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208]

Original Article

Knowledge and Practice of Standard Precautions by Health‑Care

Workers in a Tertiary Health Institution in Enugu, Nigeria
SU Arinze‑Onyia, AC Ndu1, EN Aguwa1, I Modebe2, UN Nwamoh3

Department of Community Background: Standard precautions (SPs) are crucial in protecting both health‑care

Abstract
Medicine, Enugu State
University College of
workers (HCWs) and patients from nosocomial infections. This study assessed
Medicine, 1Department the knowledge and practices of SP among HCWs in tertiary health‑care facilities.
of Community Medicine, Methods: This descriptive study was done in October 2014 among 629 HCWs
University of Nigeria, Enugu, at the University of Nigeria Teaching Hospital, Ituku‑Ozalla, Enugu State.
2
Department of Community A pretested questionnaire was used and analysis done using SPSS version 13.
Medicine, Nnamdi Results: The HCWs studied were 629, mostly females (64.4%), married (62.3%),
Azikiwe University, Awka,
3
Department of Community
Christians (94%), and within 20–59 years. Majority were nurses (46.1%) working
Medicine, Federal Medical in the wards. Over 90% of respondents had heard of SP, mainly from formal
Centre, Umuahia, Nigeria training (62%). Over 70% could define SP, 74.6% had knowledge of when SP
is needed and >70% identified most components of SP. Over 90% agreed that
SPs are useful and that employers should provide SP training. Most respondents
washed hands after removal of gloves (73.6%) and before leaving patient’s care
area (33.1%). More than 70% had been exposed to patient’s body fluids and
washed the exposed part with water, soap, and disinfectant (52.1%). Gloves were
the most commonly used personal protective equipment (PPE) (53.4%) and the
major reason for inconsistent use was irregular access (57.7%). Over 50% recap
needles before discarding. Exposure to patients’ serum was significantly higher
among doctors and nurses P < 0.05, while the use of PPEs was highest among
the laboratory scientists (82.4%). Those who were trained on SP (70.8%) and
PPE (69.7) were significantly more likely to use PPEs, P < 0.05. Conclusions: SP
training and regular provision of PPEs are vital in compliance to SP.

Date of Acceptance: Keywords: Enugu, health‑care workers, nosocomial infections, standard

26-Nov-2017 precautions

Introduction great concern in developing countries where there are

higher risks of exposure to blood‑borne pathogens,
I t is generally known that health‑care workers (HCWs)
often come in contact with blood‑borne pathogens
and other microorganisms.[1] These exposures commonly
frequent contacts with patients’ body fluids and little or
no protection against airborne infections.[2]
occur during major or minor surgical procedures, To prevent spread of nosocomial infections, the United
during routine clinical and nursing services like simple States’ centers for disease control (CDC) in 1985
physical examination, while handling laboratory introduced Universal precautions to protect HCWs from
specimen, and during disposal of hospital wastes as contact with blood and a number of other body fluids
well as during accident and life‑saving emergency
procedures. On exposure, HCWs can equally transmit Address for correspondence: Dr. AC Ndu,
Department of Community Medicine, University of Nigeria,
healthcare‑associated infections (HAI) to their patients Nsukka, Nigeria.
and may be the source of infection for their families E‑mail: [email protected]
and communities. Occupational exposure to HAI is of
This is an open access article distributed under the terms of the Creative Commons
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Access this article online and build upon the work non‑commercially, as long as the author is credited and the new
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For reprints contact: [email protected]

DOI: 10.4103/njcp.njcp_69_17
How to cite this article: Arinze-Onyia SU, Ndu AC, Aguwa EN, Modebe I,
Nwamoh UN. Knowledge and Practice of Standard Precautions by Health-
PMID: ******* Care Workers in a Tertiary Health Institution in Enugu, Nigeria. Niger J
Clin Pract 2018;21:149-55.

