Health care workers knowledge, attitude and practice towards hospital acquired infection prevention at Dessie referral hospital, Northeast Ethiopia

Conclusion: Even though the majority of the health care workers had good knowledge and favorable attitude, more than two third of them had poor practice towards hospital acquired infection prevention. Therefore health workers should strictly follow hospital acquired infection prevention guidelines. Improving sustainable supplies like personal protective equipment, water supply and hand washing facilities at patient care site is vital to correct the poor practice of infection prevention.

Hospital acquired infection (HAI) continues to be burden to the world health care system through increased risk to patient and employees. These infections have remarkable health and inancial costs with an estimate incidence of

Research Article
Health care workers knowledge, attitude and practice towards hospital acquired infection prevention at Dessie referral hospital, Northeast Ethiopia 2,000,000 infection per year, 20,000 death per year and increased costs of billion dollars per year [6]. It is also estimated that more than 1.4 million people worldwide suffering from HAI. Approximately in the United States, 2 million patients develop HAI, and nearly 90,000 of these patients are estimated to die. In Sub-Saharan countries the problems associated HAIs hampered by inadequate data. However, prevalence from some African countries reported that high infection rates (Mali 18.9%, Tanzania 14.8%), rates of infection can exceed 20% [7]. Study in Ethiopia revealed that high prevalence of both life times (28.8%) and one year (20.2%) HAI exposure among health care workers (HCWs) [8].
Hospital acquired infection prevention (HAIP) is standardized guide line contain multitude protocols needed to be implemented by HCWs to reduce HAIs [9]. But several factors such as poor awareness among HCWs, compliance associated with personal, logistical and organizational barriers have negative effect on proper application of HAIP protocols [10].
HAIP which is the back bone of reducing HAIs didn't get enough attention in Ethiopia. Moreover, in our study area there is scarcity of studies on health care workers knowledge, attitude and practice (KAP) towards HAIPs so that we tried to investigate KAP of Dessie referral hospital (DRH) health workers towards HAIP in order to indicate measures to be taken to address the problem.

Study design, setting and period
Facility based cross sectional study was conducted in Dessie referral hospital among health care workers to assess their KAP towards HAIP from March 11-17, 2017. DRH found in Dessie town, Amhara region, North east Ethiopia, 401 km away from Addis Ababa, the capital of Ethiopia and 480 km from Bahirdar, capital of Amhara regional state. This hospital gives many services including preventive, curative and rehabilitative care for patients coming from all woredas and zones of Eastern Amhara and Afar regional state.

Population
This study was done on HCW working in DRH. Those HCW providing health care service during data collection period were included in the study. HCW who were not providing service during the study period such as health workers who were on annual breaks and educational leave were excluded in this study.

Sample size determination and sampling technique
The sample size was determined by using single population proportion formula, the level of con idence = 95% (Z = 1.96), degree of precision (marginal error) = 5% and by taking estimate of prevalence towards HAIP practice = 54.2% [11]. Based on this assumption, the sample size for the study was 381. Since total population is 388 which is less than 10,000; we used population correction formula, we got 192. Then by adding 10% for non-response rate the inal sample size was 211 health care providers. To select the study participants, the total sample size was allocated proportionally based on the number of professional size in each department. Finally, from each department, health workers were selected by using simple random sampling method to attain the inal individuals.

Data collection tools and procedure
Self-administered questionnaire was used for data collection. It includes four parts; the irst section containing socio demographic characteristics such as age, sex, educational status, work experience and profession. The second part elicits about knowledge, the third part includes questions concerning attitude and the last part includes practice assessment questions towards infection prevention. Before data collection one day training was given for data collectors and supervisor regarding the study, the questionnaires and data collection procedure by the main investigator. Pre-test in 10% of the sample size was done in Boru hospital which was not included in the actual study. The respondents encouraged to respond to all items in the questionnaire within the time they devoted.

Operational defi nitions
• Good knowledge: Health workers who answered ≥ 70% of knowledge questions correctly.
• Poor knowledge: Health workers who answered < 70% of knowledge questions correctly.
• Favorable attitude: Health workers who answered ≥ 70% of attitude questions.
• Unfavorable attitude: Health workers who answered < 70% of attitude questions.
• Good practice: Health workers who have properly practiced ≥ 70% of practice questions.  • Poor practice: Health workers who have practiced < 70% of practice questions.

Data analysis
The data was entered, cleaned and analyzed by using SPSS version 20 software and described by using tables and graph.

Ethical consideration
Ethical clearance was obtained from Wollo University, college of medicine and health sciences, department of comprehensive nursing research committee. Of icial letter from department of nursing was written to DRH. Written consent was obtained from all study participants after information is provided about purpose of the study and con identiality of the information.

