Compliance with infection prevention and control standard precautions and associated factors among healthcare workers in four health facilities in Fako division, Cameroon

Abstract

Background

Healthcare-associated infections (HAI) are a serious public health problem. Healthcare workers are exposed to HAI, which in turn exposes patients to nosocomial infection. Compliance with infection prevention and control (IPC) measures can help break the infection chain and halt the transmission of infection to healthcare workers and patients. There is a paucity of evidence-based data on the level of compliance of healthcare workers (HCWs) with IPC in the Fako division. This study assessed healthcare workers’ compliance with infection prevention and control standard precaution measures and its associated factors, in Fako division, Cameroon.

Methods

A hospital-based cross-sectional study was conducted in four health facilities in the Fako division of Cameroon. A standardised observation checklist and a validated questionnaire were used to assess healthcare provider compliance with standard precautions for the prevention of infection. Data was analysed using StataMP 18.0. A multivariable logistic regression analysis was used to identify independent factors associated with compliance with infection prevention control (IPC) measures.

Results

We recruited 276 participants, and the Overall compliance with the IPC was 64.5%. Laboratory technicians had a compliance to IPC proportion of 91.7%, nurses 62.4%, doctors 60.9%, and midwives 45.8%. Professional Cadre [aOR = 8.32 (95% CI: 1.90–36.53), P = 0.005], health facility [aOR = 3.61 (95% CI; 1.29–10.07), P = 0.014], and the need for transmission-based precaution [aOR = 2.41 (95%: 1.38–4.19), P = 0.002] were independently associated with good compliance with IPC measures.

Conclusion

Compliance with infection prevention control standard precaution measures of HCWs in the Fako Division was suboptimal and varied according to professional qualifications, health facilities, and departments. Factors associated with good compliance with IPC measures have been identified. These findings highlight the need for hospital-based interventions to improve HCW compliance with IP measures and break the infection transmission chain in the hospitals.

Background

Healthcare-associated infection (HAI) increases morbidity and mortality, extends the length of hospital stay, fuels the emergence of antimicrobial resistance, and raises healthcare costs for patients and providers [1]. In high-income countries, HAI affects about 7% of patients, meanwhile, in low and middle-income countries (LMICs), it is as high as 15% [2]. A study conducted in 2016 at the Yaoundé Teaching Hospital in Cameroon showed that the incidence of HAI was 19.25%, with a mortality rate of 28% [3]. Healthcare workers (HCWs), due to the nature of their work, are exposed to body fluids, and the World Health Organization(WHO) estimates that about 2.5% of HIV cases and 40% of Hepatitis B and C cases among HCWs are the result of these exposures [4]. The WHO estimated that about 3 million HCWs are exposed to blood-borne viruses each year, and 90% of the exposures occur in LMICs [5]. Good infection prevention control programs can aid in decreasing the burden of HAI by 70% [6].

Infection Prevention and Control (IPC) refers to event-based practices and methods likely to prevent or reduce the transmission risk of microorganisms to healthcare providers, other patients, hospitalised patients, and visitors if they are evenly applied in healthcare structures [7]. The two main components of IPC are standard precautions and complementary precautions.

Standard Precautions or Universal Precautions (UP) are a standard set of guidelines to prevent the transmission of bloodborne pathogens and other potentially infectious materials [8]. This includes practicing hand hygiene and using personal protective equipment (PPE) such as gowns, gloves, masks, and face shields or goggles, as they serve as a barrier to protect the skin, mucous membranes, airway, and clothing.

To prevent the spread of infections, HCWs need to comply with IPC. However, several observational studies have shown limited adherence to recommended practices by healthcare personnel [9]. This problem with noncompliance is significant because more than 6 million HCWs are at risk, and there is a 0.3% risk of infection with HIV after percutaneous exposure to HIV-contaminated blood [10]. Despite these glaring problems, there is a paucity of evidence-based data on the level of compliance of HCWs with standard precautions (SPs) in these settings. The absence of data makes it difficult to advocate for a positive change.

Materials and methods

Aim

This study sought to close the data gap in the Fako Division by assessing the compliance of HCWs with infection prevention and control measures (standard precautions) and identifying the factors associated with HCWs’ compliance level with these measures.

