross sectional study among hospital workers using multistage sampling method was used. Research instruments were semi structured self administered and pre-tested questionnaires, and data analyzed using the SPSS software. Eighty three (91.2%), 77 (84.6%) and 59 (64.8%) of the health workers were aware of patients, hospital staff and hospital environment, respectively as causes of nosocomial infections. Thirty one (34.1%) were aware of presence of their hospital policy on control of nosocomial infections, while 36(39.6%) were aware of presence of infection control committee in the hospital. Twelve (13.2%) has ever notified nosocomial infection. Preventive practices towards nosocomial infections were favourable for hand washing, and unfavourable for self reporting to the staff clinic when sick. There is no significant association between ever reported or willingness to report nosocomial infections and awareness of hospital policy or presence of infection control committee in the hospital (P > 0.05). There is a need to raise awareness on nosocomial infections among health care workers as well as preventive measures against these infections.


INTRODUCTION
Nosocomial infections (NIs) are a significant and serious public health problem throughout the world (Alvarado, 2000).These are infections occurring in a patient in a hospital or other health care facility in whom the infection was not present or incubating at the time of admission.This includes infections acquired in the hospital but appearing after discharge, and also occupational infections among staff of the facility (WHO, 2002).
Several studies have however reported a prevalence of *Corresponding author.E-mail: lekanadebimpe@yahoo.com, lekanadebimpe@gmail.com.
Nosocomial infections between 5 and 10% (Somwang et al., 2007;Olawale et al., 2011; Pittet et al., 2008;Hopmans et al., 2007).These infections pose serious threat to hospital admissions and those who work or dwell around hospital premises and often increase costs of health care both for patients and the health services.Despite advances in the health care system, the threat to public health due to NIs still remains.NI also caused the suffering of about 1.4 million people across the world at any given time (Allegranzi et al., 2007).NIs are estimated to cause or contribute to nearly 80,000 deaths annually in the United States (Rosner, 2000).They are also regarded as a substantial factor in 3% or 15,000 deaths per year in Britain (Comptroller and Auditor General, 2000).
Many Nosocomial infections are caused by pathogens transmitted from one patient to another, by way of health care workers who do not routinely observe simple hospital hygiene measures like handwashing, and also between patients.Susceptibility to these infections has been associated with use of invasive devices, extremes of age, immune status and infection control practices (Amita et al., 2003).Most nosocomial infections are thought to be transmitted by the hands of health care workers.It has long been known that hand hygiene among health care workers plays a central role in preventing the transmission of infectious agents.Handwashing has been reported as one of the most effective way of preventing the spread of infectious diseases (Anderson et al., 2008).It is thus important to assess knowledge and attitude of these health care workers towards NIs prevention and control.
In a Nepalese study on Nosocomial infection among HCWs, only 16, 14, and 0.3% of the respondents achieved maximum scores for knowledge, attitude, and practice items, respectively (Paudyal, 2008).Poor knowledge of definition of NI amidst good attitude and poor compliance with simple procedures such as handwashing and use of gloves has also been reported among HCWs (Raka et al., 2006;Flores and Pevalin, 2006;Khaled et al., 2008).It is interesting to note that approximately onethird of hospital-acquired infections may be preventable (Comptroller and Auditor General, 2000), and that their rates can be reduced by up to one-third if healthcare workers comply with guidelines issued by their hospitals and notable regulating bodies such as the Centers for Disease Control (Pittet et al., 2000).However, compliance rarely exceeds 50% (Bischoff et al., 2000;Maury et al., 2000;Moongtu et al., 2000), and this will have a bearing effect on disease prevalence.
With reports of low compliance, cases of multi-drug resistance infections and poor awareness of NIs, a study on knowledge, attitude and practice of nosocomial infections is long overdue.This is so in an environment like ours in which personal and organizational attitudes towards interventions such as hand washing, cost containment and logistical barriers may be described as still existing at low pace.The objective of this study was to assess the awareness and attitude of tertiary level health care workers towards nosocomial infections in Osogbo, Southwestern Nigeria.

