J Community Med Health Edu

Community Medicine & Health Education

Research Article

Open Access

Knowledge, Awareness and Compliance with Standard Precautions among

Health Workers in North Eastearn Nigeria
Abdulraheem IS1*, Amodu MO2, Saka MJ1, Bolarinwa OA1 and Uthman MMB1
1
2

Department of Epidemiology & Community Health, College of Medicine, University of Ilorin, Nigeria
Department of Community Medicine, College of Medical Sciences, University of Maiduguri, Nigeria

Abstract
Background: Health care workers (HCWs) are at risk of various occupational hazards in the hospital, including

Objective: To assess knowledge, awareness and compliance of universal precautions among health workers in
Method:
<
Results:

Keywords: Health workers; Knowledge; Compliance; Universal

control health care-associated infections in patients and health workers

[15,16].

Introduction

Standard precautions include hand washing; use of barriers

(gloves, gown, cap and mask); care with devices, equipment and
clothing used during care; environmental control (surface processing
protocols and health service waste handling); adequate discarding of
sharp instruments; and patients accommodation in accordance to
requirement levels as an infection transmission source [15]. Hand
hygiene is most important among the standard precautions advocated
[17,18]. Adoption of safe practices for handling needle sticks and other
sharp objects, in view of the possibility of outbreaks, especially of
Hepatitis B and C is also a preventive measure worthy of mentioning
[15].

precautions; Nigeria

Standard precautions are set of measures formulated to prevent

transmission of blood borne pathogens when providing health care.
Since identification of patients infected with these pathogens cannot
be reliably made by medical history and physical examination, the
Centers for Disease Control (CDC) has recommended that standard
precautions are used on all patients, regardless of knowledge about
their infection status [1]. Health care workers (HCWs) are at risk of
various occupational hazards in the hospital, including exposure to
blood borne infections such as HIV and hepatitis B and C virus from
sharps injuries and contact with body fluids [2-4].
Developing countries, which account for the highest prevalence
of HIV-infected patients in the world, also record the highest rate of
needle-stick injuries [5]. The World Health Organization estimates
that about 2.5% of HIV cases and 40% of HBV and HCV cases among
HCWs worldwide are the result of these exposures [6]. The risk of
seroconversion following a needle-stick injury from an HCV-antigenpositive patient is estimated to range from 1.2% to 10% [7].
Compliance with standard precautions reduces the risk of exposure
to blood and body fluids [8]. Gershon et al. [9] observed that better
knowledge of universal precautions among HCWs was one of the
correlates of good compliance. Michalsen et al. [10] observed the same
among physicians. Knowledge of standard precautions by HCWs may
be influenced by their type of training [9,11-13]. Jeong et al. [14] in
Korea observed that nurses who were working in the operating room
need training to increase their compliance with standard precautions.
Compliance on the part of healthcare workers with standard
precautions has been recognized as an efficient means to prevent and
J Community Med Health Edu

Many factors are responsible for non-adherence to the basic

principles of universal precautions among health care providers
[19,20]. From the available literature, the compliance with universal
precautions among health workers in the Northern Borno State has not
been assessed. This study is being conducted to assess the knowledge,

*Corresponding author:

Received

Accepted

Published

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, et al

Citation:

awareness and compliance with universal precautions among health

workers in Northern Borno State, Nigeria.

