Introduction

Infection prevention (IP) is a realistic and evidence-based strategy to prevent unnecessary infections harming patients and healthcare professionals.^1-3 As well as ensuring patient safety, it raises universal health coverage standards.⁴ Healthcare professionals (HCPs) can be exposed them to infectious body fluids, and blood, and body parts.^5,6 It is also common for them to be exposed to microorganisms that can cause serious and even fatal illness.^7,8

A nosocomial infection is an infection that develops while receiving medical treatment but is absent upon admission.^9,10 Health-related nosocomial infections are on the rise worldwide.^9,11-13 The rate of healthcare-acquired infections (HAIs) ranges from 5.7% to 19.2% in low-income nations, whereas it is 7.5% in high-income ones.¹⁴ In some countries in Europe and the United States, nosocomial infections are less than 1%, while in Asia, Latin America, and Sub-Saharan Africa they are more than 40%.¹⁵ It is estimated that between 3% and 15% of hospital inpatients in Africa have HAIs¹⁶ and it is found between 1.6% and 28.7% in Sub-Saharan Africa.¹⁷ The overall HAI prevalence in Ethiopia was 16.96%.¹⁸ The prevalence of HAI is highly dependent on the type of hospital ward or unit. For example, intensive care units typically see a much higher rate of HAI compared with general wards.^10,19-21

Patients, healthcare professionals, and communities are at risk when IP measures are not well implemented.¹¹ It is essential for all medical professionals to practice IP to protect their health and to decrease nosocomial infections, thereby increasing patient safety.^22,23 Risks to HCPs are always present, including infections from infectious patients, although risks can be minimized by properly following an IP strategy.²⁴ How well IP methods are used depends on HCP knowledge, attitudes, and behaviors.²⁵ The proportion of good knowledge of IP among Ethiopian studies ranged from 50.9% to 99.3%.^4,25-30 The proportion of positive attitude among Ethiopian studies ranged from 40.8% to 93.4%.^4,-29 The proportion of good practice of IP among Ethiopian studies ranged from 36% to 66.1%.^4,25-33

In accordance with some studies, factors that are related to having good knowledge of IP include age, sex, the presence of IP guidelines, participation in IP training, having 5 years or more of work experience, and working in a maternity unit.^25,34-37 Sex, occupation, work history, working in an emergency room, knowing that an IP committee exists, having previously experienced HAIs, handling high-risk medical wastes—all of these factors were strongly associated with safe infection control procedures.^13,26,35

The overall impact of HAIs in Ethiopia has received relatively little consideration.³⁸ In many healthcare facilities, managing the risk of nosocomial infections is difficult due to IP. This is due to the fact that control techniques for IP and patient safety in healthcare facilities will surely require resources, staff, training, policies, and standards.^39,40 A crucial initial step in creating and executing an effective infection control program is determining the current infection control KAPs among healthcare professionals.^41,42 For providing high-quality healthcare, knowledge of the relevant evidence-based recommendations is required.³⁷ Nurses’ ignorance of the guidelines may contribute to a lack of adherence to the evidence-based recommendations for avoiding infections.^43,44

Ethiopia’s Federal Ministry of Health (FMoH) developed standards and recommendations for IP,⁴⁰ however, the implementation of IP is still not well applied in many health institutions.⁴⁵ Although there are fragments of evidence about the KAP of IP in Ethiopia,^4,25-33 nearly all research was carried out in northern and central Ethiopia, which is geographically distant from the current study area and has very different staff profiles, infrastructures, training programs, and financial support. Furthermore, as far as I am aware, no one research has been conducted in south-west Ethiopia. According to the MTUTH annual report on its health information management system, the implementation of IP is neglected, and demonstrated by a higher prevalence of HAIs.⁴⁶ For devising appropriate IP strategies, information of health professionals’ KAP of IP is of paramount importance. Therefore, this study aimed to assess the KAP of IP and its associated factors among healthcare professionals at MTUTH in southwest Ethiopia.

Methods

Populations

All healthcare professionals in the hospital were the source population. The study population consisted of randomly selected healthcare professionals. All healthcare professionals who work for at least 6 months in the direct treatment of patients at Mizan-Tepi University Teaching Hospital—specialists, general practitioners, health officials, midwives, nurses, X-ray technicians, pharmacists, and medical laboratory technicians—were included. Healthcare professionals who were seriously ill, and on annual leave during data collection and not willing to participate in the survey were excluded.