Socio-demographic characteristics of the study participants
Out of the total sample size (n = 211), 191 study subjects were participated in the study which gives a response rate of 90.5%. The mean age of the study subjects was 29.87 years (+ 6.76 SD). One hundred ifteen (60.2%) of respondents were males and the rest 76 (39.8%) were females (Table 1).

Health care workers knowledge towards hospital acquired infection prevention
Overall 165 (86.4%) health workers had good knowledge and the rest 26 (13.6%) of respondents had poor knowledge towards HAIPs. Even though most of the respondents had good level of knowledge regarding HAIPs, a signi icant number of respondents had misconception about HAI includes Ventilator associated pneumonia (VAP), Tuberculosis (TB), UTI, gastroenteritis (30.4%) and patient history will in luence decision in choosing personal protective equipment (PPE) (44.5%) ( Table 2).

Health care workers attitude towards hospital acquired infection prevention
In general the result indicates that 146 (76.4%) had favorable attitude while 45 (23.6%) had unfavorable attitude towards HAIP activities. Signi icant number of respondents didn`t agree in the importance of changing mask before going to another patient as a nosocomial infection control measure (disagree + not sure = 37.2%) ( Table 3).

Health care workers practice towards hospital acquired infection prevention
Overall the result showed that majority of respondents had poor practice 147 (77%) and 44 (23%) of them had good practice towards HAIP activities. Only 56 (29.3%) always wash hands before start work (Table 4).

Discussion
In this study 86.4% of health workers had good knowledge which was in line with the study conducted in Bahirdar city, Gondar and Debre Markos referral hospital which were reported as 84.2%, 81.6% and 84.7% of health workers had good knowledge respectively [11][12][13]. On the other hand this inding is relatively lower than similar study conducted in Egypt, Cairo university hospital which reported as 90% of respondents had good knowledge [14]. In the current study  93.8% of respondents were knowledgeable as gloves should always be worn in contact precaution which is higher than a study conducted in Mizan Aman general hospital which was reported as 70.4% of respondents knew this [15]. This difference might be attributed to the difference in the academic background of the study respondents, setting of the study, sampling technique, sample size between studies and infection prevention guideline availability. More than two third (76.4%) of the respondents had favourable attitude about HAIP which was higher than similar study conducted in Bahirdar city 55.6% [11] and Gondar (64.2%) [12]. The possible explanation for difference might be due to difference in methodology, work experience, educational level, training opportunity, and personal characteristics of the study participants between various studies.
Less than one fourth (23%) of HCW had good practice towards HAIP. This showed that presence of main concern in HCW practice regarding to HAIP that needs immediate attention. This inding was much lower than similar studies conducted in different areas like Bahirdar city (54.2%), Gondar university referral hospital (57.4%) and Debre Markos (57.3%) and Mekele (42.9%) [11][12][13]16]. This lower result might be due to scarcity in availability of sanitary facilities and logistics required for HAIP activities at the current study site. Our study showed that 25.1% of respondents wash their hand before handling new patients which extremely lower than similar studies conducted in Mizan Aman general hospital and Saudi Arabia reported as 68.7% of study subjects and 88.5% nurses and 68% doctors wash their hands always before handling new patients respectively [15,17] but higher than a study conducted in Cairo University, Egypt and Addis Ababa Ethiopia reported only 15% and 7% of respondents wash their hands before handling new patients respectively [14,18]. The reason for this difference might be explained by the differences in logistics and facilities required for prevention of HAI in the study areas. In this study 31.9% of respondents always change gloves before handling new patients. This result was lower than the study conducted in Italy in which 87% always change gloves [19]. The reason for this poor practice might be due to inaccessibility of gloves in each outpatient department, ward and laboratory rooms in the present study. In the current study only 16.2% of respondents always discard infectious materials and left over samples according to the guide line. This showed that presence of huge gap concerning to infection prevention of the hospital.
Overall this study result indicates poor practice towards HAIP so that the health system and the policy makers should put their effort in order to improve quality of health care with regard to infection prevention. Even if the majority of health care provider had good knowledge and favourable attitude towards HAIP, still it needs improvement. Therefore the health system and the policy makers should do to increase KAP of the health care workers towards HAIP so that the community will be bene ited.

Conclusion and Recommendations
Most of respondents had good knowledge and considerable high level of favorable attitude but majority of respondents had poor practice i.e. they do not always wear masks and gloves, wash hands and they do not discard infectious materials according to the recommendations of the  guideline. Therefore Dessie referral hospital health workers should strictly follow HAIP guideline and the hospital administrators should ful il necessary supplies for infection prevention. Researchers should also do further study by using mixed qualitative and quantitative methods to address the unreached problems of the hospital.

Implications for clinical practice
The health care workers play signi icant role in preventing infection among the hospital patients and themselves. The inding of this study alerts health workers to follow the infection prevention guide line to prevent infection and consequently enhance the quality of hospital care. Regarding research, the study indings also provide basis for other researchers who would want to carry out further research on infection prevention and control principles.