Chapter I

INTRODUCTION

Background of the Study

Health has always been a global issue which concerns not only our nation but the entirety

of the nations on the globe. Health care settings being institutions designed to provide health care

services are also the setting most susceptible to harboring infections and diseases. Thus, health

care workers are confronted with the risk of harboring infections like those that can be acquired

through direct and even indirect contact of the causative agents.

Transmission of viruses of Hepatitis B and other Blood-borne pathogens like Human

Immunodeficiency Virus (HIV) and Hepatitis C, has been reported from patient to Health Care

Providers (HCP), from Health Care Providers to patient, and from patient to patient. Although all

three viruses are blood borne and share common routes of transmission, the epidemiology of

transmission of each differs based on the virus involved and circumstances of the exposure.

Hepatitis B Virus (HBV) is more efficiently transmitted than Hepatitis C Virus (HCV) or Human

Immunodeficiency Virus (HIV), especially if the source is positive for hepatitis B e antigen

(HBeAg), a marker for increased infectivity. In fact, when HBeAg is present, HBV is 100 times

more likely than HIV to be transmitted after a percutaneous exposure to infected blood. HCV,

while less infectious than HBV, is on average six times more likely than HIV to be transmitted

after a percutaneous exposure. Although much attention has focused on preventing HIV

transmission, it is important for HCPs to be mindful of all of these common bloodborne

pathogens. Measures for preventing transmission are common to all three of these viruses. The
risk of occupational transmission of HBV, HCV, and HIV is influenced by: a) the prevalence of

infection with bloodborne pathogen infection in the patient population and b) the nature and

frequency of occupational exposures to blood or other body fluids, and the risk of infection

transmission after exposure. (Alter, 2003)

Precautions on handling patients with such conditions have been employed as an

effective way to prevent transmission of these diseases. Standard Precautions are intended to

prevent parenteral, mucous membrane, and nonintact skin exposures of health-care workers to

bloodborne pathogens. Precautions include hand hygiene, double gloving, protective eyewear,

protective outer clothing, and footwear . Standard precautions apply to blood and to other body

fluids containing visible blood. Blood is the single most important source of HIV, HBV, and

other blood borne pathogens in the occupational setting. Infection control efforts for HIV, HBV,

and other blood borne pathogens must focus on preventing exposures to blood as well as on

delivery of HBV immunization. Practice of Standard Precaution also includes: semen and

vaginal fluids and tissues of the following fluids: cerebrospinal fluid (CSF), synovial fluid,

pleural fluid, peritoneal fluid, pericardial fluid, and amniotic fluid. (Healthcare Infection Control

Practices Advisory Committee, 2007)

In the Philippines, health and health care delivery to the people is a continuing effort that

is addressed through time. Provision of healthcare in our country has also been connected with

the constraints of financial risks and issues. The nation is facing what is pointed out as “diseases

of poverty”. Diseases in it are also contributing to poverty, giving our country a feedback loop.

The detection and diagnosing of these blood borne diseases are not adequately facilitated. Thus,

patients and health care providers are posed to a great risk of acquiring these diseases in the

health care setting especially in the practice of the health care profession. Methods of early

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screening and detection of cases transmitted through blood are also poorly implemented due to

constraints in resources. ( Department of Health, 2011)

In Davao del Sur Provincial Hospital, 110 cases of Hepatitis B have been detected over

the last five years, reported and documented. In the hospital setting, late detection of these

conditions are commonly encountered. Notice to health care workers of positive laboratory

results come in a much later time because not every patient is subjected to Hepatitis B Surface

Antigen (HBsAg) testing. Also, not all patients are able to afford laboratory fees because the

common clients of the only Government-Owned Tertiary Hospital in the province of Davao del

Sur, the Davao del Sur Provincial Hospital, are those belonging to the Quintile 1 and Quintile 2

of the population. Sometimes, the problem encountered by the institution is the unavailability of

HBsAg reagent in the laboratory due to insufficiency of fund allocated by the Provincial

Government. Health of patients and the health care workers are placed in a great risk due to these

circumstances. Commonly, these documented cases are encountered in the Obstetrics and

Gynecology Department, Operating Room and Delivery Room departments. In these areas, many

personnel are aware of the precautions that must be taken when dealing with such cases but there

are limited supplementary trainings or seminars discussing the implications and importance of

employing Standard Precaution hence, events of non-compliance occur. Stated reasons are that in

their length of service in the hospital, it is only in recent times that people have been very

conscious about precautions and that it had not done them harm over the past years and have not

contracted the disease. Needle stick injuries are under reported which is a mode of transmitting

the disease through blood. In cases of needle stick injuries, no contingency fund is allocated by

the hospital to support employees who come across such. These hazards encountered in the

workplace may greatly affect the health and productivity of the workers. It is the responsibility of

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the employees and the institution to safeguard not only the health of those they serve but also the

health of those giving care.

Presented with these encounters in the practice, the researcher came up with the effort to

assess the level of knowledge, the attitude and the level of compliance of Health care Workers in

the Obstetrics and Gynecology Department on the use of Standard Precaution against Hepatitis B

and other Blood borne Pathogens in detected cases and even in undetected cases. Thus, the main

objective of this assessment is to establish a basis to suggest or develop a plan of action to better

protect the health of the healthcare workers in Davao del Sur Provincial Hospital.

