Infection prevention knowledge, practice, and its associated factors among healthcare providers in primary healthcare unit of Wogdie District, Northeast Ethiopia, 2019: a cross-sectional study

Background Adequate knowledge and safe practice of infection prevention among healthcare providers are vital to prevent nosocomial infections. Thus, this study aimed to assess the level of knowledge and practices of healthcare providers towards infection prevention and its associated factors in the health facilities of Wogdie District, Northern Ethiopia. Methods Institution based cross-sectional study was conducted among 171 healthcare providers who were selected by a simple random sampling technique. Data were collected using interviewer-administered questionnaire. Multivariable logistic regression was performed to identify factors associated with knowledge and practice of infection prevention. Result About 70.8 and 55.0% of healthcare providers had adequate knowledge and safe practice of infection prevention respectively. Having infection prevention guideline (AOR = 3.65, 95% CI; 1.26, 10.54), taking infection prevention training (AOR = 2.2, 95% CI; 1.01, 4.75), having five years or more work experience (AOR = 1.52:95%CI; 1.13, 4.51), and working in maternity unit (AOR = 1.67:95%CI; 1.38–5.23) were positively associated with adequate knowledge of infection prevention. The odds of safe practice were higher in participants who received infection prevention training (AOR: 2.4; 95% CI; 1.01, 4.75) but lower among healthcare providers who are working in the facility which has no continuous water supply (AOR = 0.48:95% CI; 0.21, 0.83). Conclusion A significant proportion of healthcare providers had inadequate knowledge and unsafe practice of infection prevention. To improve healthcare worker’s knowledge of infection prevention, adequate pre-service as well as on job training should be given.


Background
Healthcare-associated infection is defined as infections acquired in the healthcare facilities during the clinical, diagnostic and therapeutic procedure that was not present at the time of the client's admission [1].It is a main problem encountered in healthcare delivery services worldwide and constitutes one of the most important causes of morbidity and mortality [1][2][3].A systematic review of the literature reported that the pooled prevalence of healthcare associated infection was 7.6% in high-income countries and 10.1% in low and middleincome countries [4].
In Africa including Ethiopia, the prevalence of hospitalacquired infection was significantly high (12-35%) [5][6][7][8].However, awareness of the problem remains extremely limited because of other health priorities take precedence over infection prevention and patient safety considerations [4].Most of the healthcare associated infections are caused by the transmission of pathogens from one patient to another, especially by healthcare workers who failed to practice infection prevention measures consistently [9][10][11][12].
In Africa, many studies have shown that significant proportion of healthcare providers had inadequate knowledge on infection prevention.Only 58% of health care workers in Ghana [13] and 70-80% in Nigeria [14,15] had adequate knowledge about infection prevention.Similarly, past evidence in Ethiopia showed that merely 54-60% of healthcare providers had adequate knowledge about infection prevention [16][17][18] and only 32-55% of healthcare providers demonstrated a safe practice on infection prevention [15,17,19].
Studies have shown that different factors such as availability of infection prevention guidelines, training on infection prevention and availability of personal protection equipment can promote safe infection prevention practices at the hospital level [16][17][18]20].However, the factors associated with knowledge and practice of infection prevention in the primary health care unite of Ethiopia have not previously been explored.
The Federal Ministry of Health (FMoH) of Ethiopia started initiatives to protect patients and health workers from healthcare associated infection by setting infection prevention standards and guidelines.Adequate knowledge of infection prevention is crucial to implement these infection prevention standards and to improve infection prevention practice.However, very little has been published on the level of knowledge and practices towards infection prevention among health workers in Ethiopia.Besides, the majority of previous studies [17,[21][22][23] in Ethiopia have done at the hospital level which differs from the primary health care unit in regarding to staff profile, infrastructure, training and financial support.Therefore, this study aimed to assess the knowledge and practices towards infection prevention and its associated factors among primary healthcare providers in Wogdie district, Northern Ethiopia.