MATERIALS AND METHODS
This descriptive cross sectional study was carried out among health care workers in selected Teaching Hospital in Osun state in Southwestern Nigeria.The state has two teaching hospitals, and both admit patients and employ various cadres of health workers relevant to their settings.Both LAUTECH and Obafemi Awolowo University Teaching Hospital have NI control committee, hospital policy on control of NIs as well as adequate protective and other facilities required for effective control of NIs for the use of their staff.LAUTECH Teaching Hospital has about 300 beds and 400 workers, Obafemi Awolowo Teaching hospital have about 480 beds and 650 members of staff.Administrative and non clinical related staff and health workers who have spent less than a year working in the hospital environment were excluded from this study.Clinically related staff eligible for this study should have spent at least 2 years in the employment of the hospital, a period enough to have familiarized one with hospital policies and systems.
Using a prevalence figure of 5.9% in the calculation of sample size for population less than 10,000 using Leslie Fischer's formular (Olawale et al., 2011;Olawuyi, 1996), a sample size of 85 was calculated.The sample size was approximately brought up to 100.Multistage sampling method was used in selecting respondents into this study.In the first stage, one teaching hospital (LAUTECH Teaching Hospital) was chosen by simple random sampling employing simple balloting.In stage two, a list of clinically related categories of health workers in the hospital were obtained from the hospital administrative unit, and three (nurses, ward orderlies and doctors) were chosen by simple random sampling.Questionnaires were proportionately allocated according to the ratio of the total number of health care workers on the group list.In stage three, a systematic sampling of one in three health workers in each group were selected until number of allocated questionnaires were exhausted.These health workers were located where they were in the hospital and subjected to the research instruments.A total of 91 health care workers returned completely filled questionnaires, giving a response rate of 91.0%.
A pre-coded semi structured self administered questionnaires was administered on sampled health care workers.Questionnaires for ward orderlies were interviewer administered for better and direct understanding of the contents of the questionnaires.Questionnaires were pre-tested among ten health care workers in a nearby general hospital in neighboring Oyo state.Validation of questionnaires was conveniently done by 2 of the lead researchers during pre test.During pretest and data collection proper, 2 research assistants were trained for the administration of the questionnaires on the professional HCWs while 2 additional assistants were used in the translation and back-translation of the Yoruba language version of the questionnaires for ward orderlies who may prefer local language for better understanding.Data were validated by data cleaning, double entry, manual and random checks and location of outliers' data.About six visits to each of the facilities were made over a period of one month including weekend in order to meet the health workers on rotational duty.
Study variables include socio-demographic data of respondents, their awareness of NIs as well as attitude and practice of HAIs and preventive measures.The index used to assess awareness was how they knew about NIs based on the questions asked.Practices were explained under discussions as favourable, less favourable and un-favourable based on grading of the practice responses to the questions asked.Ethical issues were settled at the levels of the ministry of health, the health workers as well as the management and ethical review committee of LAUTECH Teaching Hospital, Osogbo.Data was analyzed using the SPSS software version 13.0 after sorting out the questionnaires.Consistency of data entered were done by double entry and random checking.Data was presented in forms of frequency tables.Association between categorical variable were done using chi-square test at a level of significance of P < 0.05.

RESULTS
Ninety one respondents returned completely filled questionnaires giving a response rate of 91.0%.Table 1 shows that 39 (42.9%) of respondents were in the age group 20 to 39 years, 20 (22.0%) were doctors while 52 (57.1%) were nurses and 32 (35.2%) of respondents have spent 1 to 5 years in practice.Table 2 shows that

Variable N (%) All the time
Sometimes Occasionally Never Respondents said they report self to the staff clinic when sick 13 (14.3)13 (14.3)48 (52.7) 17 (18.7)Respondents said they wear overalls or coats, gloves, face masks etc 40 (44.0)28 (30.8) 14 (15.4) 9 (9.9)Respondents said they wash their hands before and after examining patients 73 (80.2) 11 (12.1) 5 (5.5) 2 (2.2) Respondents said they wash their hands before and after handling specimens 82 (90.1) 7 (7.7) 2 (2.2) wash hands before and after procedures.Fifty two (57.1%) of respondents were ready to report themselves to staff clinic when sick, 82 (90.1%) were ready to always wear protective gears as required on duty while, 89 (97.8%) were ready to always wash their hands before and after procedures.Table 3 shows that preventive practices towards nosocomial infections were favourable for hand washing, less favourable for wearing gloves, and un-favourable for self reporting to the staff clinic when sick.There is no significant association between ever reported NIs or willingness to report and awareness of hospital policy on NIs, aware-ness of presence of infection control committee in the hospital or number of years put in practice (P > 0.05).