Review of Related Literature and Studies

In the study of Dhaliwal, et al in 2011 in India on the use of Standard Precaution against

blood borne pathogens among Health Care Providers in their community hospital, results show

that hundred percent of doctor had knowledge about standard precaution where as it was 80% in

staff nurse and 82% in occupational therapy technician. Around thirty eight percent of the

respondent always used double gloving, 18.4% protective eyewear, 34.5% protective outer

clothing (plastic inner covering wear inside gown) and 10.5% used Gumshoes (protective foot

wear). Around six percent of the respondents did not use double gloving, 64% protective eyes

wear, and 13.3% protective outer clothing and 61.2% gumshoes. Reasons for noncompliance

with standard precaution as elicited by this study included time constraints (53%), inconvenience

(19.3%), non-availability of protective barrier (88%) and presumption that patient was not

infected (51.6%). Results from this study reveal that there is a fair level of knowledge about

standard precaution among the Health Care Worker (HCW). But Compliance with standard

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precautions by participant is poor. So, Training programs and other strategy should be put in

place to promote the appropriate use standard precaution among health care workers.

In the 2007 Guideline for Isolation Precautions: Preventing Transmission of Infectious

Agents in Healthcare Settings, a study by Siegel, et al in 2007, results show that the successful

experience with Standard Precautions, first recommended in the 1996 guideline, has led to a

reaffirmation of this approach as the foundation for preventing transmission of infectious agents

in all healthcare settings.

In the study by Janjuan, et al in 2005, entitled “Poor Knowledge – Predictor of

Nonadherence to Standard Precautions for Blood Borne Pathogens (BBP) at First Level Care

Facilities in Pakistan”, the team conducted a cross-sectional survey and selected three different

types of public, general practitioners and unqualified practitioners through stratified random

sampling technique. At each facility, the team interviewed a prescriber, a dispenser, and a

housekeeper for knowledge of BBPs transmission and preventive practices, risk perception, and

use of standard precautions. They then performed multiple linear regression to assess the effect

of knowledge score (11 items) on the practice of standard precautions score (4 items- use of

gloves, gown, needle recapping, and HBV vaccination). Results show that qualified practitioners

had the highest knowledge score while the housekeepers had the lowest. Mean standard

precautions use score was 2.7 ± 2.1. Knowledge about mode of transmission and the work

experience alone, significantly predicted standard precaution use in multiple linear regression

model (adR2 = 0.093). The conclusion reached in the study is that Knowledge about mode of

transmission of blood borne pathogens is very low. Use of standard precautions can improve

with increase in knowledge.

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 In the 2001 Center for Disease Control Recommendations for Preventing Transmission of

Human Immunodeficiency Virus and Hepatitis B Virus to Patients During Exposure-Prone

Invasive Procedures, the document has been developed by the Center for Disease Control (CDC)

to update recommendations for prevention of transmission of human immunodeficiency virus

(HIV) and hepatitis B virus (HBV) in the health-care setting. Current data suggest that the risk

for such transmission from a health-care worker (HCW) to a patient during an invasive

procedure is small; a precise assessment of the risk is not yet available. The document contains

recommendations to provide guidance for prevention of HIV and HBV transmission during those

invasive procedures that are considered exposure-prone.

Recommendations have been made by the Centers for Disease Control (CDC) for the

prevention of transmission of the human immunodeficiency virus (HIV) and the hepatitis B virus

(HBV) in health-care settings. These recommendations emphasize adherence to standard

precautions that require that blood and other specified body fluids of all patients be handled as if

they contain blood-borne pathogens. The recommendations outlined in the document are based

on the following considerations: a. infected HCWs who adhere to standard precautions and who

do not perform invasive procedures pose no risk for transmitting HIV or HBV to patients; b.

infected HCWs who adhere to standard precautions and who perform certain exposure-prone

procedures pose a small risk for transmitting HBV to patients; c. HIV is transmitted much less

readily than HBV. In the interim, until further data are available, additional precautions are

prudent to prevent HIV and HBV transmission during procedures that have been linked to HCW-

to-patient HBV transmission or that are considered exposure-prone.

Previous recommendations have specified that infection-control programs should

incorporate principles of standard precautions (i.e., appropriate use of hand hygiene, protective

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barriers, and care in the use and disposal of needles and other sharp instruments) and should

maintain these precautions rigorously in all health-care settings. Proper application of these

principles will assist in minimizing the risk of transmission of HIV or HBV from patient to

HCW, HCW to patient, or patient to patient.

In the 2000 recommendation of the Center for Disease Control on the “Perspectives in

Disease Prevention and Health Promotion Update: Standard Precautions for Prevention of

Transmission of Human Immunodeficiency Virus, Hepatitis B Virus, and Other Bloodborne

Pathogens in Health-Care Settings,” this stated the clarification on the body fluids to which

Standard Precautions apply and to which they do not. It specified that standard precautions apply

to blood and to other body fluids containing visible blood. Occupational transmission of HIV and

HBV to health-care workers by blood is documented. Blood is the single most important source

of HIV, HBV, and other bloodborne pathogens in the occupational setting. Infection control

efforts for HIV, HBV, and other bloodborne pathogens must focus on preventing exposures to

blood as well as on delivery of HBV immunization. Standard precautions also apply to semen

and vaginal secretions. Although both of these fluids have been implicated in the sexual

transmission of HIV and HBV, they have not been implicated in occupational transmission from

patient to health-care worker. This observation is not unexpected, since exposure to semen in the

usual health-care setting is limited, and the routine practice of wearing gloves for performing

vaginal examinations protects health-care workers from exposure to potentially infectious

vaginal secretions.