Study design, setting and population
Institutional-based cross-sectional study design was conducted from February to May in Wogdie district which is located in the Northern part of Ethiopia.It is 581 Km away from Addis Ababa (the capital city of the country) and 640Km from Bihar Dar (regional capital city).According to Wogdie woreda health office 2019 annual plan, the district had a total population of 155, 960 and it has one governmental primary Hospital and five health centers.All healthcare workers (Laboratory, Nurse, Health officer, and Midwifery) working in all three departments of healthcare facilities (Out-patient, In-patient and Emergency department) and providing care and have direct involvement in patient care were eligible to be included in the study.Healthcare providers who were on annual leave for longer than 2 weeks, maternity leave and who were critically ill during the study period were excluded.

Sample size determination & sampling technique
The sample size was determined by using single population proportion formula by considering the proportion of practices on infection prevention method 87.5%, from the study conducted in Dessie Referral Hospital [24] using the assumptions: 95% confidence interval, 5% margin of error.The calculated sample size was 162 but after adding a 5% non-response rate, the final sample size became 171.A simple random sampling technique (table of random number) was used to select the representative subjects from all healthcare providers list in the Woreda Health Office.

Variables
The outcome of interest was knowledge (adequate/inadequate) and practice (safe/unsafe) towards infection prevention.Independent variables include socio-demographic characteristics, water supply, presence of infection prevention committee, presence of infection prevention guidelines in a health facility and training on infection prevention.Knowledge of infection prevention was computed from 11 questions.The mean value was used to classify HCWs infection prevention knowledge as having adequate knowledge if the score was equal or above the mean.Respondents who scored less than the mean value of correct answers were classified as having inadequate knowledge on the infection prevention.Infection prevention practices of healthcare provides were assessed for main components of infection prevention measures like hand hygiene practices, utilization of personal protective equipment (PPE), and post-exposure prophylaxes (PEP), healthcare waste management practices, and instrument disinfection practice.Respondents were asked to indicate the frequency of use (practice) for these 7 infection prevention measures.Practice assessment questions had either three or two possible alternative responses ("Always" or "Yes", "Sometimes" and "Never" or "No").One point was given for each acceptable or correct practice and zero point for all other responses.Practice scores were summed up to give a total practice score for each healthcare worker.Therefore, the total score of practice questions ranging from zero (all prevention measures not practiced safely) to seven (all infection prevention measures practiced safely) were classified into two categories of response: safe practice (equal or above the mean) and unsafe practice (below the mean) [25,26].

Data collection techniques
Two trained BSc Nurses collected the data through faceface interview using a structured and pre-tested questionnaire which was prepared in the local language (Amharic).The tool was developed after reviewing related kinds of literature [2,17,18,24,27].Data collectors were trained and supervised during the data collection period.

Data quality control
To assure the data quality, data collection instruments were pre-tested on 5% of the sample on two health centers of Borena woreda.For each component, a reliability test was done.The reliability coefficient for practice and knowledge items had a Cronbach's Alpha value of 0.832 and 0.753 respectively.The data were examined for completeness and consistency during data collection on a daily base by the supervisor.

Data analysis
Data were entered using Epi-data version 3.1 and analyzed by SPSS version 20.Before analysis, data were cleaned and checked for outliers and missing's.Logistic regression was done and variables with a P-value of less than 0.2 at bivariable logistic regression model were entered into the multivariable logistic regression model.In all cases, p-values of less than 0.05 were considered as statistically significant.

Socio-demographic characteristics
In this study, a total of 171 study participants were included and the mean age of the study participants was 27.98 with SD ± 3.56 years.Of the total participants, 119 (69.6%) of them were males and the majority 110 (64.3%) were married.About 83(48.5%)study participants were Nurses regardless of their educational level.In terms of educational status, 102(59.6%)study participants were diploma and nearly one-third of respondents were currently working at the outpatient clinics (Table 1).
More than two-thirds of health facilities had infection prevention committee and around 73% of health facilities had infection prevention guidelines.About 33(19.3%)study participants didn't take any training on infection prevention and universal precaution (Table 2).