Methods
This is a cross-sectional study conducted between March to August
2010 among primary health workers in Mobbar, Gubio and Guzamala
Local Government Areas of Borno State. The health workers included
those that had full-time employment with the LGA and had direct
contact with patients, specimen and chemicals during their routine
clinical duties. All the 30 Primary Health Care centers in the LGAs
of study were selected. The health centers were visited on week days
between 10:00 am and 4:00 pm over a period of 6 months. All categories
of trained health workers (Nurses, midwifes, community health officers,
community health extension workers and health assistant) were invited
to participate in the study after signing an informed written consent
form.
The study was divided into 2 parts. The first part assessed the
knowledge on standard precautions which was evaluated by means of
a questionnaire. The second part used a check list to record practical
activities performed by the health workers. The questionnaire was
drafted according to Garners [15] recommendations and included
questions on the health workers knowledge of: Hand hygiene
(indication, areas deserving particular attention and minimum time for
the procedure); sterile and non-sterile gloves (indication); needle sticks
and other sharp objects (handling and disposal). The questionnaire was
developed after a thorough review of the literature and further perusal
by experts in public health to ensure quality and content validity.
The questionnaire was piloted in a different Local Government Area
(Abadam LGA). After the pilot the questionnaire was fine tuned before
finally self administered to assess the health workers knowledge,
awareness and compliance on standard precautions. Information on
socio-demographic variable and work experience of the health workers
was also collected. The questionnaire was a 32-item one with both
open-ended and closed questions in English language but translated
to local language for proper understanding. The questionnaire
administration took about 20 minutes to complete. The questionnaire
also assessed awareness on policy regarding universal precautions,
exposure to biological and chemical agents and awareness of potential
harm when exposed to these agents, availability and use of protective
equipment. Before administration of the questionnaire, the purpose
of the study was explained to the respondents and they were assured
of the confidentiality of the information given. Informed consent for
participation was obtained from each health worker.
The knowledge of universal Precautions was measured by
examining five questions on mode of transmission of HIV & hepatitis
B and C virus, exposure to body fluids, use of protective barriers such
as gloves and gown, recapping of needles and disposal of biohazards.
A score of 1 for a correct answer and 0 for an incorrect answer was
assigned. A health care worker who obtained a total score of 5 was
considered good knowledge; 4 or 3 fair knowledge; and 1 or 0
poor knowledge.
A passive and non-participative observation on health workers
was performed during the study period. The parameters observed
were recorded on the check list corresponding to the practice aspects
evaluated during the knowledge assessment phase. The data from the
questionnaire were coded and entered into a computerized data base
and analyzed using SPSS, version 17. The chi-squared test was used to
find the association between variables. A p-value of equal to or less than
0.05 was considered statistically significant.

J Community Med Health Edu

Results
Among the 276 health workers studied, only 5.4% declined to
participate thus giving a response rate of 94.6%. Among the participants,
74.7% were females and 25.3% were males (Table 1). The age range of
respondents was 21-53 years while the mean age was 26.4 years (SD
4.2). Life time work experience varied between 13 months and 19 years.
The mean duration of clinical experience was 64.5 (SD 4.8) months.
Half (55.2%) of the respondents had between 5 and 10 years of working
experience, 19.5% had less than five years and 25.3% had more than 10
years experience. Half (50%) of the respondents had no knowledge of
universal precautions; with more females (64.2%) than males (35.8%)
(p< 0.05).
About one third (37%) of the respondents had fair knowledge
of universal precautions while 13% had good knowledge (Table 1).
About two third (67.8%) women and one-third (32.2%) men were
very knowledgeable (p<0.05). A significant relationship exists between
knowledge of universal precautions and occupation status; nurses
(85.7%), midwifes (80.2%) and community health officers (69.8%)
were knowledgeable of universal precautions compared with only
5.4% of community health extension workers and 0.9% of health
assistants (p<0.05). The level of awareness of universal precautions
was significantly associated with many factors (Table 2). Respondents
with experience of 10 years and above (88.9%) reported higher levels
of awareness of universal precautions compared with those less than
5 years experience (51%). Among those aware of standard precaution,
48 (55.2%) had information about it from seminars and workshops, 24
(27.6%) from classroom lectures and only 15 (17.2%) from books and
health programmes on television and radio.
About one third (33.3%) of the respondents knew that the aim
of standard precautions was to protect both health care workers and
patients from transmission of infection (Table 3); 162 (62.1%) thought
that standard precautions were meant to protect health workers alone
from getting infections from patients, while 9.1% agreed that standard
precautions aimed at protecting health workers while handling
infectious waste.
Variables

Frequency

Age (Years)

Sex
66
Marital Status
Single

Widow
Work Experience (Years)

66
Knowledge of Standard Precaution

Table 1:

Percentage

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Discussion

Level of Awareness
Factors

None (%)