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Arinze‑Onyia, et al.: Standard precautions among health care workers

visibly contaminated with blood.[3] However, research Teaching Hospital (UNTH), Ituku‑Ozalla, Enugu. The
around stigma and discrimination in health‑related HCWs studied were medical doctors, nurses, laboratory
settings implicated Universal precautions as a means by scientists, and hospital attendants/orderlies. These groups
which HCWs discriminate against patients because by of HCWs are known to come in contact with hospital
failing to mainstream Universal precautions in practice, hazards. UNTH is located in Ituku Ozalla a semi‑urban
health professionals are making judgment based on community about 30 min drive from the state capital.
individual’s health status.[4,5] It is the biggest teaching hospital in the Southeast and
As a result, in 1996, CDC revised the infection control South‑south regions of Nigeria with about 750‑bed
practice from Universal precautions to Standard spaces and gets referrals from most parts of these two
precautions (SP). SPs are the minimum infection regions. The staff strength is about 5000, and the study
prevention practices that apply to all patients regardless population constitutes 30% of the staff strength. The
of suspected or confirmed infection status of the patient departments and units studied were those ones that
in all settings where health care is delivered.[6] These handle biohazards, namely, Intensive Care Unit, theater,
practices are designed to protect both the HCWs and wards, laboratories, casualty, outpatient departments, and
the patients from nosocomial infections. Thus, SPs are blood bank.
crucial in hospital infection control as well as in issues Sample size estimation
related to biosafety and security of patients, professionals, A minimum sample size of 380 was calculated
and students in direct or indirect health‑care delivery. using a previous prevalence of personal protective
For SP to be effective, consistency of application is equipment (PPE) use of 55% among HCWs in
of the essence. Hence, a combination of an enabling North Eastern Nigeria.[11] This was however doubled for
environment (in terms of regular supply of necessary a better representation of the study population.
facilities and equipment) and the willingness by HCWs
to observe SP at all times is vital for a successful Ethical permit
compliance. Ethical approval with reference number NHREC/05/01/
2008B‑FWA00002458‑1RB00002323 was obtained from
Although SPs’ policy was introduced 20 years ago, the Ethics Committee of UNTH while informed consent
adherence to these precautions is poor in health‑care was obtained from the management and staff of UNTH.
facilities particularly in resource‑limited countries.[7]
Hence, HAIs remain a critical challenge for the public Data collection
health sector. Poor knowledge of infection control Multistage sampling technique was used. First stage was
practices among HCWs has been noted to hinder selection of departments and units which was done by
compliance with SP.[8] In addition, strengthening SP’ simple random sampling. Then, for those departments
training for HCWs is variously recommended as a major that are more than one in number like the wards,
means of promoting adherence to SP and protecting theater and outpatient departments, half of them were
HCWs and patients from nosocomial infections.[9,10] selected by simple random sampling. The next stage
Nonavailability of materials, limited organizational was selection of the respondents which was done by
support, and lack of knowledge regarding infection cluster sampling. Thus, the entire staff in these selected
control practices among HCWs were some of the factors departments were enrolled into the study. Pretested
responsible for poor compliance to SP.[7,8] self‑administered questionnaires were used to collect
data from respondents. Pretesting was done among
Changing current behavior requires knowledge of
20 HCWs (doctors, nurses, laboratory scientists, and
the factors that can influence HCWs’ compliance
orderlies were represented) at the State tertiary health
with SP and implementing programs and preventive
institution in Enugu. Contents of the questionnaire
actions that contribute to the avoidance of occupational
exposure.[10] The objective of the present study is include demographical variables, knowledge/attitude,
to assess the knowledge and practices of SP among and practice of SP.
tertiary level HCWs in Enugu, Nigeria. It is also hoped Data analysis
that findings will be of value in determining ways of Data were entered and analyzed in Epi-Info version 7
promoting compliance with SP in all public health by Centers for Disease Control and Prevention, Atlanta,
institutions in Nigeria. Georgia. Discrete variables were presented as frequencies.
The mean and standard error of the mean were calculate
Methods for the age and years of service. The knowledge score
The study was descriptive cross‑sectional done in was obtained as follows: Each correct answer scored 1
October 2014 among HCWs at University of Nigeria while wrong answer or nonresponse is scored zero. Total

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Arinze‑Onyia, et al.: Standard precautions among health care workers

knowledge score = total correct answers divided by total Sociodemographic variables

