|Ahead of print publication
Infection prevention and control: Practice, uptake, and administrative control among primary health-care workers in enugu metropolis, Southeast Nigeria
Casmir Ndubuisi Ochie1, Elias C Aniwada2, Chukwueloka K Uchegbu1, Thaddeus C Asogwa1, Chika N Onwasoigwe2
1 Department of Community Medicine, University of Nigeria Teaching Hospital, Ozalla, Nigeria
2 Department of Community Medicine, University of Nigeria Teaching Hospital, Ozalla; Department of Community Medicine, College of Medicine, University of Nigeria, Nsukka, Enugu State, Nigeria
|Date of Submission||05-Aug-2021|
|Date of Decision||16-Jan-2022|
|Date of Acceptance||23-Jan-2022|
|Date of Web Publication||11-Apr-2022|
Casmir Ndubuisi Ochie,
Department of Community Medicine, University of Nigeria Teaching Hospital, Ituku, Ozalla, Enugu
Source of Support: None, Conflict of Interest: None
Introduction: Administrative supervision of infection prevention and control (IPC) is the most important aspect of IPC/hazard controls. The practice, uptake, and compliance to IPC is a documented, cost-effective method of interrupting the infection transmission pathways. Poor or nonadherence to this has led to disabilities and loss of lives among health-care workers, especially in the face of emerging and re-emerging infections. The present study evaluated the practice of IPC as well as its uptake and administrative control among the primary health-care workers in Enugu metropolis, Southeast Nigeria. Methodology: This was an analytical cross-sectional study using semi-structured self-administered questionnaires and an observation checklist. Eligible health-care workers (HCWs) were selected using simple random sampling from ten primary health-care (PHC) facilities. Chi-square test was used to examine associations of interest. Binary logistic regression was employed to identify predictors of good IPC practices. Results: Three hundred eligible health-care workers participated in this study. More than a fifth (n = 65, 21.7%) of HCWs exhibited good practice of IPC measures. Correct practice of handwashing was noted among 275 (95.7%) of the respondents. Majority (n = 224, 74.7%) reported recapping of needles and engaged in unsanitary disposal of health-care wastes (n = 257, 85.7%). The prevalence of needlestick injuries 3 months prior to the study period was 53.3% (n = 160). Majority of those sampled reported a lack of IPC committee (n = 220, 73.3%), conspicuous signage to aid movement (n = 230, 76.7%), and an IPC policy (n = 217, 72.3%) in their respective centers. Identified predictors of good practice of IPC were age <40 years (adjusted odds ratios [AORs] 0.572; 95% confidence interval [CI] 0.382–0.57), being a community health extension worker or community health officer (AOR 3.759; 95% CI 1.564–9.034), and working for <20 years (AOR 5.1;95% CI 5.0-5.73). Conclusion: Poor level of practice of IPC and compliance to administrative control among PHC workers, in addition to lack of administrative facilities, remains a great challenge. There is an urgent need for capacity building on IPC and administrative support to reverse this trend.
Keywords: Administrative control, compliance, infection prevention and control, practice, primary health-care workers
|How to cite this URL:|
Ochie CN, Aniwada EC, Uchegbu CK, Asogwa TC, Onwasoigwe CN. Infection prevention and control: Practice, uptake, and administrative control among primary health-care workers in enugu metropolis, Southeast Nigeria. Int J Adv Med Health Res [Epub ahead of print] [cited 2022 Oct 1]. Available from: https://www.ijamhrjournal.org/preprintarticle.asp?id=342826
| Introduction|| |
The practice of infection prevention and control (IPC) commences and continues during the design stage of the health-care facility, construction, renovation, repairs, and refurbishment. It is a continuous process which serves both preventive and curative purposes and includes administrative control, good environmental practices such as proper management of health-care wastes and quality water provision, and compliance to standard and transmission-based precautions. To ensure the well-being of patients, staff, and visitors, each health-care facility needs to develop and adopt an infection control policy and program. Good infection control practices and uptake, in addition to rapid case detection, immediate isolation, and contact tracing, can contain most health situations during disease outbreaks, epidemics, or pandemics, especially in the absence of vaccines and effective treatments.
