Awareness & knowledge of medical students and interns about infection control measures.
IntroductionHospital-associated infections (HAI) are those infections acquired during the patient's stay in hospital. They form a major worldwide public health problem despite advances in our understanding and control of these infections. [1,2] The best clinical care in the world can be worthless if patients pick up other infections while they are in the hospital. HAI also include occupational infections which occur in HCW due to occupational hazards. [3]
Regardless of where the infection originates, it is surely the first duty of every member of the staff in a hospital to do everything he can make sure that patients are cared for, and returned to health, as quickly as possible and as free from HAI as possible. [4,5]
New students or interns annually start their practical training of different specialties in the different hospitals from different colleges and schools. Previous studies have demonstrated that the levels of awareness and knowledge of IC protocols or policies vary between specific groups of medical staff, and that compliance is greatly influenced by the examples set by senior staff members. [3,6]
For implementation of all the preventive measures to decrease the risk of infection hazards and maintain safety of our future physicians and other HCW as well as patient safety, adequate awareness and knowledge of MS and interns about IC measures and policies are essential. To our knowledge, on the nation level, no similar study has been conducted to address the knowledge and awareness about IC policies among medical and paramedical students and interns.
Objectives
1. To assess the awareness of MS and interns about IC measures.
2. To assess the knowledge of MS and interns regarding IC measures.
3. To define the impact of unawareness & noncompliance with IC measures.
Materials and Methods
Study Design
A cross-sectional, interview-based survey was conducted using a validated questionnaire to MS and interns of CM and CAMS, Taif University who were receiving training in the Ministry of Health (MOH) hospitals, Armed Forces Hospitals (AFH) and University Hospitals. Interns and MS in the above-mentioned hospitals, who gave written consent, were interviewed.
Questionnaire Design
A valid and modified questionnaire which was designed based on the study objectives, taking help from the previous literature and studies available on the topic. It demonstrated the following aspects: (i) participants demographic data; (ii) awareness assessment and (iii) knowledge assessment
Pilot Study
A pilot study was conducted by distribution of 20 questionnaires to 20 interns to assess the validity of the questionnaire.
Study Population
Overall 144 trainees in hospitals [102 from the CM (58 interns and 44 students) and 42 from the CAMS (24 interns and 18 students)] were enrolled in this study.
Study Area
(i) MOH hospitals; (ii) Taif AFH and (iii) University's hospitals
Statistical Analysis
Data entry was done through EpiData twice. Two members of the team entered the same data and the data files were compared to rule out errors in entering the data. Data were collected and analyzed using SPSS version 16. Percentages and proportions were calculated for all the variables. Relevant tables and graphs were computed. The following statistics were applied:
1. Descriptive statistics: The number and percent of the studied personnel for different variables.
2. Analytical statistics: Chi-square test was used to compare 2 or more qualitative variables Significance was determined at p value < 0.05.
Ethical Consideration
Ethical approval was obtained from Taif University ethical review committee before starting data collection.
Results
The Studied Trainees
There were 144 interview-based questionnaires filled. One hundred and two were from CM (58 interns and 44 students) and forty two were from CAMS (24 interns and 18 students). There were in total 90 males and 54 females. They were involved in training in MOH (92), University Hospitals (39) and AFH (13). The duration of training of the enrolled trainees was variable as shown in table 1.
Awareness Assessment
The overall awareness percentage amongst the entire studied group was 64.6% as demonstrated in table 2. Comparison between students of CM and CAMS is shown in table 3. Students of CM had significantly (P<0.001) more awareness about using face masks, dealing with isolated patients and IC guide manual. On the other hand, students of CAMS had significantly (P<0.001) more awareness about the proper way of wearing sterile gloves. There was no significant difference regarding attendance orientation course in the college or hospital, hand washing technique, NS injury, rules of safety during injection and the proper methods of waste disposal. Awareness assessment among interns is shown in table 3. All of the interns of CM had attended an orientation course in the college. They were aware about NS injury, rules of safety during injection, IC guide manual (P<0.001) and dealing with isolated patients (P<0.05). However, interns of CAMS were more aware about using face masks (P<0.01) and the proper methods of waste disposal (P<0.05).
Knowledge Assessment
Table 2 showed that 73.5% of MS and interns gave correct answers about different types of questions in IC. There was no significant difference in the overall knowledge percentage between MS and interns or between CM and CAMS as shown (Figure 1). However, there were significant differences between these groups when the single parameters were compared. Students of CAMS had more knowledge about nosocomial infection (NI), hand hygiene (P<0.01) and using gloves (P<0.05). Interns of CM had more knowledge about alcohol-based hand rub (P<0.01). There was no significant difference between the 2 colleges (for both MS and interns) concerning precaution standards or their behavior after splashes (table 4).
