Knowledge , attitude and behavior of primary health care workers regarding health care-associated infections in Kuwait

Background: Health care workers (HCWs) are at high-risk for acquiring health care-associated infections (HAIs) and transmission to their patients and close contacts. Objective: The aim of the present study is to study primary health care (PHC) workers’ knowledge, attitudes and behavior towards HAIs in Kuwait. Methods: This study was a cross-sectional survey that was conducted in all primary health centers located in two randomly selected health regions in Kuwait. An anonymous self-administered questionnaire was distributed to all currently working physician and nurses in the selected centers. Results: The majority of the participants were aware that a HCW can acquire HAIs from a patient, but less than 60.0% knew that a HCW can transmit these infections to a patient. physicians and nurses’ beliefs regarding various control measures of HAIs were more or less positive as 59.4% to 85.1% of them believed in these various measures. It is observed that proportions of physicians and nurses practicing infection control measurements were less than that reported when describing their positive attitude towards HAIs. Conclusions: HCWs in primary health care showed good knowledge and positive attitude, but poor practice regarding control measures against HAIs. They need health education campaigns to enhance understanding the importance of practicing control measure that they believed in


INTRODUCTION
Health care associated infections (HAIs) are infections that patients get while receiving treatment for medical or surgical conditions.They are considered as a serious problem in the healthcare services as they are common causes of illness and mortality among patients.Currently, between 5% and 10% of patients admitted to acute care hospitals acquires at least one infection and over the last decades the incidence has increased in both the United States and Europe.(Eriksen et al. 2005, Pittet et al. 2005, Hopmans et al. 2007, Klevens et al. 2007, pittet et al. 2008) They are the most common complication of hospital care, among the leading causes of preventable deaths in the United States and associated with a substantial increase in health care costs each year.(AHRQ, 2009, Klevens et al. 2007) However, recent studies suggested that implementing existing prevention practices can lead to a 70% reduction in certain HAIs.(Scott, 2009) All health care workers (HCWs) at the three levels have good awareness that patients could be a source of HAIs.However, awareness of hospital staffs, equipment and the environment as sources of transmission of HAIs was good for HCWs in both tertiary and secondary level care, but poor among primary HCWs although they are the frontline defense for applying daily infection control practices.(Adebimpe et al., 2011) reported in their studies that good knowledge and attitude, but poor practices characterize HAIs among tertiary and secondary level health care workers in Osogbo.These indices are worst and ranges from fair to poor among health workers at the primary health care (PHC) level, (Al-Damouk et al. 2004, Parker and Goldman 2006, Ellison et al. 2007, Sundaram et al. 2007).
The Centers for Disease Control and Prevention has developed specific guidelines aimed at preventing the transmission of pathogens within the hospital setting.(Siegel, 2007) Health care delivery, including complex procedures, is being shifted out to patient settings and PHC.These settings often have limited capacity for oversight and infection control compared to hospital-based settings.Many HAIs in these settings are the result of poor basic infection-control practices.Studies have shown that proper education and training of HCWs increases compliance with and adoption of best practices to prevent HAIs (Safdar and Abad 2008).The behaviors of health care providers and their interactions with the health care system influence the rate of HAIs.Physicians and nurses have the unique opportunity to directly reduce HAIs through recognizing and applying evidence-based procedures to prevent infections among patients and protecting the health of the staffs.
The aim of this study was to reveal knowledge, and behavior towards HAIs among physicians and nurses in PHC in Kuwait.

SUBJECTS AND METHODS:
The health care system in Kuwait is divided into five regional health authorities.Primary health care is provided through 92 centers distributed in the health regions proportionate to their population.This study was a cross sectional descriptive survey that was conducted from March to December 2011 in all PHC centers located in two randomly selected health regions (Capital and Farwaniya).All physicians and nurses currently working in these centers were invited to participate in the study.
The data of this study was collected through a specially designed questionnaire that was derived from other published studies dealing with the same topic as well as from our own experience.The questionnaire comprised of five categories of questions.The first one was related to socio-demographic and occupational characteristics, the second one was designed to reveal participants' knowledge about the risks of acquiring and/or transmitting certain HAIs for/to a patient and the standard precautions for prevention; the third and the fourth sections contained questions related to participants' and the last one entailed sources of up to date participants' information about HAIs.Correct answers to each item were based on a review of the available literature as well as policies and guidelines (Brinsley et al. 2005, Greig, 2011).
A pilot study was carried out on 30 physicians and nurses (not included in the final study).This study was formulated to test the clarity, applicability of the study tools, identify the difficulties that may be faced during the application.Also, the time needed for filling the questionnaire by the staff was estimated during this pilot study.The necessary modifications according to the results obtained were done.
All the necessary approvals for carrying out the research were obtained.The Ethical Committee of the Kuwaiti Ministry of Health approved the research.A written format explaining the purpose of the research was prepared and signed by the physician before filling the questionnaire.In addition, the purpose and importance of the research were discussed with the director of the health center.