The emergence of life-threatening infections such as severe acute respiratory syndrome, Middle East respiratory syndrome, and most recently, the COVID-19 pandemic as well as other re-emerging infectious diseases such as plague and tuberculosis have highlighted the need for efficient infection control practices in all health-care settings. These conditions have also shown that capacity building for IPC among health-care workers (HCWs) is inevitable so that they can implement the IPC measures and reduce harm associated with hospital acquired infections (HAIs). However, the place of training and retraining of HCWs on IPC in achieving an infection-free health-care workplace cannot be undermined. Practice and uptake of IPC among HCWs can be affected by a number of factors including overcrowding of patients and visitors in most clinical settings; this can be challenging. The risks of contracting infections in health-care facilities are increased with poor environmental conditions such as air pollutants, overcrowding, humidity, hygiene, and temperature. Lack of quality IPC measures and medical care to contain the spread of the infectious agents, such as inadequate isolation capacity at health-care facility and nonavailability of personal protective equipment (PPE), also affect the risk. Facility managers are also important in this regard as they play key roles in administrative supervision by ensuring that IPC deliverables are readily available and affordable. Similarly, increased use of health facilities can also alleviate the risks of infections contracted, especially when considering unhygienic home deliveries and health-care management. Poor infection control practices in health facilities can complicate puerperal conditions and even contribute to neonatal morbidity and mortality, especially in centers with suboptimal IPC practices and uptake.
Conventionally, infection control practices in health-care facilities place greater emphasis on the standard and additional (transmission based) precautions than administrative, environmental, and engineering controls. Administrative controls are the health-care system requirements for IPC and it is considered the most important in the hierarchy of IPC/hazard controls, but their application for IPC cannot replace elimination and substitution of the infectious agent as the best approach. It includes provision of policies and procedures for IPC promotion that are based on sound epidemiology and best practice. It also encompasses education and training for HCWs. These controls reduce risk by providing protocols and procedures for tasks. Standard precautions reduce the risk of transferring/transmitting microorganisms (infectious agents) from both recognized and unrecognized sources of infection. It must be applied every time at the point of care and should become second nature as part of health-care practice. Proper implementation of IPC can limit the spread of infection to other HCWs, patients, or visitors. Use of PPE currently lies at the bottom of the hierarchy of IPC practices and require HCW to take specific actions to reduce the risk of infection transmission.
A number of scholars had worked on IPC at the different levels of health-care system globally,,, and locally.,, They dwelt more on knowledge, attitude, perception, and practice, but few discussed compliances with administrative control. Most of these studies were also descriptive, incorporating both qualitative and quantitative aspects of research. Some of them involved the use of observation checklists to match both knowledge and acclaimed practice. An interventional Indian study found benefits for education on knowledge, attitude, and compliance to infection control among various classes of HCWs., The practice of IPC measures has gained less attention in health-care settings than it should is clear from the loss of lives of HCWs as a result of nosocomial infections.,, The Ebola outbreak of 2014 highlighted the need to observe IPC strategies not just among health-care workers, but everybody in the West Africa subregion, including Nigeria. This underscored the fact that the responsibility of IPC rests on everybody: both health-care workers and nonhealth-care workers. For instance, barrier technology innovation to stop the spread of infections was the brainchild of an engineer.
Compliance to good practice of IPC has been noted to be diverse and specific to different infectious agents and procedures including tuberculosis, HIV, deliveries, injections safety, and health-care waste disposals. Nevertheless, this is incorporated into standard precautions and transmission-based precautions. Compliance to standard precautions has been shown to reduce the risk of HAIs, patient overstay, and even protection of health-care workers. In a research carried out among health-care workers regarding compliance to injection safety and use of sharp containers, despite high rates of self-practice and high knowledge, the authors observed that there was poor compliance to use of sharps, containers, and application of injection safety practices. Against this background, this study assessed the practice, uptake, and administrative control of IPC among primary HCWs in Enugu metropolis, Southeast Nigeria.
| Methodology|| |
This study was conducted in primary health centers (PHCs) in Enugu metropolis of Enugu State, located in the Southeast geopolitical zone of Nigeria. The metropolis, made up of Enugu North, Enugu South, and Enugu East local government area (LGA), has an estimated population of 3.3 million and a total land area of 7,618 sq. km. It has well-developed coal mining, commercial, financial, and industrial centers. Enugu state has three federal tertiary hospitals. There are more than 30 primary health facilities in Enugu metropolis distributed unevenly among the three LGAs.