Sample Size Determination

The sample size was determined using a single population proportion formula based on the following assumptions: the level of KAP of IP among healthcare professionals to be 50% (since there is no previous study done in the area related to the topic), 95% confidence level, and 5% margin of error. The calculated sample size was 384.

Since the total population is less than 10 000, the corrected sample size formula was used: N = = 384/(1 + (384/333)) = 179. After adding 10% to non-response compensation, the final sample size was 197.

Sampling Technique

Study participants were selected using a systematic random sampling technique. The staff list from the hospital record was used as a sampling frame. Then, the sampling interval (which was 2) was calculated by dividing the total staff number by the calculated sample size for the study. A random start from 1 and 2 (the first person to be included in the sample) was chosen randomly then it was 2. Finally, every 2 (sampling interval) healthcare professionals were recruited until the required sample size was obtained.

Study Variables

KAP of IP were dependent variables. Socio-demographic characteristics (age, sex, marital status, educational status, professional qualification, and work experience) and occupational factors (availability of sufficient PPE, availability of IP manuals, and availability of IP training) were independent variables.

Operational Definitions

Good knowledge was defined as healthcare professionals who answered ⩾70% of knowledge-based questions correctly, low scores were considered as poor knowledge.²⁷ Favorable attitude was defined as healthcare professionals who answer ⩾70% of attitude-related questions positively, low scores were considered as an unfavorable attitude.²⁷ Good practice was defined as healthcare professionals who properly practiced ⩾70% of practice-related questions, low scores were considered as poor practice.²⁷ Based on this cutoff value, a scoring system was used; 1 point was awarded for each correct response to good knowledge, favorable attitudes, and good practices. Meanwhile, poor knowledge, negative attitudes, and poor practices were given 0 points. Sufficient PPE: the availability of enough PPE for daily activity in the hospital wards/units. IP manual at work: the presence of recent and updated standard precautions documents with the minimum IP and control practices that must be always used for protecting all patients and healthcare professionals in the hospital wards/units. Taking IP training: if the health professional took IP training in the last 12 months regardless of the frequency of training.

Data Collection Instrument and Procedures

A self-administered structured questionnaire was developed after reviewing relevant literature. After preparing the English version it was translated first into Amharic and then back to English to keep its consistency. The questionnaires included questions about KAP toward IP as well as socio-demographic characteristics of the respondents. A university instructor who was a specialist in occupational health conducted the face validity study. Cronbach’s alpha was used to assess the analyses’ reliability, and the reliability coefficient was high (Cronbach’s alpha: .82). A pretest was conducted on 5% of the study population who were not part of the actual data collection in Chena hospital before data collection commenced. The pre-test was used to assess whether the questionnaire measured what it was supposed to measure and to assess the presence of any ambiguous question in the questionnaire. Data collectors and supervisors were trained concerning the objective and process of data collection. They were also trained to discuss the presence of an ambiguous question in the questionnaire.

Data Processing and Analysis

SPSS version 21 was used to input and analyze the data. Using tables, the categorical variables were presented and displayed as frequencies and percentages. Continuous variables were summarized using mean and standard deviation. Bivariate logistic regression analysis was used to pinpoint the independent factors connected to the dependent variables. The multivariable logistic regression analysis was conducted to control the confounding variables. The multivariable logistic regression model included independent variables with a P-value of <.25 in bivariate logistic regression analysis. The variance inflation factor (VIF) was determined to be acceptable (less than2) after the multicollinearity of the model’s independent variables was examined. The model met the requirements for a good fit to the data, according to the Hosmer-Lemeshow goodness of fit test (P = .456). P-values <.05 were used to define significance levels.

Ethics Approval and Consent to Participate

The Mizan-Tepi University Ethical Review Committee approved the study. Ethical approval was given on 06/06/2021 with MTUERC/29/2021. The Declaration of Helsinki was followed when conducting this study. Participants were told of its aim, their freedom to decline participation, the study’s anonymity, and data confidentiality. Participants in the study provided written informed consent.

Results

Sociodemographic characteristics and health facility factors

Of the 197 respondents recruited, 196 participated, resulting in a response rate of 99.5%. The mean age of the participants was 28.3 (±3.2 SD) with a range of ages from 24 to 43 years. The mean work experience was 3.1 (±2.2 SD) years, ranging from 1 to 13 years. One hundred fifty-nine (81.1%) and 148 (75.5%) of participants had IP training in the last 12 months and reported the presence of IP manual at their workplace, respectively (Table 1).

Table 1.

Sociodemographic characteristics and health facility-related factors among healthcare professionals in Southwest Ethiopia.