Statistical analysis
The Statistical Package for Social Sciences (SPSS-17) was used for data processing.Simple descriptive statistics were used (mean ± standard deviation for quantitative variables and frequency with percentage distribution for categorized variables).

RESULTS
Recruitment effort resulted in participation of 429 persons, 277 were nurses (64.6%) and 152 were physicians (35.4%) with an overall response rate of 55.8%.About two-thirds of the respondents (69.5%) were females, the mean age was 37.0 ± 9.3 years.Kuwaitis and non-Kuwaiti Arabs were accounting for 24.5% and 31.2%respectively, while the non-Arabs constituted 44.3%.More than three-quarters of the respondents (86.7%) were married, and 64.8% had monthly income <1000 KD whereas only 9.3% had income > 2000 KD.The mean number of years in practice was 11.5 ± 8.9, with 49.4% of the participants worked in their jobs for less than 10 years and the mean number of working hours / weeks ranged from 30 to 100 hours (42.7±6.1 hours).Only 2.6% had a family history of hepatitis A infection and 3.3% of HBV or HCV.The most frequently reported source of information about HAIs was educational courses (69.9%) followed by colleagues and physicians (63.4%), scientific journals (61.3%); and mass media (55.7%),Table 1.
Participants were asked about transmission of certain infections from patients to HCWs and the reverse.The proportions of participants who answered correctly for each infection were reported in table 2. The majority (78.3%, 73.4% and 69.2% respectively) were aware that a HCW can acquire HBV, HCV and HIV from a patient, but less than 60.0% knew that a HCW can transmit these infections to a patient.The lowest proportions were reported in infections like measles, mumps, rubella, tetanus and tuberculosis.It was clear that participants were more aware regarding acquirement of infection from patients than transmission to patients.
Table 3 showed that 80.0% and 85.1% agreed that the guidelines for preventing HAIs should be strictly followed, and hands hygiene measures after treating patients reduces the risk, respectively.These beliefs were also encountered regarding hands hygiene measures reducing the risk of HAIs among HCWs (82.5%).Only 59.4% of participants believed that hands hygiene after removing gloves is a control measure, while 84.6% believed that changing mask before going to another patient is a HAIs control measure, while 70.2% believed that wearing gloves, mask, and protective eye-wear are HAIs control measures.Concerning the perceived risk of acquiring a HAI, 50.6% and 80.7% of participants respectively thought that invasive procedures are a risk factor for HAIsand that HCWs' hands are a vehicle for transmission of nosocomial pathogens Table 3 described participants' practice towards HAIs control measurements.Only 62.7% always wore gloves when at direct contact with a patient and 64.6% of them reported always changing gloves after each patient, while 51.0% and 64.3% always performed hands hygiene measures before and after wearing gloves, respectively.A total of 67.8% and 62.5% of respondents always performed hands hygiene measures before starting the working activity and before going to another patients respectively Placing needles in sharp's containers were performed by 67.8% of the participants, while, other protective measures were encountered in lower percentages as wearing protective eye-wear (20.5%) or mask (31.5%) when at direct contact with a patient, recapping needles after use (36.8%), use syringes with retractable needle (38.5%), use syringes with protective shield (44.8%)and use intravenous cannulation with retractable needle (36.6%).