The study was a facility-based cross-sectional study among PHC workers offering health-care services in the primary health facilities in the metropolis. Various consenting cadres of PHC workers including community health officers (CHO), junior community health extension workers (JCHEW), senior community health extension workers (SCHEW), nurses, midwives, and ward orderlies were studied.
All 300 respondents participated in this study and the minimum sample size was determined using the sample size determination formulae for a descriptive cross-sectional study.
where n is the minimum sample size,
z is the standard normal deviate at 95% confidence interval (1.96),
p is the proportion of respondents with good knowledge and practice of IPC, from a previous similar study carried out in Enugu, Southeast Nigeria; this figure is estimated at 77.2% (0.772).
q is the complementary probability (1– p) =1-0.772 = 0.228,
and d is the precision of the study set at 0.05.
Substituting these figures in the above equation gave us a minimum sample size of 270 respondents. We inflated the sample by 10% to account for incomplete responses or attrition; this increased the required sample size to 297 which was rounded off to 300 respondents.
A two-stage sampling technique was employed to obtain a true representative sample of the primary health-care workers in the metropolis. In Stage 1, ten primary health facilities were selected from each of the three LGAs that make up the metropolis, whereas, in Stage 2, ten HCWs were selected from each of the facilities. Three LGAs constitute the Enugu metropolis. Ten PHCs each were selected from each LGA since there were an approximately equal number of PHCs in each LGA (12, 11, and 10), giving a total of 30 PHCs. Next, ten workers from each PHC were selected; this gave a total of 300 respondents. Random sample technique using simple balloting method was employed at both these stages to select eligible participants.
An adapted self-administered semi-structured questionnaire and an adapted observational checklist were used., The questionnaire had the following sections: sociodemographic variables, practice of standard and transmission-based precautions, and administrative compliance measures of IPC. The adapted observation checklist comprising 24 items was used to assess compliance of facility management in providing an enabling environment for IPC in each of the health facilities.
The data collection was done by the researcher and three research assistants who received rigorous training for 2 days on the data collection tools and objectives of the study. Data collection lasted for a period of 4 weeks.
The questionnaire and the observation checklist were checked for completeness upon return from the respondents. Data were coded (1 = yes, 2 = no), tabulated, and analyzed using IBM Statistical Package for Social Sciences (SPSS) Statistics for Windows, Version 23.0. Armonk, NY, USA: IBM Corp. Quantitative variables were summarized using means and standard deviation. Categorical variables were summarized using frequencies and percentages. There were 23 questions related to the level of practice of IPC. We dichotomized scores on these items as follows: a proportion score of ≥50% (12 and above) was taken as good and <50% (11 and below) as poor. The level of statistical significance was set at P ≤ 0.05. Chi-square test was used to examine associations between characteristics of respondents and practice scores; those parameters with P ≤ 0.2 were then entered into a binary logistic regression model to identify the predictors of good practices.
Ethical clearance for this study was obtained from the Health Research Ethics Committee of the University of Nigeria Teaching Hospital, Ituku-Ozalla, Enugu. Permission was obtained from the health departments of the selected LGAs and head of facilities. Verbal consent was obtained from all respondents and their confidentiality was guaranteed by using anonymous questionnaires. These respondents were also informed of their freedom to withdraw from the research at any point of the study if they so wished.
| Results|| |
Mean age of the sample was 39.9 ± 9.6 years. Majority of the respondents were aged 31–40 years (n = 104, 34.7%), females (n = 97,65.7%), had completed tertiary education (n = 253,84.3%), were married (n = 205, 68.3%), either CHEWS/CHO (n = 122, 40.7%), and had worked for over 10 years (n = 208,68.7%). Further, over three-quarter (n = 254, 84.7%) of them had received IPC training with most respondents (n = 241, 80.3%) receiving training for <10 years. [Table 1] depicts the baseline sociodemographic features of the sample of PHC workers.