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Standard Precaution.

Standard precautions also apply to tissues and to the following fluids: cerebrospinal fluid

(CSF), synovial fluid, pleural fluid, peritoneal fluid, pericardial fluid, and amniotic fluid. The

risk of transmission of HIV and HBV from these fluids is unknown; epidemiologic studies in the

health-care and community setting are currently inadequate to assess the potential risk to health-

care workers from occupational exposures to them. However, HIV has been isolated from CSF,

synovial, and amniotic fluid , and HBsAg has been detected in synovial fluid, amniotic fluid, and

peritoneal fluid. One case of HIV transmission was reported after a percutaneous exposure to

bloody pleural fluid obtained by needle aspiration. Whereas aseptic procedures used to obtain

these fluids for diagnostic or therapeutic purposes protect health-care workers from skin

exposures, they cannot prevent penetrating injuries due to contaminated needles or other sharp

instruments.

Standard precautions do not apply to feces, nasal secretions, sputum, sweat, tears, urine,

and vomitus unless they contain visible blood. The risk of transmission of HIV and HBV from

these fluids and materials is extremely low or nonexistent. HIV has been isolated and HBsAg has

been demonstrated in some of these fluids; however, epidemiologic studies in the health-care and

community setting have not implicated these fluids or materials in the transmission of HIV and

HBV infections. Some of the above fluids and excretions represent a potential source for

nosocomial and community-acquired infections with other pathogens, and recommendations for

preventing the transmission of nonbloodborne pathogens have been published.

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Knowledge.

In the study entitled, “Poor Knowledge – Predictor Of Nonadherence To Standard

Precautions For Blood Borne Pathogens At First Level Care Facilities In Pakistan,” conclusions

obtained from the study were knowledge of healthcare workers about the mode of transmission

of blood-borne pathogens and precautions was low across all types of providers. Physicians,

however, were better informed. Very few healthcare workers used standard precautions to lower

the risk of blood-borne pathogens at their workplace. Poor knowledge determined the very low

use of standard precautions that can prevent major proportion of exposure to blood-borne

pathogens. Lack of standard precautions use has implications for blood-borne pathogens

transmissions among healthcare workers, especially when prevalence of these pathogens in the

general population is high. The findings of the study suggests that training of healthcare workers

to increase their knowledge about blood-borne pathogens and standard precautions could

improve their use of standard precautions. The discussions with health care workers during this

study and in a separate training of master trainers from various health care facilities suggest that

healthcare workers are eager to improve their knowledge about use of standard precautions to

protect their health. A model to develop locally relevant educational material and to train master

trainers from different areas who in turn educate their peers can work at large scale in short run.

The outcome suggested program of training master trainers can be institutionalized at local level

through district health departments. However in the long run, a framework incorporating

training, supplies, surveillance, and post exposure prophylaxis for prevention of bloodborne

pathogens exposure is needed. (Wilkins, 2010)

Also, a study entitled, “Knowledge and Practices of Healthcare Workers in Relation to

Bloodborne Pathogens in a Tertiary Care Hospital, Western Saudi Arabia” was done to assess

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knowledge and practices of healthcare workers (HCWs) in relation to blood-borne pathogens in a

tertiary care hospital, Western Saudi Arabia. Self-administered questionnaire was distributed

assessing demographic characteristics, knowledge and practices of physicians, nurses and

technicians on risks of exposure and prophylaxis against human immunodeficiency virus,

hepatitis B virus and hepatitis C virus infections. A total of 466 participants (151; 32.4 %

physicians and 315; 67.6 % nurses/technicians) completed the questionnaire. Almost two thirds

of the physicians (60.9 %) and half of the nurses/technicians (47.6 %) had history of exposure to

risks of blood-borne infection. Results of the study revealed that although both physicians and

nurses/technicians showed acceptable level of knowledge about risks of bloodborne infections,

modest proportion knew the correct actions including reporting following exposure. Behavioral-

based in-service training interventions and strict policy should be implemented to promote

compliance of HCWs to the protective measures against hazards of bloodborne infection

(Garner, 2007).

Attitude.

In the study, “Perception And Practice Of Standard Precautions Against Blood Borne

Pathogens Amongst House Officers And Nurses In Tertiary Health Institutions In Southeast

Nigeria,” results showed that most doctors, 66.6%, were aged 26-30 years while the Nurses,

41.1%, were aged 40 years. 57.6% of the Doctors were males, while 85.7% of the nurses were

females. Perception/ Attitude of standard precautions measures was high for both categories of

respondents--97.0% for doctors and 92.0% for nurses, although practice was better for the

nurses, 75.0%, compared to the doctors, 15.2%, p < 0.05. The most important factor influencing

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standard precautions practice is the lack of provision of adequate protective equipments. Other

factors, all of which show significant difference between the doctors and nurses (p < 0.05),

include carelessness; lack of display of standard precautions guidelines; emergency nature of the

procedure; insufficient water supply; patient perceived to be at low risk of blood borne

pathogens; pressure of time; and standard precautions equipments interfering with technical

skills (Leimane, 2005).

Logistic Support.