Study design and setting

A hospital-based cross-sectional study was conducted over 5 months (1st January to 31st May 2024) among HCWs from four health facilities (two public and two private) in Fako Division. The four hospitals include Hospital #1 and Hospital #2 which are government-funded and are the region’s two main referral and teaching hospitals, whereas Hospital #3 and Hospital #4 are private district-level facilities. They were conveniently selected based on the nature of funding, high capacity, and patient turnout.

Hospital #1 is a secondary health facility and a main referral hospital in the Southwest Region. The hospital is made up of four major departments, which include: Pediatrics, Internal Medicine, Surgery, Obstetrics, and Gynecology (OBGYN). The hospital also has specialized centres such as the Dialysis Centre, Intensive Care Unit (ICU), Ophthalmology Unit, Dentistry, Medical Imaging, Neonatology, and kangaroo Mother Care (KMC). The healthcare workers are made up of doctors (30, nurses and midwives (180), laboratory technicians (lab. technician)(30), and pharmacy attendants(06). The hospital has a sanitation department but no statutory meetings.

Hospital #2 serves as a secondary health facility and a main referral hospital located in the central town of Limbe. The hospital has a Pediatric department, OBGYN department, Internal Medicine department, Surgical department, Dentistry, Ophthalmology, Physiotherapy, and Intensive Care Units. It has an Imaging Centre, two Theatres, and an equipped Laboratory. The healthcare workers are made up of doctors (39), nurses and midwives (181), lab. technicians (36), and pharmacy attendants (06). The hospital has an IPC committee with neither a specified meeting period nor regular follow-up.

Hospital #3 is situated in Buea at the foot of Mount Cameroon. The total catchment area is about 50,000. It has Internal Medicine, Pediatric, Maternity, Laboratory, and Outpatient units. The HCWs are made up of doctors (05), nurses (26), midwives (13), lab. technicians (09), and pharmacy attendants (02). Hospital 3 has an IPC committee with regular monthly meetings with staff.

Hospital #4 is located in the Buea, it is a private clinic. The clinic is made up of Medical, Surgical, Maternity, Pediatric, and Laboratory units. The HCWs are made up of doctors (9), nurses (27), midwives (09), lab. technician (08), pharmacy (05). In the clinic, the IPC committee is an ad hoc committee where they convene when needed.

Study population

All healthcare workers working within the four aforementioned health facilities for at least six months and who gave informed consent were included in the study. These HCWs included medical doctors, nurses, midwives, and laboratory scientists. A total number of 276 participants were included in the study using Yamane’s formula as shown below

$$\:\varvec{n}=\frac{\varvec{N}}{\varvec{1}+\varvec{Ne}^{\varvec{\wedge}}2}$$

n = Minimum sample size

N = Total number of functional HCWs in all four hospitals = 607

e = precision at 0.05 at a 95% confidence interval.

Minimum calculated sample = 242 HCWs. We considered 267 as our minimum sample size to account for a 10% non-response rate.

The participants were recruited using sampling proportionate to size from each of the four facilities as shown: $\:\frac{\varvec{n}\times\:\varvec{N}\varvec{f}}{\varvec{N}}$

n: minimum sample size of the study population

Nf: total number of healthcare workers in the health facility

N: the total number of healthcare workers in all the hospitals

Hospital #1 minimum sample population: $\:\frac{267\times\:240}{607}=105.56\sim106$

Hospital #2 minimum sample population: $\:\frac{267\times\:256}{607}=\;112.60\;\sim\;113$

Hospital #3 minimum sample population: $\:\frac{267\times\:53}{607}=23.31\sim24$

Hospital #4 minimum sample population: $\:\frac{267\times\:58}{607}\;=25.51\sim26$

Data collection

The data collection tool comprised a structured questionnaire and an observation sheet. The structured questionnaire was adapted from existing literature and similar studies. It contained information on sociodemographic characteristics, knowledge of IPC (made up of a set of 10 structured questions that delved into IPC-related topics), and IPC-related characteristics [11,12,13]. The observation sheet was adapted from the WHO hand hygiene observation form [14] (see Additional file 1). The data collection form was pre-tested in a different facility and modified accordingly.

The HCWs were met on duty, with informed written consent obtained 24 h before administering the data collection form to reduce the Hawthorn effect. Each participant was observed only once for at least 20 min when caring for a patient or carrying out a diagnostic procedure. Three opportunities for IPC compliance measures to be implemented were recorded per participant. The observer noted opportunities for the need for precautionary measures, the indication, and whether action was taken or not, with emphasis on the WHO five-period for hand hygiene. This was done only in the observer’s field of view (patient care area to be observed and includes visible areas where HCW can clean the hands e.g. sinks and standby alcohol dispensers which varied based on the structure of the facility) defined before the start of the observation. If the HCW left the field of view without taking any action, it was considered that the HCW never did. This observation was done per HCW per department, covering workers on day and night shifts.