|Table 1: Sociodemographic characteristics of the primary health-center workers (n=300) in Enugu metropolis|
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With regard to the practice of IPC measures, a fewer proportion (n = 65, 21.7%) of the respondents exhibited overall good practice of IPC. Almost all of them correctly practised handwashing (n = 275, 95.7%), always practised wearing hand gloves against contact with bodily fluids (n = 255, 85.5%), and always put on their gowns/plastic aprons (n = 253, 84.3%) and masks (n = 248, 82.7%) during procedures that were likely to generate fluid splash. Majority (n = 160, 53.3%) of the PHC workers reported having needlestick injuries in the previous three months. Many also reported that they recapped used needles (n = 224, 74.7%) and disposed them into a closed dust bin (n = 150, 50.0%). Reasons for noncompliance were varying; some of them (n = 18,72.0%) who did not practice handwashing believed that all contacts with the patients were not infectious, some (n = 20,42.6%) who did not gown complained of feeling of discomfort, and others (n = 21, 40.4%) attributed noncompliance to lack of supplies [Table 2].
|Table 2: Self-reported practice of infection prevention and control measures among primary health-center workers in Enugu metropolis|
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Two-third of the respondents (n = 150, 67.0%) were vaccinated against hepatitis B, but only a few of them (n = 17, 5.7%) received at least three doses. Among those who were not vaccinated against hepatitis B, majority of them blamed it on nonavailability of the supplies [Table 3]. Many (n = 204, 68.0%) of these PHC workers washed instruments with soap and water; in contrast, few (n = 11, 3.7%) practised packing instruments as part of sterilization practices [Figure 1].
|Figure 1: Bar chart depicting different sterilization methods practised as reported by the primary health-care workers in Enugu metropolis|
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|Table 3: Protection against hepatitis B among primary health-care workers in Enugu metropolis|
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There were statistically significant associations between good IPS practices and age (P = 0.042), professional cadre (P = 0.024), and years of practice (P = 0.036). HCWs who were younger than 40 years were more likely (adjusted odds ratio [AOR] 1.57;95% confidence interval [CI] 1.01–3.89) to have good practice of IPC as compared to those who were older. Likewise, a CHEW/CHO had nearly four times the odds of good practice of IPC compared to other workers (AOR 3.759; 95% CI 1.564-9.034). Working for <20 years was found to be significantly associated with good IPC practices; those who had worked for <20 years were five times more likely to have good IPC practice scores compared to those who had spent more than 20 years in service (AOR: 5.1; 95% CI 5.0–5.73) [Table 4].
|Table 4: Factors influencing good infection prevention and control and uptake among the primary health-center workers in Enugu metropolis|
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None of the selected facilities had an existing IPC plan/checklist or an IPC focal person and none had a regular reporting system of accidental injuries or near missed. However, all of them had postexposure prophylaxis facilities (n = 30, 100.0%). In most of them, handwashing facilities were available and staff used PPE when needed. Sharps containers were not available in 4 (13.3%) centers. All the facilities had adequate cross-ventilation and protective PPE, but none of them had appropriate automatic doors for opening and closing for infection risk reduction [Table 5].
|Table 5: Observation checklist for compliance to administrative control to basic infection prevention and control infection prevention and control measures in primary health centers (n=30) in Enugu metropolis|
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| Discussion|| |
Globally, the principles of infection control and practices are followed similarly., The magnitude of the problem associated with poor practice and poor administrative compliance to IPC is enormous and worse in developing economies.,,, Our findings reveal that only 21.7% of the respondents had good, overall, IPC practice levels. This clearly shows that a gap exists in practice of IPC among the centers studied. This is in line with prior research findings.,
A study done in South Africa noted suboptimal IPC practices among administrative and clinical personnel. Another study done in Enugu noted good practice levels only among 19.7% of respondents, this was despite good attitudes to IPC among them.[ By contrast, a high level of practice was observed in another study. This difference could be attributed to the cadre of the study participants; doctors were included in the latter study. Doctors were shown to be more knowledgeable and experienced compared to CHEWS, CHOs, and nurses who were less trained academically and technically in IPC. However, a few previous studies, from different regions, on IPC practices among health-care workers revealed good practice.,,,
Majority of the respondents in the present study practised handwashing after direct contact with patients. Among those who were noncompliant, majority reported that not all patient contact was contagious or nonavailability of soap and water as reasons for noncompliance. Prior studies have revealed similar findings; majority of the respondents practised handwashing after patient contact,,, and nonavailability of washing materials was cited as a reason for noncompliance. Hand hygiene has remained a cost-effective, globally recognized way of IPC. It was also noted that majority of the respondents wore PPE against contact with body fluids correctly, while few that do not use them reported discomfort as the reason for not wearing them. These findings, too, were similar to those noted by other researchers.,,,
This study also reported that some respondents manually bend the needles but recap and place them in a closed dust bin, puncture-proof container, or any available container. This practice is undesirable due to the risk associated with it for both the individual involved and other workers as well. This inappropriate injection safety practice of managing sharps and needles was also reported in by other investigators.,, The high prevalence (53.3%) of needlestick injury in previous months reported in this study was comparable to a study carried out in Pakistan where 53% of the interviewed health-care workers reported needlestick injuries in the previous six months. In Nigeria too, a similar study reported 31.0% needlestick injuries in Ilorin, Kwara State, of which 19.5% were documented officially. This high proportion could be partly explained by the practice of recapping of needles which poses an unusual risk. This would also imply an increased risk of contracting other blood-borne infections such as hepatitis B and C and HIV.