Discussion
It is easy to generally assume that health workers by virtue of their proximity to the health facility should have adequate knowledge about diseases and other health conditions.This assumption can be true for both tertiary and secondary level, but adequate knowledge is poor among PHC workers.(Adebimpeet al. 2011).This was not the case in the study done by Raka et al.(2006) where only 16.8% of respondents knew the complete definition of HAIs and 69% of HCWs knew that contact is the most common mode of transmission.
In the current study, participants' knowledge were generally high and consistent with current scientific evidence, since majority of them(78.3%, 73.4% and 69.2% respectively) were aware that a HCW can acquire HBV, HCV and HIV from a patient.This finding is however at variance with another study conducted in PHC settings in Saudi Arabia where the level of knowledge regarding HAIs by HCWs was found to be low, a finding that was attributed to the lack of resources and training opportunities, and excessive workload (Amin and Al Wehedy, 2009).Also in a similar study in Karachi, the respondents showed very low level of knowledge of HAIs (Shaheen et al. 2007).This finding is encouraging considering the fact that knowledge is usually the first step towards modification of a desirable behavior.However, there was an area where the knowledge was lower, particularly regarding infections that a HCW can transmit to a patient.Also, participants' knowledge regarding certain infectious disease was low as for measles, mumps, varicella and was very low as for tetanus.This could be explained by the fact that these disease are rarely encountered in the last years in Kuwait due to application of successful vaccination programs.
Provision of information about HAIs influence knowledge and behaviors, because HCWs would be able to answer correctly and to use appropriately, HAIs control measures if they had received information from educational courses and scientific journals.(Fakih MG et al. 2006).In the current study, the most commonly reported source of information about HAIs was educational courses, physicians, scientific journals and lastly, mass media.Education session for health workers was found to improve knowledge and attitude scores of health workers towards nosocomial infections (Suchitra and Lakshmi 2007).There is a good attitude towards readiness to wear protective devices, towards washing of hands before and after touching patients and self-reporting to staff clinic when sick among health care workers at PHC.This was better when compared with another study in which compliance of HCWs with the recommended hand washing practices remains low.In order to reduce the incidence of nosocomial infections, compliance with 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.
In the current study, physicians and nurses' beliefs regarding various control measures of HAIs were more or less positive as 59.4% to 85.1% of them believed in these various measures.However, only half of them believed that invasive procedures in medicine are a high risk factor for HAIs.This may be due to the fact that physicians and nurses in PHC settings are usually away from invasive procedures that are mostly encountered in secondary and tertiary care settings putting HCWs at high risk of infection because of their high frequency of exposure to blood and other body fluids coupled (Adesunkanmi et al.2003).
In this present study it is observed that proportions of physicians and nurses practicing infection control measurements were less than that reported when describing their positive attitude towards HAIs.That is certain participants believed in these measures but do not practice them.HCWs in Canada reported a high rate of hand washing before and after all patients, and for wearing gloves when examining patients (Parker et al. 2006).Results from the present study indicated that most respondents always used gloves and performed hands hygiene measures after removing gloves for the prevention of the HAIs.Moreover, the use of protective barriers was considerably lower than those observed in other study.For instance, in a study in the United States, 96% and 99% used gloves at least 95% of the time for their work (Ellison et al. 2007).
A national survey throughout England found out that 99% of participants routinely used gloves in a major trauma scenario, but only 18% and 21% used face mask and eye protection, respectively (Sundaram and Parkinson 2007).More HCWs always washed their hands before and after touching clients and equipment, while more has also even notified HAIs before.This is comparable with another study in which only a little over one third of HCWs studied routinely used all barrier techniques such as gloves, masks, and protective eye-wear (Angelillo et al 1999).This holds a lot of prospect for the control of HAIs since it was reported that even hand washing alone was sufficient in reducing the incidence of nosocomial infections.Never less, in the present study, lower proportions of physicians and nurses were practicing certain measurements as wearing protective eyewear or mask when at direct contact with a patient, recapping needles after using, using syringes with retractable needle, using syringes with protective shield, and using intravenous cannulation with retractable needle.This may be due to unavailability of these equipment or absence of its need in the PHC.
The recognition that HCWs in primary care were an under-provided group with respect to education about occupational hazards was not unique to HCW in PHC in Kuwait.In 2003, the UK's National Institute of Clinical Effectiveness published guidelines on the prevention of HAIs in primary health care (Infection Control 2003).Participants in the current study had positive attitudes since 80.0% and 85.1% agreed that guidelines for preventing HAIs should strictly be followed and that hands hygiene measures after treating patients reduces the risk, respectively.There is a need for health education campaigns for health workers so that they can understand the risks that they are exposed and the importance of practicing control measure that they believed in.

CONCLUSION
Good knowledge and attitude, but poor practice characterizes physicians and nurses among HCWs in PHC centers.This clearly revealed the urgency to implement initiatives for improving healthcare policies regarding HAIs