After this observation, a structured questionnaire with two parts: Part 1, with a score from 0 to 10, was immediately self-administered to collect socio-demographic and IPC-related characteristics and to assess their knowledge of infection prevention and control practices (10-item question) [15] (see Additional file 2).

Data analysis

Data was verified, entered into the data collection form designed on Kobo Collect, and exported to Excel 2016 for cleaning. All participants’ information was coded to ensure confidentiality.

Data cleaned in Excel was exported into StataMP 18.0 for analysis. The data was explored to identify hidden patterns and important variables. Categorical variables were presented as frequencies and percentages, quantitative variables as means with standard deviation (SD), or median with interquartile range after checking for normality of distribution. A cut-off for good compliance was set at an overall score of ≥ 80% according to the compliance standard precautions scale (CSPS) (Lam SC: Compliance with standard precautions scale: fact sheet, unpublished). A good knowledge level was defined as a knowledge score ≥ 7/10 since the mean score was 7.0. The overall compliance proportion was calculated as the total HCWs with ≥ 80% compliance level. This was also calculated and reported by cadre, facility, and department. The Chi-square test was used to compare proportions. Multivariable logistic regression analysis with backward elimination was used to identify factors independently associated with good compliance. Multicollinearity was checked with the mean-variance inflation factor (VIF) = 1.19 and the model fitness with Pearson’s goodness of fit (p = 0.30). The likelihood ratio p-values were reported with their adjusted odd ratios and 95% confidence intervals. The level of significance was set at p-value < 0.05.

Results

General characteristics of the participants

In this study, we recruited 276 participants, and the mean age was 26.3 (± SD 6.0) years, with 18–25 years being the most represented age group. Most participants were female, 72.8% (n = 201), and the majority of participants were from public facilities (Table 1).

Table 1 Sociodemographic characteristics of healthcare workers in four health facilities in the Fako division, Cameroon

IPC-related characteristics among study participants

In this study, 34.8% (n = 96) had good knowledge of IPC, 87.3% (n = 241) of participants had personal protective equipment available in their health facilities, 87% (n = 240) had IPC guidelines present in their department, 67.7% (n = 187) had received IPC training, and 69.9% (n = 193) had IPC committees present in the facility. Concerning the infrastructure, 85.1% (n = 235) of participants had a constant water supply in the facility, and 80.8% (n = 223) had a constant electricity supply in the facility (Table 2).

Table 2 Infection prevention and control-related characteristics among health care workers in four health facilities in Fako division, Cameroon

Compliance with IPC

Overall compliance with the IPC was 64.5% (95% CI: 58.5–70.1).

Compliance with IPC by health facility

Concerning compliance with standard precautions per health facilities, Hospital #3 had a higher proportion of compliance (75.9%), followed by Hospital #1 (68.9%), Hospital #2 (60.7%), and Hospital #4 (44.4%) (Fig. 1).

Fig. 1

Proportion of compliance with IPC in four health facilities in Fako division, Cameroon

Compliance with IPC by cadre

Laboratory technicians had a compliance to IPC proportion of 91.7%, nurses 62.4%, doctors 60.9%, and midwives 45.8% (Fig. 2).

Fig. 2

Proportion of compliance with IPC according to Professional Cadre in four health facilities in Fako division, Cameroon

Compliance with IPC by department

Among departments, the Laboratory department had a compliance proportion to IPC of 91.9%, the Pediatric department 75.9%, the Private ward 72.7%, the Surgical department 67.7%, the Outpatient department 56.8%, the Medical department 55.9%, and the OBGYN department 43.9% (Fig. 3).

Fig. 3

Proportion of compliance with IPC in the departments of four health facilities in Fako division, Cameroon

Factors independently associated with good compliance with IPC among healthcare workers

In the multivariable analysis, three variables were independently associated with good compliance with SPs. For the professional cadre, the odds of laboratory scientists practicing good compliance were 8.32 times higher [aOR = 8.32 (95%CI:1.90–36.53), P = 0.005] compared to midwives. The odds of Hospital #3 having good compliance were 3.61 times higher [aOR = 3.61 (95%CI; 1.29–10.07), P = 0.014] compared to Hospital #4. The odds of good compliance were 2.41 times higher [aOR = 2.41 (95%: 1.38–4.19), P = 0.002] when transmission-based precaution was needed compared to when it was not needed (Table 3).