In the study of Oliveria in 2008 entitled, “Knowledge And Logistic Support Regarding

Standard Precautions In A Brazilian Public Emergency Service: A Cross-Sectional Study,”

shows that physicians scored 85.3% on average; however, for items related to standard

precaution and disposal of waste produced during care, scores were below 75%. Nurses scored

83.2% on average; however for issues related to the risk of crossed transmission of infectious

agents and the risk of infection by contact between blood and the eye, scores were below 75%.

Nursing auxiliaries scored 75.9% on average; but for issues concerning crossed infection,

Standard precautions, blood-transmitted diseases, and the risk of infection by contact between

blood and the eye, scores were below 75%. Drivers had the lowest level of knowledge compared

to the other workers, scoring 65.0% (adequate answers) on average. They showed a lack of

knowledge about almost all the items assessed, except for recommending hand hygiene, care

after accidents with sharp-edged objects, and vaccination against hepatitis B. It is emphasized

that, compared to other workers, only physicians scored over 75% of adequate answers regarding

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the items concerning risk of infection by contact between blood and the ocular mucosa and risk

of crossed transmission of infectious agents when accessing peripheral veins.

In addition, there was a statistically significant difference among occupations regarding

the vehicle for transmitting infectious agents, recommending the use of disposable gloves at the

emergency service, importance of hand hygiene, infection risk by contact between blood and the

ocular mucosa; and possible infection due to contact with body fluids and blood (p< 0.01). The

analysis of occupational accidents involving biological material, per occupation, revealed that

35.3% of physicians were involved in accidents; 83.3% of cases were related to body fluid

contact. No medical intervention was followed in any cases. Serological monitoring was done in

16.7% of these accident victims during one year. An important point is that no occupational

accident reports were issued in any of these accidents. Among nurses, the occupational accident

rate was 24.0%. Of these, 50.0% involved sharp-edged materials, 33.3% resulted from contact

with body fluids, and 16.7% had both forms of contact. A medical evaluation was performed in

only 33.3% of cases, and no occupational accident report was issued. Serological monitoring

during one year was also not done in any of these cases. This showed poor logistic support from

the institution when these cases are encountered.

Also, in the study of Watanabe in 2013 entitled, “Factors Influencing Compliance with

Infection Control Practice in Japanese Dentists,” results showed that the associations of

knowledge about standard precautions are strong factors that affect compliance. Also, logistic

support, funding for Personal Protective Equipments, also motivates Healthcare workers to

practice Standard Precaution.

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 Three Personal Protective Equipment items (ie, wearing glass, exchanging handpiece,

installing extra-oral vacuum) that was practiced with a frequency of <50% were compared

between those who had disadvantageous characteristics (age ≥50 years, being a general dentist,

treating ≤35 patients/day) with and without knowledge about standard precautions. For wearing

glass, the odds ratio was highest for those who had fewer visits. On the contrary, in exchanging

handpiece and installing extra-oral vacuum aspiration, the odds ratios were highest for those who

aged 50 years or more. This showed that one factor that contributed to the poor compliance is

poor provision of materials for body surface isolation.

In the study of Efsthathiu in Cyprus in 2011 entitled, “Factors influencing nurses'

compliance with Standard Precautions in order to avoid occupational exposure to

microorganisms: A focus group study,” results showed that non-availability of equipment was

reported as an obstacle for implementing Standard Precautions, as they cannot be followed if the

health care worker does not have direct access to them. In fact, some participants argued that

equipment is stored or even locked far away from the place nursing care is provided, making

their use impossible under certain situations (for example emergency situation). It is therefore

vital for nurses to have the protective equipment at their disposal, for use when necessary.

Compliance.

In the study of Jawaid in 2009 entitled, “Compliance with Standard Precaution: A Long

Way Ahead,” conducted in a hospital in Pakistan, results revealed that of the 120 doctors who

participated in this study (which includes 60% interns, 34.2% residents and 5.8% consultants) a

total of 95% respondents were vaccinated against Hepatitis B virus but only 27.4% knew their

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antibody titers. Majority of the doctors, 52.5% didn’t know anything about Centers for Disease

Control guideline for standard precautions while 40% of the respondent had some idea and only

7.5% knew them well. Among responders, 56.7% changed gloves for each patient and only

39.2% washed hand in between examining patients. Most of the doctors, 58.3% said they always

wear apron while dealing with patients while 20% wear only when dealing with high risk

patients. Protective goggles were not used by any of the respondents. The reasons given for non-

compliance included non-availability of protective modalities by 58.3% while 20% were of the

opinion that it is not practical. The conclusion obtained from this study was that the knowledge,

attitude and compliance among doctors towards standard precautions is inadequate. Availability

of supplies and awareness programs for these standard precautions are recommended for better

compliance.

Also in a study by BMC Nursing in 2011 entitled, “Study Explores Nurses' Compliance

With Standard Precautions,” reached a conclusion that changing current behavior requires

knowledge of the factors that may influence nurses' compliance with standard precautions. This

knowledge will facilitate in the implementation of programs and preventive actions that

contribute in avoiding occupational exposure. This study utilized a focus group approach was

used to explore the issue under study. Four focus groups (N=30) were organized to elicit nurses'

perception of the factors that influence their compliance with standard precautions. The Health

Belief Model (HBM) was used as the theoretical framework and the data were analyzed

according to predetermined criteria.