Knowledge of health care providers on infection prevention
In this study, 70.8% of participants had adequate knowledge about infection prevention.Sixteen (9.4%) were believed that gloves cannot provide complete protection against acquiring infection.One hundred sixty-three (95.3%) of the study participants responded that washing hands with soap or an alcohol-based antiseptic decreases the risk of transmission of hospital acquired pathogens (Table 3).

Practice of health care providers on infection prevention
In this study, 55% of healthcare providers had safe infection prevention practice.From all participants, 68.4% wash their hands before patient care and 77.2% used soap to wash their hands.Around 50.3% of healthcare providers have used all personal protective equipment's and 90.6% participant changes chlorine solution every 24 h (Table 4).

Factors associated with knowledge of infection prevention
In this study, all variables with a P-value of less than 0.2 at bivariate logistic regression model were included in the multivariable analysis.Thus age, sex, educational status, profession, work experience, presence of infection prevention guideline, getting of infection prevention training, availability of continuous water supply, type of health center and currently working unit were evaluated as possible factors associated with knowledge of infection prevention.But, we removed two variables; type of health center and member of infection prevention committee to avoid multicollinearity (detected through chi-square test).In multivariable analysis presence of IP guidelines, IP training, work experience and currently working unit were significantly associated with knowledge of infection prevention (P < 0.05).The odds of having adequate knowledge of infection prevention among health care providers who have IP guidelines in their health institutions were 3.7 times higher (AOR: 3.65, 95% CI;1.26, 10.54) than those who have not IP guideline.The odds of having adequate knowledge towards infection prevention were higher in health worker who has trained about infection prevention (AOR = 2.19: 95% CI; 1.01, 4.75) than those who were not trained.Similarly, participants who had more than 5 years' work experience had higher odds of having adequate infection prevention knowledge (AOR = 1.52: 95%CI; 1.13-4.51).Healthcare providers who were currently working in maternity and laboratory unit had higher odds of having adequate knowledge about IP ((AOR = 1.67:95%CI; 1.38-5.23),(AOR = 2.56:95%CI; 1.26-4.13))respectively (Table 5).

Factors associated with infection prevention practice
In this study, age, sex, educational status, profession, work experience, presence of infection prevention guideline, getting of infection prevention training, availability of continuous water supply, type of health center and currently working unit were evaluated as possible factors associated with safe infection prevention practices.But,