Table 3 Factors associated with IPC compliance among healthcare workers in four health facilities in Fako division, Cameroon

Discussion

This study aimed to assess healthcare workers’ compliance with infection prevention control standard precaution measures and its associated factors. Overall, approximately 13 out of 20 HCWs had good compliance with IPC. Professional cadre(lab.technician), facility(Hospital #3), and the need for transmission-based precautions were independently associated with good compliance with IPC measures.

The compliance proportion with IPC of 64.5% in our study was congruent with what was obtained in similar studies conducted in Ghana in 2022 (65.6%) [15] and in Ethiopia in 2021 (57.8%) [16]. However, this is higher than the compliance rate of 34.49% reported in a study conducted by Senbato et al., 2024 in Addis Ababa [13]. This discrepancy can be explained by the fact that in their study, optimal compliance was set at a stricter score of > 85% compared to the score of > 80% in our study. Concerning compliance per stratum of the profession, laboratory technicians had the highest. This high level of compliance among laboratory technicians can be explained by their higher level of knowledge and a higher risk of exposure to HAI.

Our study showed that Cadre, health facility, and the need for transmission-based precaution were independently associated with good compliance with IPC. We found that the odds of better compliance among laboratory technicians was 13.0 compared to the midwives. These higher odds of compliance among laboratory technicians can be explained by the fact that in our study population, laboratory technicians had the highest proportion of compliance (91.7%). A similar study conducted in Northern Ethiopia found that compared to laboratory technicians, doctors, and nurses had 80% and 70% reduced odds of good practice, respectively [17]. Contrary to our study, a study conducted in Tanzania in 2024 found that nurses were more likely to comply with IPC compared to other cadre of healthcare workers [18]. According to that study, nurses were found to have IPC training in their educational curriculum, which they applied in practice.

Our study found that compliance varied significantly by health facilities with Hospital #3 showing the highest compliance rate. Moreover, Hospital #3 had an IPC committee with regular monthly meetings with staff to discuss IPC compliance. This is similar to the finding of Alhumaid et al., 2021 where HCW’s participation in the IPC committee improved adherence to IPC measures [19].

The need for transmission-based precaution was statistically significantly associated with compliance with IPC. This could be explained by the fact that transmission-based precautions are applied in patients known or suspected to be colonised or infected with highly transmissible or epidemiologically significant pathogens [20]. This knowledge will, therefore, have a significant positive impact on good compliance with IPC.

In our study, knowledge of IPC was not statistically significantly associated with good compliance with SPs. This could be explained by the fact that in our study, only 34.8% of the population had good knowledge of IPC. Similarly, a study conducted in Ghana in 2022 concluded that knowledge of IPC doesn’t influence compliance with SPs [15]. This is because knowledge alone does not necessarily translate into good practice but requires consciousness and other personal facility-level and policy that will enable standard practice. However, a study conducted by Adil Aboulkhail and Thamer Alslamah in 2022 stated that a lack of knowledge of the recommended practices hinders compliance with IPC [21].

Study strength

In our study, we used an observation form which is standard according to WHO to evaluate the compliance of healthcare workers.

Study limitations

Our study may have experienced the Hawthorne effect, with the participants possibly adjusting their practice because they were being observed. However, we tried to mitigate this effect by allowing at least 24 h to elapse from the time of signing of the informed consent form to participant observation. We also reduced this effect by administering the structured questionnaire only after participant observation.

Furthermore, our study did not include students who were involved in the clinical and paraclinical aspects of patient care including infection control. This excluded a good proportion of the workforce in the health facilities who were exposed to infection and likely to transmit HAI.

Conclusion

The compliance with infection prevention control standard precaution measures of HCWs in the Fako Division is suboptimal and varies with the professional qualification, health facilities, and departments. Factors associated with good compliance have been identified. These findings highlight the need for hospital-based interventions to improve HCW compliance with IPC measures and to break the infection transmission chain in the hospitals. To curb the burden of HAI, we recommend that health facilities implement regular IPC compliance follow-ups through IPC committees to reinforce and sustain compliance with IPC measures. HCWs should make a conscious effort to participate in IPC training and make good use of the available guidelines to adhere to IPC measures.