In a study by Hedayati in 2014 entitled, “Barriers to standard precautions adherence in a

dental school in Iran: A qualitative study,” results was that proximal factors of poor Standard

Precaution adherence were a lack of knowledge and technical difficulties. These factors were

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compounded by intermediate factors in the work environment: lack of facilities, heavy workload,

patient expectations, interprofessional conflicts, and lack of good role models. Two underlying

distal factors were financial issues and unsupportive organizational culture. The social

constructionism theory was useful in analyzing the situation and suggesting an educational

approach as part of the solution. Consequently, the conclusion reached was that complex and

intertwined barriers of Standard Precaution adherence were found in this dental school. A social

construction approach may assist in addressing these problems by shifting the culture through

education to construct a contextual new knowledge. Further research in medical sociology of SP

practices would be useful.

In the study of McCoy in 2013 entitled, “Percutaneous Injury, Blood Exposure, and

Adherence to Standard Precautions: Are Hospital-Based Health Care Providers Still at Risk?,”

recommendation reached for this study included that epidemiology of percutaneous injury and

blood exposure and factors associated with compliance and underreporting need to be better

understood. The results argued for longitudinal surveillance research aimed at identifying trends

over time and the impact of interventions. New strategies for education and randomized trials to

test alternative strategies should be pursued. In addition, organizational characteristics

contributing to compliance need more study. Furthermore, protective devices for handling sharps

and engineered devices have been strongly advocated as an approach to decreasing percutaneous

injury. Increasing regulatory, legislative, and political pressure should increase the use of these

devices within hospitals. Further funding is needed for all of these areas of research. Potential

approaches to be evaluated could include widespread implementation of programs to better train

health care workers and monitor adherence, improved surveillance for and analysis of injury

data, and widespread implementation of safer devices where they are most likely to be beneficial.

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Theoretical Framework

This study is anchored in the Health Belief Model. This theory is about the psychological

health behavior change model developed to explain and predict health-related behaviors,

particularly in regard to the uptake of health services. The health belief model was developed in

the 1950s by social psychologists at the U.S. Public Health Service and remains one of the most

well-known and widely used theories in health behavior research. The health belief model

suggests that people's beliefs about health problems, perceived benefits of action and barriers to

action, and self-efficacy explain engagement (or lack of engagement) in health-promoting

behavior. A stimulus, or cue to action, must also be present in order to trigger the health-

promoting behavior. Theoretical constructs include: a. Perceived Severity- this refers to

subjective assessment of the severity of a health problem and its potential consequences. The

health belief model proposes that individuals who perceive a given health problem as serious are

more likely to engage in behaviors to prevent the health problem from occurring (or reduce its

severity). Perceived seriousness encompasses beliefs about the disease itself (e.g., whether it is

life-threatening or may cause disability or pain) as well as broader impacts of the disease on

functioning in work and social roles; b. Perceived Susceptibility- this refers to subjective

assessment of risk of developing a health problem. The health belief model predicts that

individuals who perceive that they are susceptible to a particular health problem will engage in

behaviors to reduce their risk of developing the health problem. Individuals with low perceived

susceptibility may deny that they are at risk for contracting a particular illness; c. the

combination of perceived seriousness and perceived susceptibility is referred to as perceived

threat. Perceived seriousness and perceived susceptibility to a given health condition depend on

knowledge about the condition. The health belief model predicts that higher perceived threat

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leads to higher likelihood of engagement in health-promoting behaviors; d. Perceived Benefits-

this refers to the health-related behaviors which are also influenced by the perceived benefits of

taking action. Perceived benefits refer to an individual's assessment of the value or efficacy of

engaging in a health-promoting behavior to decrease risk of disease; e. Perceived Barriers-

health-related behaviors are also a function of perceived barriers to taking action. Perceived

barriers refer to an individual's assessment of the obstacles to behavior change. Even if an

individual perceives a health condition as threatening and believes that a particular action will

effectively reduce the threat, barriers may prevent engagement in the health-promoting behavior.

In other words, the perceived benefits must outweigh the perceived barriers in order for behavior

change to occur; f. Cues to Action- the health belief model posits that a cue, or trigger, is

necessary for prompting engagement in health-promoting behaviors; and g. Self-Efficacy refers

to an individual's perception of his or her competence to successfully perform a behavior. Self-

efficacy was added to the health belief model in an attempt to better explain individual

differences in health behaviors (Tomey, 2002).

The Illness-Wellness Continuum

Health and disease lie along a continuum and there is no single cut-off point. The lowest

point on the health and disease spectrum is death and highest point corresponds to the World

Health Organization (WHO) definition of positive health .It is thus obvious that health fluctuates

within a range of optimum well being to various levels of dysfunction, namely the death. The

transition from optimum health to ill health is often gradual, and where state ends and the other

begin is a matter of judgment. So the spectral concept of health of an individual is not static. It is

a dynamic phenomenon and a process of continuous change, subject to frequent stable variations.

That is a person may function at maximum level of health today and diminished level of health

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tomorrow. It implies that health is a state not to be attained once and for all, but ever to be

renewed. There are degrees or ‘levels of health ‘as there are degrees or severity of illness. As

long as we are alive there is some degree of health in us (Tomey, 2002).

R. Dubois, a medical expert, views health as adaptation, a function of adjustment. He

believes a utopian state of health can never be so perfectly adapted to the environment that life

will not involve struggle, failure and suffering. Human can adapt to environment but each new

adaptation procedures have new problems that demand new solutions.