Knowledge of healthcare professionals about IP

All respondents knew how to use PPE and 174 (88.8%) knew wearing PPE reduces infection risk. One hundred twenty-four (63.3%) and 165 (84.2%) of the respondents were aware of the maximum number of supplies that should be kept in the safety box containing sharp medical supplies and WHO recommended maximum delay to start HIV post-exposure prophylaxis respectively (Table 2). The mean IP knowledge score was 9.8 (±1.6 SD) out of 13, ranging from 5 to 11. The level of good IP knowledge was 141 (71.9%) (Figure 1).

Table 2.

Knowledge-related questions of IP among healthcare professionals in Southwest Ethiopia.

Figure 1.

The KAP of IP status among respondents at MTUTH in southwest Ethiopia.

Healthcare professionals’ attitude toward IP

One hundred eighty-seven (95.4%) and 183 (93.3%) of the respondents agreed occupational health and safety training is critical for healthcare professionals and healthcare professionals are at high risk of infection respectively. More than three-fourths (78.1%) of respondents disagreed regarding “needles should be capped after use” (Table 3). The mean IP attitude score was 35.2 (±3.6 SD) out of 13, ranging from 13 to 39. The level of positive attitude toward IP was 125 (63.8%) (Figure 1).

Table 3.

Attitude-related questions of IP among healthcare professionals in Southwest Ethiopia.

Healthcare professionals practice IP

One hundred seventy-five (89.3%) and 117 (59.7%) of respondents always wear gloves during risky procedures and use proper PPE during professional practice respectively. One hundred seventy-one (87.2%) and 153 (78.1%) of the respondents always practice proper disposal of clinical waste and change gloves between contacts with different patients respectively (Table 4). The mean IP practice score was 18 (±3.6 SD) out of 12, ranging from 12 to 30. Good IP practice was 105 (53.6%) (Figure 1).

Table 4.

Practice-related questions of IP among healthcare professionals in Southwest Ethiopia.

Factors associated with the knowledge, attitude, and practice of IP

A multivariable logistic regression analysis was performed for controlling potential confounding variables. Being a General Practitioner (GP)/specialist [aOR = 10.6, 95% CI (2.13-52.9)] and having an IP manual at work [aOR = 3.43, 95% CI (1.33-8.82)] were factors linked to good IP knowledge (Table 5). The presence of sufficient PPE in the work area [aOR = 2.73, 95% CI (1.36-5.50)] and taking IP training [aOR = 3.05, 95% CI (1.28-7.29)] were factors associated with favorable attitudes toward IP (Table 6). Having good IP knowledge [aOR = 3.08, 95% CI (1.39-6.86)] and the presence of sufficient PPE in the work area [aOR = 3.63, 95% CI (1.71-7.72)] were factors linked to good IP practice (Table 7).

Table 5.

Factors associated with knowledge of IP among healthcare professionals in southwest Ethiopia.

Table 6.

Factors associated with attitude toward IP among healthcare professionals in southwest Ethiopia.

Table 7.

Factors associated with practice toward IP among healthcare professionals in southwest Ethiopia.

Discussion

HAIs are a factor in lengthened hospital stays, increased mortality, and increased healthcare expenses.³⁸ HAI prevention and management is a crucial public health issue.³⁵ Determining the present infection control KAPs among healthcare professionals is a critical first step in developing and implementing an effective infection control program.^41,47 Therefore, this study aimed to assess KAP of IP among healthcare professionals at MTUTH in southwest Ethiopia.

The level of good IP knowledge was 71.9%, 95% CI (65.6%-77.2%). This finding was consistent with 67.6% in Saudi Arabia³⁵ and 70.8% in Ethiopia.²⁵ This finding was lower than 86.4%,⁴⁸ 99.3%,²⁸ and 90%²⁷ found in other studies in Ethiopia. However, this finding was higher than 20.3% in Trinidad and Tobago,⁷ 53.9% in Palestine,⁸ 60.4% in Saudi Arabia,¹³ 51.1% in Nigeria,²³ and 59.7% in Ethiopia.⁴

The level of favorable attitude to IP was 63.8%, 95% CI (57.1%-70.5%). This finding was consistent with 61.5% in Saudi Arabia³⁵ and 57.2% in Ethiopia.²⁷ This finding was lower than 78.6% in Nigeria²³ and 76.4%,⁴⁸ and 93.4%²⁸ studies in Ethiopia. However, this finding was higher than 46.7% in Trinidad and Tobago⁷ and 40.8% in Ethiopia.⁴