Training of IC Policies
About 67% of the studied trainees had received training in one or more of IC policies (table 2). Higher percentage of MS of CAMS had attended training about wearing gloves and safe waste disposal (P<0.05 and P<0.01 respectively). On the other hand, higher percentage of interns of CM had attended training about dealing with infectious patients P<0.01) and safe IV cannulation (P<0.05). There was no significant difference regarding hand washing, and wearing of face masks or gloves (table 5).
Compliance with IC Policies During Training
Table 2 showed that 25.4% of the studied trainees had been exposed to a problem during training (NS, SBF, CNS, SO or AI). Students of CM were more significantly exposed to CNS, SO and AI (P< 0.01, P<0.05 and P<0.05 respectively) (Figure 2A). On the other hand, interns of CAMS were more significantly exposed to SO (P< 0.001) as shown in Figure 2B.
Requirement for further Training
Table 2 shows that 78.5% of the studied trainees desired further training about IC. However, there was no significant difference between the 2 colleges or between students and interns regarding the need of further training (Figure 3).
HBV Vaccination
About 65% of the trainees had received HBV vaccination; however, 54.9% of those who received the vaccine did not complete the regimen (table 2). There was no significant difference between 2 colleges or between students & interns regarding receiving HBV vaccine (Figure 4).
Discussion
Exposure to infectious diseases is one of the most frequently identified occupational hazards facing HCW. Awareness and adequate knowledge are important requirements for all HCW. In this study, the overall awareness of the studied trainees about IC measures was about 65%. Our results showed that students of CM had more awareness about using face masks, dealing with isolated patients and IC guide manual while those of CAMS had more awareness about wearing sterile gloves. Medical and paramedical students and trainees, being a part of the healthcare delivery system, are exposed to the same, if not greater magnitude of risk as other HCW when they come into contact with patients and contaminated instruments. [5,7] In many teaching centers, medical and paramedical students and trainees are the first level of contact with patients. [8,9] They are expected to undertake activities related to patient care with the starting of their clinical years. [10] All of the interns of CM had attended an orientation course in their college. They were aware about NS injury, rules of safety during injection, IC guide manual and dealing with isolated patients. Interns of CAMS were more aware about using face masks and safe use and disposal of sharps. However, not all of them were aware about all aspects of IC although they have to face the risks associated with occupational hazards facing HCW. [11,12]
The overall percentage of knowledge assessment of the trainees was about 73.5%. There was no difference between students and interns or between MS and CAMS in the overall assessment. However, students of CAMS had more knowledge about NI, hand hygiene and using gloves while interns of CM had more knowledge about alcohol-based hand rub. There were some wrong answers for some of the questions, indicating presence of some defects in their knowledge. To protect MS and interns from injuries and to prevent NI, they should have adequate knowledge before their initial training period. [13,14] Lack of adequate knowledge of standard precautions [9,15] and isolation precautions has been reported to be insufficient [7]. Significant improvement in short-term knowledge of IC practices by MS was previously reported. [16] As IC is a part of the curriculum for MS in both CM and CAMS, continuous improvement of this course is mandatory. [17]
Our results showed that about 67% of the studied trainees had received training in one or more of IC policies. Higher percentage of students of CAMS had attended training about wearing gloves and safe waste disposal. On the other hand, higher percentage of interns of CM had attended training about dealing with infectious patients and safe IV cannulation. However, some of the studied trainees had r no previous training. Therefore, the provision of training programs that provide information about IC is a priority for both medical and paramedical students. Moreover, efforts are required for bringing a reduction in the risk perception of interns through awareness campaigns and reorientation trainings. [18]
Our findings revealed that about 25% of the studied trainees had been exposed during training to one or more of these conditions (NS, SBF, CNS, SO or AI). This result indicates a possible lack of compliance with IC measures. Despite the continuing impact of HAI on the National Health Care System, reports suggest that medical staff have poor compliance with even the most basic IC procedures. [19] Our findings showed that students of CM were more significantly exposed to CNS, SO and AI while interns of CAMS were more significantly exposed to SO. NS injuries have been reported to be among the potential occupational hazards for HCW and to be associated with a number of different health hazards as acquisition of potentially fatal diseases such as Hepatitis B and C and human immunodeficiency virus [6]. Therefore, a high level of noncompliance with basic IC measures by medical staff may exist and may be attributed to lack of familiarity with IC guidelines. [19]
A large percentage (78.5%) of our studied trainees had a desire for further IC training. Those personnel included participants from the 2 colleges as well as from both students and interns. These findings may indicate the importance of implementation of continuous training about the different IC policies for all the medical and paramedical students and interns. The provision of training programs will protect both the HCW and patients from exposure to HAI [19], however, educational aims and strategies must depend on the target group. Poor IC practices will be regarded in a negative light by patients and their families, regardless of any other manifest skills of the practitioner. [19]
Occupational exposure to blood or other body fluids in health care settings constitutes a small but significant risk of transmission of blood-borne viruses. [20] Only 65% of the trainees enrolled in our study had received HBV vaccine and 54.9 % of those who received the vaccine did not complete the regimen. This was noticed in students and interns of both CM and CAMS, indicating that lack of protective antibody level may occur in a large proportion of them. Dental students were reported to have occupational exposure to blood or other potentially infectious materials. [21] Therefore, the medical universities should take necessary action to inform, educate and vaccinate the trainees who may be at risk. The MOH should make HBV vaccination mandatory for all health professionals. However, there may be a false impression about prophylaxis, vaccination and treatment of HBV. [22] Therefore, knowledge alone is not sufficient to bring about behavioural changes, but is imperative for health education personnel to remove misconceptions. This can be done by well-structured health education programs, seminars, workshop and conferences.