Fair (%)

Good (%)

Occupational Status
Nurse

Work experience (years)

Place of training

Private health Institution

Table 2:

Concerning knowledge about infectious blood and body fluids,

about one third (32.2%) of the respondents agreed that all patients
were potentially infectious irrespective of their diagnostic status, while
63.2% believed that only those diagnosed were infectious and only 4.6%
believed that those suspected of being infected are potentially infectious
(Table 3). With regards to work experience affecting knowledge, 58.8%
of those who had less than 5 years work experience agreed that all
patients were potentially infectious and 72% of those with more than
10 years experience had correct knowledge of standard precautions
guidelines (Table 4).
Among the 63 procedures observed, 47.6% and 34.9% had an
indication for sterile and non-sterile gloves usage respectively; only
19.5% required washing of the hands. All respondents reported very
inadequate provision of protective materials. More than two-thirds
(80.6%) reported that only gloves and face mask were provided for
surgical and delivery procedures and only 55.5% made use of these
protective materials
Concerning the knowledge and practice of hand hygiene, this study
revealed that 56.7% of the health workers knew that their hands had
to be washed before and after patient care. However, compliance with
hand hygiene was noticed in only 38.7% of the knowledgeable health
workers. Three (3%) did not wash their hands before or after taking
care of patients.
Regarding the use of sterile gloves, there was statistical difference
only in those with more than 10 years clinical experience (p=0.05).
Even in those with more than 10 years experience, the practice among
those who wore gloves adequately was superior to their knowledge on
the matter. A comparative evaluation of the level of knowledge and
practice in handling and disposal of needles and other sharp objects
among those with above 10 years experience revealed a lower level
of knowledge (43.8%) than the observed practice (47.2%), and the
difference was not statistically significant (p >0.05).
More than four-fifth (90.8%) of the nurse were aware of the potential
harmful effects of biological agents compared to 82.5.0% of midwifes,
78.4% of Community health officers and 23.6% of community health
extension workers. None of health attendants was aware of the potential
harmful effects of biological agents. Majority (95%) of the respondents
identified HIV as a potential harmful biological agents, followed by
hepatitis (82.6%) and bacterial infections (77.8%). Knowledge of
potential harmful effects of biological agents was relatively high and
despite the high level of knowledge and awareness about the potential
harmful effects of biological agents very few (2.5%) wear protective
gear/apron.
J Community Med Health Edu

Half (50%) of the respondents reported no knowledge of universal

precautions; more than one third (37%) had average knowledge of
universal precautions while 13% had good knowledge. Knowledge of
universal precautions was highest among women than men, and among
nurses (85.5%) compared with other health workers. The results of this
study are almost similar with that by Vaz et al. [21] who reported that
90.0% of nurses had knowledge of standard precautions. The adequate
knowledge of universal precautions among nurses and midwives
may be due to incorporation of universal precautions in the Nigerian
nursing and midwife student curriculum and on-the-job training. The
low level of knowledge of universal precautions among community
health extension worker and health assistant may be attributed to their
poor educational background and non-provision of this information
by their immediate superior.
The deficient knowledge base among some of the health workers
may be due to a lack of investment in staff training by the their employer
or to limited understanding of health care workers safe behavior in the
clinical setting or complacency [22,23]. Due to insufficient information
retention, knowledge and adherence to taught, practice may still
be deficient in spite of training and education [24,25]. Training
and education have been found to be of paramount importance to
developing awareness among health care workers, as well as improving
adherence to good clinical practice [26,27].
The greater awareness of universal precautions among health care
workers with longer years of experience in this study may be due to
their participation in a greater number of seminars, conferences
and training some of which may include universal precautions
which not only encouraged safer work practices but also improved
concordance with policy and procedures [28,29]. In this study, about
one third (33.3%) of the respondents believed that standard precautions are aimed at protecting both health workers and patients from
Objective

Frequency

Percentage

Protection of health workers and patients from

infection
infection from patient
Protecting health workers while handling
Infectious agent alone

irrespective of their diagnostic

Status
tious

Table 3:

Total

blood

as infectious
Those suspected
Table 4:
n =261

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transmission of infection; 62.1% thought that standard precautions

were meant to protect health workers alone from getting infections
from patients, while 42 (9.1%) agreed that standard precautions were
aimed at protecting health workers while handling infectious waste
only. This finding is in contrast with a Brasil study [30], where 11.0%
understood standard precautions as protective measures for health
workers only and 52.4% for both health workers and patients.
Protective barriers help to reduce the risk of exposure of the health
workers skin or mucous membranes to potentially infectious materials.
They also reduce the risk of exposure to blood and other body fluids to
which universal precautions apply. All the respondents reported very
inadequate provision of protective materials. Gloves and face mask
were the only protective materials being provided with. In spite of the
inadequate provision, only 55.5% used these protective materials. This
finding is in agreement with that of Sadoh et al. [31] in which less than
two-thirds of health care workers used personal protective equipment
such as aprons, gowns and gloves, during surgeries and deliveries.
However, there is sometimes a high rate of non-compliance among
health workers and this may be due to a lack of understanding among
them on how to properly use protective barriers [32]. In addition,
non-compliance among health workers is associated with insufficient
knowledge, workload, forgetfulness, workplace safety and the insight
that colleagues also failed to follow [33,34].
Non-compliance among health care workers could also be
due to their belief that their workload is increased by adhering to
universal precautions and therefore, these procedures are difficult
to accommodate due to day to day current clinical pressures [35].
Other reasons include perceived reduction in dexterity when wearing
gloves, and the absence of penalties [36]. This study also reported
lack of penalty even for not using protective devises. Availability of
supplies and awareness programs increase compliance on standard
precautions [21]. Studies have reported significant improvement
in compliance with the standard precautions from 48% to 74% after
an educational symposium [37], and after a 30-minute educational
program [38]. In this study, compliance with hand hygiene was 38.7%
among health workers that had the knowledge. Our data corroborate
those found in other studies [39,40], which goes to show that education
and knowledge, although fundamental, but not sufficient to foster a
behavioral change regarding hand hygiene. The use of gloves was 18%
(with <5yrs experience) though the level of use increase with age. This
finding is almost similar to a Pakistan study in which 20.9% of health
workers wore gloves for most of the time to always, [41].

The Ministry of Health, Borno State, Nigeria and its health

institutions and facilities need to;
Develop specific policies on the practice of Standard
Precautions
Ensure strict implementation of these policies
Train and re-train health care providers in the implementation
of standard precautions
Ensure consistent supply of all protective materials at all times
within institutions
Rewarding of those health care workers who comply with
safety measures, while penalizing those who failed to comply.

Key Points
No specific policy on the practice of Standard Precaution.
The level of knowledge and implementation of standard
precaution in this study is unacceptably below standard to
guarantee infection safety in health workers and patients.
Less than one-fifth (19.4%) of the respondents were provided
with protective gear/apron and only 2.5% wear them.
References

Conclusion
The level of knowledge and implementation of standard precaution
in this study is unacceptably below standard to guarantee infection
safety in health workers and patients. This study calls for a need to
build the capacity of health workers on standard precaution either
through continuous health education programme or regular training
or sponsor for workshop and seminars. This is the most effective and
long-lasting means to improve health workers knowledge and foster
compliance with standard precaution measures.

Recommendation
Due to a poor knowledge and a fair level of awareness among
health workers on standard precautions, this study suggests a capacity
building of health workers in order to increase their knowledge on the
subject matter. Regular training should include the initial biohazard
handling, safety policies, safety practices, safe handling of equipment
and materials, monitoring of potential exposure and hazard.

J Community Med Health Edu

Compliance with universal precautions among health care workers at three

Citation:

Nurses understanding of standard precautions at a public hospital in Goiania

Rev
Practice
:

:
Infect

precautions and the associated risk of mucocutaneous blood exposure among

:
:

Hosp Infect
:

predictor of nonadherence to universal precautions for blood borne pathogens

needle stick prevention devices for hospitals (letter to House of Representatives

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