Illness is more than signs and symptoms. It is a process and an experience. It is failure of

the person’s adaptive power to maintain physical and emotional balance and to utilize the usual

health promoting resources in the face of internal and external stressors.

It is a disturbance or adaptation of the person, with observable or felt changes, discomforts and

social behavior expectations appropriate to customary role and status.

H.S.Sullivan, an American Psychologist, defines mental or emotional illness as inappropriate

interpersonal behavior or behavior that is inadequate for the social context. Sullivan believes that

each person has some small degree of illness, physical or emotional even when he or she feels

and looks well. The illness may be minor aches, temper flares, inappropriate forgetfulness, or

over use of certain defense mechanisms such as rationalization or forgetfulness. Similarly the

emotionally ill person manifests some degree of health.

Health Illness Continuum Model

Health always involves a continuum, a range of degree from optimal health at one end to

death or total disability at the other. The health of an individual moves back and forth along this

continuum throughout life according to health and illness continuum model.

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Health is a dynamic state fluctuates as a person adapts to change in the internal and external

environment (Tomey, 2002).

High level of wellness and severe illness are at opposite ends of the continuum.

According the Neumann’s 1990 health on a continuum is the degree of client’s wellness that

exist at any point in time running from an optimal wellness condition, with available energy at its

maximum to death. Risk factors are important in identifying level of health. They include genetic

and physiological variables such as age, lifestyle, and environment.

Most of us think of wellness in terms of illness; we assume that the absence of illness

indicates wellness. There are actually many degrees of wellness, just as there are many degrees

of illness. The Illness-Wellness Continuum illustrates the relationship of the treatment paradigm

to the wellness paradigm. The Illness-Wellness Continuum was first envisioned by John in 1972,

and published in 1975.

Figure 1. The Illness-Wellness Continuum

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 In Figure 1, it is shown that moving from the center to the left shows a progressively

worsening state of health while moving to the right of center indicates increasing levels of health

and wellbeing. The treatment paradigm (drugs, herbs, surgery, psychotherapy, acupuncture, and

so on) can bring you up to the neutral point, where the symptoms of disease have been alleviated.

The wellness paradigm, which can be utilized at any point on the continuum, helps you move

toward higher levels of wellness. The wellness paradigm directs you beyond neutral and

encourages you to move as far to the right as possible. It is not meant to replace the treatment

paradigm on the left side of the continuum, but to work in harmony with it. If you are ill, then

treatment is important, but don't stop at the neutral point. Use the wellness paradigm to move

toward high-level wellness (Tomey, 2002).

Wellness is not a static state. High-level wellness involves giving good care to your

physical self, using your mind constructively, expressing your emotions effectively, being

creatively involved with those around you, and being concerned about your physical,

psychological, and spiritual environments.

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Chain of Infection

Figure 2. The Chain of Infection

As described in Figure 2, the traditional epidemiologic triad model holds that infectious

diseases result from the interaction of agent, host, and environment. More specifically,

transmission occurs when the agent leaves its reservoir or host through a portal of exit, is

conveyed by some mode of transmission, and enters through an appropriate portal of entry to

infect a susceptible host. This sequence is sometimes called the chain of infection. The chain

of infection is a way of gathering the information needed to interrupt or prevent an epidemic.

Each of the links in the chain must be favorable to the organism for the epidemic to continue.

Breaking any link in the chain can disrupt the epidemic. Which link it is most effective to

target will depend on the organism. (Tomey, 2002) 1a. Reservoir. The reservoir of an

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infectious agent is the habitat in which the agent normally lives, grows, and multiplies.

Reservoirs include humans, animals, and the environment. The reservoir may or may not be

the source from which an agent is transferred to a host. 1b. Human reservoirs. Many

common infectious diseases have human reservoirs. Diseases that are transmitted from

person to person without intermediaries include the sexually transmitted diseases, measles,

mumps, streptococcal infection, and many respiratory pathogens. Because humans were the

only reservoir for the smallpox virus, naturally occurring smallpox was eradicated after the

last human case was identified and isolated. Human reservoirs may or may not show the

effects of illness. A carrier is a person with unapparent infection who is capable of

transmitting the pathogen to others. Asymptomatic or passive or healthy carriers are those

who never experience symptoms despite being infected. Incubatory carriers are those who

can transmit the agent during the incubation period before clinical illness begins.

Convalescent carriers are those who have recovered from their illness but remain capable of

transmitting to others. Chronic carriers are those who continue to harbor a pathogen such as

hepatitis B virus or Salmonella Typhi, the causative agent of typhoid fever, for months or

even years after their initial infection. Carriers commonly transmit disease because they do

not realize they are infected, and consequently take no special precautions to prevent

transmission. Symptomatic persons who are aware of their illness, on the other hand, may be

less likely to transmit infection because they are either too sick to be out and about, take

precautions to reduce transmission, or receive treatment that limits the disease. 1c. Animal

reservoirs. Humans are also subject to diseases that have animal reservoirs. Many of these

diseases are transmitted from animal to animal, with humans as incidental hosts. The

term zoonosis refers to an infectious disease that is transmissible under natural conditions