Conclusion
This study points to inadequate knowledge and awareness about IC amongst the medical and paramedical students and interns. Only through proper education of the future HCW, the burden of HAI can be reduced.
Recommendations: (1) Improvement of IC education programs must be performed to increase safety of our graduates and patients. (2) A medical education program should be started at the hospital level along with seminars which highlight the importance of IC policies. (3) More emphasis should be placed on IC curriculum taught in undergraduate education. (4) Administration of HBV vaccine to all non-immune medical and paramedical students and interns.
ABBREVIATIONS
AFH: Armed Forces Hospitals; AI: acquired infection; CAMS: College of Applied Medical Sciences; CM: College of Medicine; CNS: contact with non-intact skin; HAI: Hospital-associated infections; HBV: hepatitis B virus; HCW: health care workers; IC: infection control; MS: medical students; MOH: Ministry of Health; NI: nosocomial infection; NS: needle stick; SBF: splash of blood or body fluid; SO: sharp objects.
References
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[15.] Houang ETS, Hurley R. Anonymous questionnaire survey on the knowledge and practices of hospital staff in infection control. J Hosp Infect. 1997;35 (4): 301-306.
[16.] Calabro K, Weltge A, Parnell S, Kouzekanani K, Ramirez E. Intervention for medical students: effective infection control. AJIC 1998;26:431-436.
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[18.] Lal P, Singh MM, Malhotra R, Ingle GK. Perception of risk and potential occupational exposure to HIV/AIDS among medical interns in Delhi. J Commun Dis. 2007 Jun;39(2):95-9.
[19.] Ferguson JK. Preventing healthcare-associated infection: risks, healthcare systems and behaviour. Intern Med J. 2009 Sep;39(9):574-81.
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Source of Support: Nil
Conflict of interest: None declared
Saad Al-Zahrani (1), Fahad Al-Amry (2), Mabrouk Ghonaim (3), Osama Abo-Salem (3)
(1) Department of Family Medicine, College of Applied Medical Sciences, Taif University, KSA
(2) Al-Hada Military Hospital, Taif, KSA
(3) Department of Medical Laboratories, College of Applied Medical Sciences, Taif University, KSA
Correspondence to: Saad Al-Zahrani (ssmz2002@hotmail.com)
DOI: 10.5455/ijmsph.2013.2.331-337
Received Date: 15.12.2012
Accepted Date: 16.12.2012
Table-1: Characteristics of the Studied Group
Characteristics CM CAMS
No. % No. %
Level Interns 58 56.86 24 57.14
Students 44 43.14 18 42.86
Sex Males 66 64.71 24 57.14
Females 36 35.29 18 42.86
Training Place AFH 6 5.88 7 16.67
(hospital) MOH Hospitals 64 62.75 28 66.66
University 32 31.37 7 16.67
Hospitals
Duration (month) 0-3 32 31.37 10 23.81
3-6 20 19.61 14 33.33
6-9 20 19.61 9 21.43
9-12 30 29.41 9 21.43
Table-2: Overall Assessment of IC Parameters among
the Studied Population
Parameters Average
Awareness (%)
Awareness assessment 64.6
Knowledge assessment 73.5
Receiving training 66.9
Exposure to a problem during training 25.4
Requirement of further training 78.5
Receiving HBV vaccination 64.6
Completing HBV vaccine regimen 54.9
Table-3: Awareness Assessment about IC among MS
Awareness Parameter CM
Total Yes %
No.