The level of good IP practice was 53.6%, 95% CI (46.6%-60.6%). This finding was consistent with 47.7% in Nigeria²³ and 54.8%,⁴ 55%,²⁵ 60.5%,²⁸ and 60.4%²⁶ studies in Ethiopia. This finding was lower than 91.1% in Palestine,⁸ 73.2% in Saudi Arabia,³⁵ and 77% in Ethiopia.⁴⁸ However, this finding was higher than 44% in Trinidad and Tobago,⁷ 24.6% in Saudi Arabia,¹³ and 36% in Ethiopia.²⁷

The variation observed between this, and other studies could be due to the difference in the sample size, number of questions and the operational definition used. The increment and decrement of the proportion of the outcome variables greatly depend on the sample size used. The number of questions used to measure the KAP of IP is not uniform across studies (some studies used as few as 5 questions, and some used as much as 22 questions). The use of different cut-off values to categorize the KAP of IP as good/favorable and poor/unfavorable was mentioned as a cause of the variation. Some studies used mean value as a cutoff value, some used median value as cutoff value and some others used percentage like 70% including this study as a cutoff value to categorize the KAP of IP as good/favorable and poor/unfavorable, while some previous studies used ⩾80% cut-off point).

GP/Specialists were 11 times more likely [aOR = 10.6, 95% CI (2.13, 52.9)] to know IP than other health professionals. This finding was consistent with studies conducted in Nigeria²³ and Saudi Arabia.⁴⁹ This could be due to GP/Specialists taking more infection-related courses than other healthcare professionals.^8,50

Healthcare professionals who had an IP manual in their working room were 3times more likely [aOR = 3.43, 95% CI (1.33, 8.82)] to know IP than those who did not. This finding was consistent with a study done in Northeast Ethiopia.²⁵ This may be explained by the higher likelihood of receiving updated information for healthcare professionals with IP guides that increases their IP understanding. Nurses’ ignorance of the guidelines may contribute to a lack of adherence to the evidence-based recommendations for avoiding infections.⁴⁴

Healthcare professionals who had sufficient PPE in their working room were 3 times more likely [aOR = 2.73, 95% CI (1.36, 5.50)] to have a favorable attitude toward IP than those who did not. This finding was consistent with a study conducted in Jordan,⁵¹ which revealed that the lack of PPE and inadequate infection control training associated with poor attitude toward IP. When there is a sense of a safe working environment (the availability of enough PPE), health professionals exhibit positive attitudes toward IP.⁵²

Healthcare professionals who previously took IP training were 3 times more likely [aOR = 3.05, 95% CI (1.28-7.29)] to have a favorable attitude toward IP than those who did not. This finding was consistent with a study conducted in Saudi Arabia.⁴⁹ Training program are very effective and that all health professionals should be exposed to infection control training to equip them with the necessary knowledge, better attitudes, and skills.⁵³

Healthcare professionals with good IP knowledge were 3 times more likely [aOR = 3.08, 95% CI (1.39-6.86)] to have good IP practice than those with poor IP knowledge. This finding was consistent with studies conducted in Ethiopia.^31,32 A possible explanation could be that the more you know about it, the better you do it. However, the finding was inconsistent with other studies,^54,55 which revealed good knowledge does not necessarily predict good IP practice. Implementing IP measures is hindered by a lack of awareness regarding IP. Ensuring the implementation of the measures requires consistent infrastructure, training, and resources.⁵⁶

Healthcare professionals who had sufficient PPE in their working room were 3.6 times more likely [aOR = 3.63, 95% CI (1.71-7.72)] to have good IP practices than those who did not. This finding was consistent with studies conducted in Ethiopia.^29-31 The first step to practicing IP activities is to have sufficient PPE. Without sufficient PPE, it is difficult to implement IP practices.³³ Lack of materials and equipment both contributed to and exacerbated the issue of non-compliance with recommended precautionary measures.⁵⁷

Limitations of the Study

The study has some flaws. First, the small sample size and the utilization of a single institution may restrict the generalizability of the study findings. Second, the study findings were analyzed using self-reported questionnaires with a possible self-preservation bias when reporting practice questions.

Conclusion

The level of KAP of IP among study participants was poor. The study also discovered that sociodemographic and health facility-related characteristics are connected to IP KAP. The provision of adequate PPE, IP manuals and in-service training will help to improve the KAP of healthcare professionals toward IP. Therefore, the hospital management authority and other concerned stakeholders like local NGOs and regional health bureau should provide consistent support to the health professionals in terms of training, resources, and infrastructure to improve and integrate universal precaution in everyday services.