22
from vertebrate animals to humans. 1d. Environmental reservoirs. Plants, soil, and water in

the environment are also reservoirs for some infectious agents. Many fungal agents, such as

those that cause histoplasmosis, live and multiply in the soil. Outbreaks of Legionnaires

disease are often traced to water supplies in cooling towers and evaporative condensers,

reservoirs for the causative organism Legionella pneumophila. 2.Portal of exit. Portal of exit

is the path by which a pathogen leaves its host. The portal of exit usually corresponds to the

site where the pathogen is localized. Some bloodborne agents can exit by crossing the

placenta from mother to fetus (rubella, syphilis, toxoplasmosis), while others exit through

cuts or needles in the skin (hepatitis B) or blood-sucking arthropods (malaria).3. Modes of

transmission. An infectious agent may be transmitted from its natural reservoir to a

susceptible host in different ways. There are different classifications for modes of

transmission. Here is one classification: a. Direct which includes Direct contact and Droplet

spread; b. Indirect contact including Airborne, Vehicleborne and Vectorborne (mechanical or

biologic). In direct transmission, an infectious agent is transferred from a reservoir to a

susceptible host by direct contact or droplet spread (Tomey, 2002).

Direct contact occurs through skin-to-skin contact, kissing, and sexual intercourse.

Direct contact also refers to contact with soil or vegetation harboring infectious organisms.

Thus, infectious mononucleosis (“kissing disease”) and gonorrhea are spread from person to

person by direct contact. Hookworm is spread by direct contact with contaminated soil.

Droplet spread refers to spray with relatively large, short-range aerosols produced by

sneezing, coughing, or even talking. Droplet spread is classified as direct because

transmission is by direct spray over a few feet, before the droplets fall to the ground. Pertussis

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and meningococcal infection are examples of diseases transmitted from an infectious patient

to a susceptible host by droplet spread (Tomey, 2002).

Indirect transmission refers to the transfer of an infectious agent from a reservoir to a

host by suspended air particles, inanimate objects (vehicles), or animate intermediaries

(vectors).

Airborne transmission occurs when infectious agents are carried by dust or droplet nuclei

suspended in air. Airborne dust includes material that has settled on surfaces and become

resuspended by air currents as well as infectious particles blown from the soil by the wind.

Droplet nuclei are dried residue of less than 5 microns in size. In contrast to droplets that fall to

the ground within a few feet, droplet nuclei may remain suspended in the air for long periods of

time and may be blown over great distances. Measles, for example, has occurred in children

who came into a physician's office after a child with measles had left, because the measles virus

remained suspended in the air.

Vehicles that may indirectly transmit an infectious agent include food, water, biologic

products (blood), and fomites (inanimate objects such as handkerchiefs, bedding, or surgical

scalpels). A vehicle may passively carry a pathogen — as food or water may carry hepatitis A

virus. Alternatively, the vehicle may provide an environment in which the agent grows,

multiplies, or produces toxin — as improperly canned foods provide an environment that

supports production of botulinum toxin by Clostridium botulinum.

Vectors such as mosquitoes, fleas, and ticks may carry an infectious agent through purely

mechanical means or may support growth or changes in the agent. In contrast, in biologic

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transmission, the causative agent of malaria or guinea worm disease undergoes maturation in an

intermediate host before it can be transmitted to humans.

4. Portal of entry. The portal of entry refers to the manner in which a pathogen enters a

susceptible host. The portal of entry must provide access to tissues in which the pathogen can

multiply or a toxin can act. Often, infectious agents use the same portal to enter a new host

that they used to exit the source host. For example, influenza virus exits the respiratory tract

of the source host and enters the respiratory tract of the new host. In contrast, many pathogens

that cause gastroenteritis follow a so-called “fecal-oral” route because they exit the source

host in feces, are carried on inadequately washed hands to a vehicle such as food, water, or

utensil, and enter a new host through the mouth. Other portals of entry include the skin

(hookworm), mucous membranes (syphilis), and blood (hepatitis B, human

immunodeficiency virus). 5. Host. The final link in the chain of infection is a susceptible host.

Susceptibility of a host depends on genetic or constitutional factors, specific immunity, and

nonspecific factors that affect an individual's ability to resist infection or to limit

pathogenicity. An individual's genetic makeup may either increase or decrease susceptibility.

For example, persons with sickle cell trait seem to be at least partially protected from a

particular type of malaria. Specific immunity refers to protective antibodies that are directed

against a specific agent. Such antibodies may develop in response to infection, vaccine, or

toxoid (toxin that has been deactivated but retains its capacity to stimulate production of toxin

antibodies) or may be acquired by transplacental transfer from mother to fetus or by injection

of antitoxin or immune globulin. Nonspecific factors that defend against infection include the

skin, mucous membranes, gastric acidity, cilia in the respiratory tract, the cough reflex, and

nonspecific immune response. Factors that may increase susceptibility to infection by

25
disrupting host defenses include malnutrition, alcoholism, and disease or therapy that impairs

the nonspecific immune response.

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Conceptual Framework

Independent Variable Dependent Variable

Standard Precaution Compliance on Universal

Attitude

Logistic Support

Respondent’s Profile
 Age
 Gender
Intervening
Category Variable
as Healthcare
Worker
 Length of Service

Intervening Variable

Figure 3: Conceptual Framework of the Study

The figure above shows that the independent variables of the study are the level of

knowledge, attitude and logistic support on Standard Precaution. The dependent variable of the

study is the level of compliance to the Standard Precaution among the respondents.

The study included the respondents’ profile as intervening variable. The profile is in

terms of the age, sex, category of respondents as healthcare worker and length of service.