The Studied College (MS)
Orientation attendance in college 44 24 54.55
Orientation attendance in hospital 44 18 40.91
Hand washing technique 43 30 69.77
Using face mask 44 44 100.00
NS injury 43 26 60.47
Rules of safety during injection 44 20 45.45
Dealing with isolated patients 44 38 86.36
Proper way of wearing sterile gloves 44 16 36.36
IC guide manual 44 34 77.27
Proper methods of waste disposal 44 22 50.00
The Studied College (Interns)
Orientation attendance in college 58 58 100.0
Orientation attendance in hospital 58 34 58.62
Hand washing technique 58 56 96.55
Using face mask 58 44 75.86
NS injury 58 56 96.55
Rules of safety during injection 58 34 58.62
Dealing with isolated patients 57 36 63.16
Proper way of wearing sterile gloves 58 56 96.55
IC guide manual 58 34 58.62
Proper methods of waste disposal 58 52 89.66
Awareness Parameter CAMS
Total Yes %
No.
The Studied College (MS)
Orientation attendance in college 18 14 77.78
Orientation attendance in hospital 18 4 22.22
Hand washing technique 18 8 44.44
Using face mask 18 12 66.67
NS injury 18 12 66.67
Rules of safety during injection 18 6 33.33
Dealing with isolated patients 17 10 58.82
Proper way of wearing sterile gloves 18 18 100.0
IC guide manual 18 4 22.22
Proper methods of waste disposal 18 8 44.44
The Studied College (Interns)
Orientation attendance in college 24 22 91.67
Orientation attendance in hospital 23 12 52.17
Hand washing technique 24 22 91.67
Using face mask 24 24 100.0
NS injury 24 16 66.67
Rules of safety during injection 24 4 16.67
Dealing with isolated patients 24 8 33.33
Proper way of wearing sterile gloves 24 22 91.67
IC guide manual 24 6 25.0
Proper methods of waste disposal 24 16 100.0
Awareness Parameter [chi square]
The Studied College (MS)
Orientation attendance in college 3.33
Orientation attendance in hospital 1.95
Hand washing technique 3.46
Using face mask 16.26 *
NS injury 0.21
Rules of safety during injection 0.77
Dealing with isolated patients 22.4 *
Proper way of wearing sterile gloves 20.9 *
IC guide manual 16.3 *
Proper methods of waste disposal 0.17
The Studied College (Interns)
Orientation attendance in college 20.91 *
Orientation attendance in hospital 0.27
Hand washing technique 0.87
Using face mask 6.98 ([euro])
NS injury 13.68 *
Rules of safety during injection 12.02 *
Dealing with isolated patients 6.07 ([pounds
sterling])
Proper way of wearing sterile gloves 0.87
IC guide manual 7.68 ([euro])
Proper methods of waste disposal 6.33 ([pounds
sterling])
([pounds sterling]) P<0.05; ([euro]) P<0.01; * P<0.001
Table-4: Knowledge Assessment about IC
Knowledge Parameter CM
Total No. RA %
The Studied College (MS)
NI 44 25 56.82
Precaution standards 44 27.5 62.50
Hand hygiene 43 23.5 54.65
Using gloves 44 29.5 67.05
Behavior after splashes 44 37.5 85.23
Alcohol-based hand rub 42 15 35.71
The Studied College (Interns)
NI 58 45 77.59
Precaution standards 56 50 89.29
Hand hygiene 58 55.5 95.69
Using gloves 58 50.5 87.07
Behavior after splashes 58 56.5 97.41
Alcohol-based hand rub 58 46 79.31
Knowledge Parameter CAMS
Total No. RA %
The Studied College (MS)
NI 18 16 88.89
Precaution standards 18 12 66.67
Hand hygiene 18 16.5 91.67
Using gloves 18 16.5 91.67
Behavior after splashes 17 15 88.24
Alcohol-based hand rub 18 8.5 47.22
The Studied College (Interns)
NI 24 16.5 68.75
Precaution standards 24 22.5 93.75
Hand hygiene 24 23.5 97.92
Using gloves 24 18 75.00
Behavior after splashes 24 23.5 97.92
Alcohol-based hand rub 24 11.5 47.92
Knowledge Parameter [chi square]
The Studied College (MS)
NI 8.21 [euro]
Precaution standards 0.05
Hand hygiene 8.58 [euro]
Using gloves 4.79 [pounds
sterling]
Behavior after splashes 0.03
Alcohol-based hand rub 1.07
The Studied College (Interns)
NI 1.23
Precaution standards 0.91
Hand hygiene 0.85