This study further revealed that majority (67.0%) of health workers were vaccinated against hepatitis B though only very few (5.7%) had complete vaccination (at least three doses). This finding aligns with observations from a similar study done in Enugu where it was noted that 57.0% of the health-care workers were vaccinated against hepatitis B, but only 28% of them were fully vaccinated. This may mean that most of them were immune and would restrict the spread to both patients and coworkers. With regard to reasons for not being vaccinated against hepatitis B, most of them cited nonavailability of the vaccine; similar findings have been noted earlier.
Age, professional cadre, and years of practice were shown to be predictors of good practice of IPC. In a prior study, additional predictors such as female sex were identified. Another study showed that educational status and training/retraining were determinants of good IPC practices. These findings were comparable to observations from Pakistan, where poor practice like needlestick injuries was reported to be influenced by non-attendance to IPC training (relative risk 2, 95% CI 1.17-3.41). Re-evaluating the academic curriculum of these workers to include IPC training might close the gap among professional cadres, and giving on-the-job IPC capacity training would help immensely.
Findings from this study showed that most of the administrative measures of IPC were nonexistent in majority of the primary health facilities studied. This finding was comparable to that found in South Africa, where only 20% of the facilities were noted to have IPC plans, whereas 50% reported having IPC focal person. The reason, perhaps, could be ascribed to low-risk perception of health-care workers in primary health facilities, unlike most tertiary health facilities, where most of those administrative facilities are likely to exist. Poor availability of administrative facilities among PHCs should be of grievous concern. It points to the deficiencies of supervising agencies as well as a lack of political will of the government in providing those basic necessities. This would encourage the intractable spread of infection among workers in PHC facilities.
Most of the centers had basic running water facility, unlike what was reported elsewhere: 1 in 4 health-care facilities did not have basic water services and 712 million people lacked running water at the point of care. The implication is that this hand hygiene product is readily available, and it is expected that health-care workers should be observing hand hygiene with the aim of reducing HAI at the point of care. In a related study in Jos, Nigeria, a good proportion of respondents frequently attended IPC meetings, unlike what was observed in the present study. This discrepant finding can be, partly, attributed to differences in study methodology and sample size. In this study, the sample size was smaller than ours; further, we used an observational checklist as the method of data collection, whereas a questionnaire was used in the comparison study. Consequences of poor compliance to administrative control are that IPC programs cannot be effectively carried out in the absence of a robust IPC system.
We acknowledge the limitation of this study in using adapted study tools which may have introduced an element of information bias. However, the questionnaire was pretested and validated by the authors; during this process, necessary changes were made.
| Conclusion|| |
The need for the sound practice of IPC and robust administrative control of IPC cannot be overemphasized. The outcomes of this work show that most respondents had a poor level of practice with almost nonexistent administrative measures of IPC among the primary health-care facilities in Enugu metropolis. Determinants of good practice of IPC were age, marital status, professional cadre, and years of practice. The poor practice and uptake of IPC should be a call to action for stakeholders in the health system. There is also the need for further research on the reasons for poor administrative compliance to IPC.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]