DISCUSSION
In this study, majority of HCWs were aware of common causes of NIs, half of them were aware of its conse-quences and about one third were aware of predisposing factors to HAIs.This awareness is higher when compared to a similar study in which only 16.8% of respondents knew the complete definition of nosocomial infection and sixty-nine percent of health care workers knew that contact is the most common mode of transmission (Raka et al., 2006).The higher awareness rate obtained in this study could be as a result of inclusion of nosocomial infections as a topic taught in the medical curriculum in Nigeria, and it usually feature as part of sensitization seminars and continuous medical education for hospital workers.This poses a great prospect for control of nosocomial infections in Nigeria.
The fact that about one third of respondents were aware of presence of hospital policy and presence of infection control committee in their hospital suggested that health workers had a poor knowledge of the notification of Nis and the legal backing for the notification process.This could be responsible for a low rate of notification of NIs to the relevant authority observed in this study.The poor practice of reporting despite good attitude towards notification of NIs however suggested that serial or routine on-the job sensitization seminars to the health workers could lead to a better practice of reporting of NIs.This suggestion is supported by another study in which education sessions for health workers was found to improve knowledge and attitude scores of health workers towards nosocomial infections (Suchitra and Lakshmi, 2007).
In this study, reported preventive practices of HCWs towards NIs were favourable for hand washing, and fair for wearing protective materials like gloves.This supports a similar study in which majority of health care workers reported hand washing after using gloves (84%) (Raka, 2006).This study however disagreed with another in which routine handwashing before and after glove use was reported by fewer than half of the HCWs studied (Askarian, 2005).In yet another study, health care workers reported a good overall knowledge and positive attitude towards glove use (Flores and Pevalin, 2006).Many factors could have been responsible for low use in these comparative studies.This include availability of gloves, cost of gloves if clients are to buy, availability of hand washing facilities, and attitude of the health care workers towards these simple procedures.All these amenities were available in LAUTECH Teaching Hospital and may influence the prevalence of these infections.
Most of the HCWs in this study were ready to always wash their hands before and after procedures.This observation was better when compared with a study in which attitude to compliance of HCWs with the recommended hand washing practices remains low (Vincent et al., 1995).In order to reduce the incidence of nosocomial infections, good attitude and compliance with preventive interventions are mandatory (Suchitra and Lakshmi, 2007).In many settings, hand washing may be seen as a trivial issue that is not routinely taken serious, most especially in non surgical and non invasive sessions.To this effect, sensitization seminars for all categories of health Care staff will go a long way in reducing prevalence of the different types of NIs within our hospital settings.Regular monitoring and mentoring of health workers, most especially by concerned authority would ensure routine universal precautions and regular hand washing practices.In addition, infection control committees in hospitals should live up to the task of making the provision of hospital NI prevention policy available and accessible to health care workers and take active part in creating awareness.

Conclusion
Majority of health care workers are aware of causes and transmission of NIs, but with a bad attitude towards reporting of Nis.Improved awareness through routine sensitization seminars for health care workers and monitoring of compliance could lead to a reduction in prevalence of nosocomial infections in our health care settings.

Table 1 .
Personal data of respondents.

Table 2 .
Awareness and attitude to hospital acquired infections.
Thirty one (34.1%)wereaware of presence of hospital policy on NI while 36 (39.6%) were aware of presence of infection control committee in their hospital.About 12 (13.2%)hasever notified NIs while 85 (93.4%) were ready to notify in the event of cases of NIs.About 89 (97.8%) of the HCWs were ready to always

Table 3 .
Pattern of practice of nosocomial infections preventive measures.