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Statement of the Problem

This study aims to determine the Level of Knowledge, Attitude and Logistic Support and

the Level of Compliance on the Standard Precaution among healthcare workers in Obstetrics and

Gynecology Departments of the Davao del Sur Provincial Hospital.

Specifically, this study aims to answer the following:

1. What is the profile of the respondents in terms of:

1.1 Age

1.2 Sex

1.3 Category of respondents as healthcare worker

1.4 Length of Service in the institution?

2. What is the level of knowledge of the respondents on Standard Precaution in terms of:

2.1 Hand hygiene

2.2 Double Gloving

2.3 Protective Clothing

2.4 Protective Eyewear

2.5 Footwear?

3. What is the level of attitude of the respondents on Standard Precaution in terms of:

3.1 Hand hygiene

3.2 Double Gloving

3.3 Protective Clothing

3.4 Protective Eyewear

3.5 Footwear?

4. What is the level of Logistic Support in terms of:

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 4.1 Provision/ Availability of Personal Protective Equipments

4.2 Availability of Facilities for Early Detection and Screening

4.3 Skill Enhancement Program

5. What is the level of compliance to the Standard Precaution among the respondents in

terms of:

5.1 Hand hygiene

5.2 Double Gloving

5.3 Protective Clothing

5.4 Protective Eyewear

5.5 Footwear?

6. Are there significant relationships between the level of compliance on Standard

Precaution and each of the following variables?

6.1 Knowledge

6.2 Attitude

6.3 Logistic Support

7. Are there significant differences in each of the following variables when respondents

are grouped according to their demographic profile?

7.1 Knowledge

7.2 Attitude

7.3 Logistic Support

8. Is there a significant difference in the level of compliance to the Standard Precaution

when respondents are grouped according to their demographic profile?

9. What regression model maybe drawn from the findings of the study?

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Hypotheses

The research employed the following hypotheses:

Ho1: There are no significant relationships between the level of compliance on

Standard Precaution and the knowledge and attitude of the respondents and logistic

support.

Ho2: There are no significant differences in the knowledge, attitude and logistic

support when respondents are grouped according to their demographic profile.

Ho3: There is no significant difference in the level of compliance to the Standard

Precaution when respondents are grouped according to their demographic profile.

Definition of Terms

To establish a common ground of understanding, the terms are defined below as they are

operatively used in the study.

Attitude. This refers to the perception of favor or disfavor about the practice of Standard

Precaution.

Compliance. This refers to the adherence to a preset policy on Standard Precaution in

terms of hand hygiene, wearing double gloving, wearing protective clothing, wearing protective

eyewear, and wearing footwear.

Double Gloving.This refers to the use of two protective hand covers before, during and

after handling a patient.

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 Footwear.This refers to the use of appropriate shoes which are non-absorbent and

protects the foot from splashes of blood and other body fluids.

Hand hygiene. This refers to the conduct of hand washing using water and other agents

for disinfection of hands.

Healthcare Workers. This refers to the personnel responsible for rendering healthcare

services which include: doctors, nurses, midwives and nursing aides.

Knowledge.This refers to the familiarity and in depth understanding to the Standard

Precaution that must be employed when dealing with Hepatitis B and Other-Blood Borne

Pathogens

Logistic Support. This refers to the perceived adequacy of procurement and distribution

of equipment, facilities, and trained personnel, essential to the proper operation of a protocol.

Protective Clothing. This includes the use of apron, surgical cap and gown.

Protective Eyewear. This includes the use of googles, face shield and facemask.

Standard Precaution. These are practices employed to avoid contact with patients'

bodily fluids, by means of the wearing of nonporous articles. In the study, this includes the use of

double gloving, protective eyewear, protective clothing, footwear and hand hygiene.

Significance of the Study

The results of the study are deemed beneficial to the following:

The Healthcare Workers of Davao del Sur Provincial Hospital. This study will

directly benefit the Healthcare Workers of Davao del Sur Provincial Hospital who are directly

involved in the daily encounter of rendering healthcare services to the people of Davao del Sur.

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Results may also serve as basis for recommendation for improvement and trainings on putting

into practice the Standard Precaution against Hepatitis B and Other Blood-Borne Diseases.

The Clients of Davao del Sur Provincial Hospital. This study will benefit the people

whom the institution provides healthcare services to. Transmission of blood-borne diseases will

be minimized and lesser threat or harm maybe posed to the clients. In putting Standard

Precaution against Hepatitis B and Other Blood-Borne Diseases into practice, patients are

provided with security that the services the institution provide are always directed to their

protection and betterment.

The Administration of Davao del Sur Provincial Hospital. This study will also benefit

the administration of Davao del Sur Provincial Hospital since the result of the study may serve as

a basis for recommendation for the improvement of the healthcare services the institution

provides which may increase the influx of patients to the hospital. This will not only increase the

revenue of the institution but will also help more members of the lower-class society of the

province obtain fiscal austerity or equality towards availability of healthcare services.

The Province of Davao del Sur. The Davao del Sur Provincial Hospital being the only

Government-Owned Tertiary Hospital in the province of Davao Del Sur serves as the referral

hospital for other primary and secondary health institutions in the province thus, improving the

provision of basic health services to mostly indigent members of the society belonging to the

Quintile 1 and Quintile 2 will bring equality to the services the poor people can avail.

The Future Researchers. The result of the study may serve as a source of data for future

related studies.

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