Discussion
Adequate knowledge about infection prevention is vital in reducing healthcare-associated infection.The finding in this study suggested that approximately one-third of healthcare providers working in primary healthcare unit demonstrated inadequate knowledge about infection prevention.This finding is supported by previous studies [14,16,28] done in different parts of Africa.But it was low when compared with studies done in Ethiopia [17,23].This discrepancy may be due to differences in the study settings.The majority of previous studies were done at teaching and referral hospitals but this study was limited to the primary healthcare units (health centers).In teaching and referral hospitals healthcare providers might get the opportunities for various infection prevention training which could increase knowledge level about infection prevention [14,29].Even though FMoH of Ethiopia is scaling-up its activities related with infection prevention, the current study showed that only 55% of healthcare providers had safe infection prevention practices.This finding was in line with a study done in Bahir-Dar [23] but lower when compared with studies done in other parts of Ethiopia [24,30].The discrepancy might be due to a difference in the study setting and composition of healthcare providers [24].In Ethiopia, the composition of health worker staffs were different among hospitals and primary healthcare unit.Majority of health workers in hospitals were experienced and specialized which might improve their practice towards infection prevention.This finding implies that improving safe infection prevention practices are vital in primary healthcare units of Ethiopia where a high proportion of patients developed healthcare associated infection [31].Remarkably, in the current study, about 90% of health care providers believed that gloves can't provide complete protection against acquiring infection.This finding is higher than previous studies done in Ethiopia [17,18] and Eritrea [32].As similar to previous studies done in Ethiopia [17,27], in this study, only one-third of healthcare providers had hand hygiene practice after patient care and 68.4% of healthcare workers wash their hands before patient care.
This study revealed that healthcare providers who had more than five years of work experience were 1.5 times more likely to have adequate knowledge than their counterparts.This is in line with findings from Ethiopia [17,25].This might be due to the fact that as the number of years of practice increases, healthcare providers are exposed to infection prevention information and became more experienced through working with senior staff.
According to WHO recommendation, all primary healthcare facilities should develop their own standard operating procedures based on national infection prevention and control guidelines [33,34].Developing and implementation of infection prevention guidelines is one of the core components of infection prevention and control programs at all healthcare facilities [33,34].In this study, similar to previous studies [18,22], the presence of infection prevention guidelines in health institutions also increases the odds of having adequate knowledge about infection prevention.This might be attributed to the fact that healthcare workers who have infection prevention guidelines were more likely to get updated information, which improves their knowledge of infection prevention.
Healthcare providers who are currently working in maternity and laboratory unit had higher odds of having adequate knowledge about IP.This might be due to the availability of infection prevention standard operating   procedures in the laboratory unit which might improve their knowledge.Besides, this could be due to the difference in infection prevention training among units.Health workers who had ever attended any form of training program on infection prevention were more likely to practice than those who didn't take training on infection prevention.This is supported by a study done in Ethiopia [18].According to different international guidelines, infection prevention education & training is the core components of infection prevention and control programs [33,34].Infection prevention and control guidelines in combination with health care workers' education and training are effective to reduce hospital acquired infection [34].Previous studies have verified that training of health care workers on infection control has a valuable effect on healthcare staff by improving their compliance with the standard precaution [35,36].But the current study showed that only 33.9% of the health workers had ever attended any form of training program on infection prevention.This implies more than twothird of healthcare providers need training for infection prevention.Similarly, healthcare providers who had infection prevention guidelines were more likely to have safe infection prevention practice than those who had no infection prevention guidelines.The finding highlights the necessity of infection prevention guideline in the improvement of healthcare providers' practice.
Healthcare providers working in health facilities without continuous running water supply were 52% less likely to have safe infection prevention practices as compared with HCPs working in a facility with continuous water supply.This finding is supported by a study done in Ethiopia [30].
One of the limitation of this study was temporal relationships cannot be established between the explanatory and outcome variables due to the cross-sectional nature of study design.Recall bias might be the other limitation of this study.Finally, since the study was conducted in governmental healthcare facilities, generalizability of the study findings is limited to these governmental healthcare facilities.

Conclusion
The findings of this study showed that a significant proportion of HCPs had no adequate knowledge on infection prevention and 45% of healthcare providers practiced infection prevention unsafely.Knowledge towards infection prevention has been significantly associated with work experience, getting of infection prevention training and presence of infection prevention guideline.As a result, to improve knowledge on infection prevention, adequate pre-service as well as on job training for HCPs should be given.Besides, infection prevention guideline should be availed to improve knowledge and practice of infection prevention.

Table 1
Socio-demographic characteristic of health care providers in five health facilities of Wogdie district, South Wollo zone, Amhara region, Ethiopia, 2019

Table 2
Characteristic of health care providers in Wogdie district, South Wollo Zone, Amhara region, Ethiopia, 2019

Table 3
Knowledge questions for health care providers in health facilities of Wogdie district, South Wollo zone, Amhara region, Ethiopia (n = 171), 2019

Table 4
Infection prevention practice questions for health care providers in health facilities of Wogdie district, South Wollo zone, Amhara region, Ethiopia (n = 171), June 2019

Table 5
Bivariate and multivariate logistic regression of factors associated with knowledge of health care providers towards infection prevention of Wogdie district, south Wollo zone Amhara region, Ethiopia, 2019 IP infection prevention, COR crude odds ratio, AOR adjusted odds ratio; * = significantly associated at P < 0.05

Table 6
Bivariable and multivariable logistic regression of factors associated with infection prevention practice of health care providers in Wogdie district, south Wollo zone, Amhara region, Ethiopia 2019 * = significantly associated at P-value < 0.05