Using gloves 2.04
Behavior after splashes 1.00
Alcohol-based hand rub 7.05 [euro]
RA; Right answer; P < 0.05 [pounds sterling]; P < 0.01 [euro]
Table-5: Training about IC Polices among Students and Interns
CM
Total No. Yes %
The Studied College (MS)
Hand washing 44 24 54.55
Wearing gloves 44 22 50.00
Wearing face mask 44 16 36.36
Dealing with infectious patients 44 18 40.91
Safe IV cannulation 44 16 36.36
Safe use and disposal of sharps 44 18 40.91
The Studied College (Interns)
Hand washing 58 56 96.55
Wearing gloves 58 52 89.66
Wearing face mask 58 50 86.21
Dealing with infectious patients 58 44 75.86
Safe IV cannulation 58 34 58.62
Safe use and disposal of sharps 58 56 96.55
CAMS
Total No. Yes %
The Studied College (MS)
Hand washing 18 12 66.67
Wearing gloves 18 14 77.78
Wearing face mask 18 8 44.44
Dealing with infectious patients 18 8 44.44
Safe IV cannulation 18 10 55.56
Safe use and disposal of sharps 18 14 77.78
The Studied College (Interns)
Hand washing 24 24 100.00
Wearing gloves 24 22 91.67
Wearing face mask 24 22 91.67
Dealing with infectious patients 24 10 41.67
Safe IV cannulation 24 8 33.33
Safe use and disposal of sharps 24 24 100.00
[chi square]
The Studied College (MS)
Hand washing 3.16
Wearing gloves 4.05 [pounds
sterling]
Wearing face mask 0.35
Dealing with infectious patients 0.07
Safe IV cannulation 1.93
Safe use and disposal of sharps 6.96 [euro]
The Studied College (Interns)
Hand washing 0.86
Wearing gloves 0.07
Wearing face mask 0.48
Dealing with infectious patients 8.81 [euro]
Safe IV cannulation 4.34 [pounds
sterling
Safe use and disposal of sharps 0.86
P < 0.05 [pounds sterling]; P < 0.01 [euro]
Figure-1: Comparison of Knowledge Assessment
between CM and CAMS among Interns and Students
(There was no significant difference between the 2
colleges or between interns and students)
% of Right Answer
Interns Students
Medicine 79.000 77.00
CAMS 64.50 65.80
% of Right Answer
Medicine CAMS
Interns 79.00 64.50
Students 77.00 65.80
Note: Table made from bar graph.
Figure-2: Comparison of Compliance with IC Policies
during Training between CM and CAMS among
Students and Interns (A) Students of CM were more
significantly exposed to CNS, SO and AI (P< 0.01, P<0.05
and P<0.05 respectively); (B) Interns of CAMS were more
significantly exposed to SO (P< 0.001). [NS; needle sticks:
SBF; splash of blood or body fluids: CNS; contact with non-intact
skin: SO; sharp objects: AI; acquired infection]
Yes % of students
CM CAMS
NS 36.00 11.00
SBF 18.00 23.00
CNS 23.00 11.00
SO 36.00 0.00
AI 27.00 0.00
Yes % of interns
CM CAMS
NS 28 33.00
SBF 41.000 17.00
CNS 55.000 25.00
SO 21.000 42.00
AI 14.000 8.00
Note: Table made from bar graph.
Figure-3: Comparison between Interns and Students
and between CM and CAMS Concerning Requirment of
Further Training (There was no significant difference
between the 2 colleges or between interns and students.)
% of training requirment
CM CAMS
Intern 67.00 83.00
Students 86.00 100.00
Interns Students
CM 67.00 86.00
CAMS 83.00 100.00
Note: Table made from bar graph.
Figure-4: Comparison between Interns and Students
and between CM and CAMS Concerning Receiving HBV
Vaccine (There was no significant difference between the
2 colleges or between interns and students.)
CM CAMS
Intern 62.00 100.00
Students 55.00 56.00
Interns Students
CM 62.00 55.00
CAMS 100.00 56.00
Note: Table made from bar graph.
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| Title Annotation: | RESEARCH ARTICLE |
|---|---|
| Author: | Zahrani, Saad Al-; Amry, Fahad Al-; Ghonaim, Mabrouk; Abo-Salem, Osama |
| Publication: | International Journal of Medical Science and Public Health |
| Geographic Code: | 1USA |
| Date: | Apr 1, 2013 |
| Words: | 4523 |
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