possible correct answers multiplied by 100%. A score The number of HCWs studied was 629. They were mostly
of <50% is considered poor, 50%–<70% is fair while females (64.4%), married (62.3%), Christians (94%),
70% and above is considered good. Chi‑square was used and within 20–59 years of age range. Majority of the
to identify association between demographic variables/ respondents were nurses (46.1%), followed by doctors,
training and exposure to patient’s serum/use of PPEs. 143 (22.7%). The job locations of most respondents
were the wards, laboratories and the outpatient
Results departments while the range of years of service was
Out 760 possible respondents, 629 agreed to participate 1–34 years [Table 1].
in the study giving a response rate of 83%. Knowledge of standard precautions
Over 90% of the respondents have heard of SP, mainly
Table 1: Sociodemographic distribution of health from formal training (62%) or colleagues (25%). A total
workers (n=629) of 442 (70.3%) could define SP; over 70% knew the
Demographic variables Frequency (%) indications and could identify most components of SP.
Gender However, 272 (43.2%) knew about respiratory etiquette
Female 405 (64.4)
and 21.9% knew of anal or perineal hygiene. Some of
Male 224 (35.6)
the advantages of SP noted were: Protects both HCWs
Age range
and patients (84.4%), reduces spread of communicable
20‑29 137 (21.8)
30‑39 253 (40.2)
40‑49 158 (25.1) Table 2: Knowledge and source of information on
50‑59 81 (12.9) standard precaution (n=629)
Marital status Variables Frequency (%)
Married 392 (62.3) Ever heard of SP 594 (94.4)
Single 187 (29.7) Main source of information for those who have
Widow/widower 39 (6.2) heard of SP
Divorced/separated 11 (1.8) Formal training 390 (62.0)
Religion Colleague/friend 157 (25.0)
Christianity 591 (94.0) Media 33 (5.2)
Islam 24 (3.8) Others 14 (2.2)
African traditional religion 14 (2.2) Have not heard 35 (5.6)
Occupation Correct knowledge of SP
Nurse 290 (46.1) Definition of SP 442 (70.3)
Doctor 143 (22.7) Components of SP
Laboratory scientist 136 (21.6) Hand hygiene 508 (80.8)
Orderly/cleaners 60 (9.5) Use of PPE 477 (75.8)
Location of work Safe injection practices 471 (74.9)
Ward 256 (40.7) Safe handling of potentially contaminated 451 (71.7)
Laboratory 121 (19.2) equipment or surfaces
Outpatient department 98 (15.6) Respiratory hygiene etiquette 272 (43.2)
Theater 58 (9.2) Anal/perineal hygiene 138 (21.9)
Casualty 43 (6.8) Indications for SPs 469 (74.6)
ICU 20 (3.2) Examples of body fluids to be guarded against 501 (79.7)
Blood bank 12 (1.9) Advantages of SP
Others 21 (3.3) Protects both health workers and patients 531 (84.4)
Years of service Reduced spread of communicable disease 494 (78.5)
1‑5 269 (42.8) Not associated with stigma and discrimination 182 (28.9)
6‑10 169 (26.9) Indications for hand hygiene include
11‑15 83 (13.2) After contact with blood, body fluids or excreta 431 (68.5)
16‑20 55 (8.7) Before performing any aseptic procedure 379 (60.3)
21‑25 26 (4.1) After glove removal 340 (54.1)
26‑30 19 (3.0) Before touching a patient 287 (45.6)
31‑35 8 (1.3) Before exiting the patient’s care area 246 (39.1)
Age range: 20-59 (mean±SEM=37.20). Years of service 1-35 Summary of correct knowledge on SP ‑ total correct response/total possible
(Mean±SEM=8.85=0.299). SEM=Standard error of mean; correct answer multiplied by 100%=3729/5661×100%=65.8% (fair).
ICU=Intensive Care Unit SPs=Standard precautions; PPE=Personal protective equipment

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Arinze‑Onyia, et al.: Standard precautions among health care workers

Table 3: Attitude of health workers to standard precaution

Attitude Strongly Disagree (%) Indifferent (%) Agree (%) Strongly
disagree (%) agree (%)
Employers should always provide training on SP 3 (0.5) 6 (1.0) 18 (2.9) 152 (24.1) 450 (71.5)
SPs are useful in protecting against hazards in workplace 14 (2.2) 4 (0.6) 17 (2.7) 164 (26.1) 430 (68.4)
SPs are not really necessary in hospitals 386 (61.3) 183 (29.2) 42 (6.7) 9 (1.4) 9 (1.4)
SPs are meant only for theatre workers 397 (63.1) 189 (30.0) 23 (3.7) 13 (2.1) 7 (1.1)
SPs=Standard precautions

Table 4: Practice of standard precautions by health workers

Practice of SP Frequency (%)
Time to wash or decontaminate hands*
After removal of gloves 463 (73.6)
Before leaving a patient’s care area 208 (33.1)
Before wearing gloves 85 (13.5)
Before touching a patient 77 (12.2)
Before performing an aseptic procedure 72 (11.4)
Contact with patient’s blood or other body fluids during work 457 (72.7)
Action taken during the most recent contact with patient’s body fluid (n=457)
Washed off fluid with soap, water, and disinfectant 238 (52.1)
Washed off fluid with soap and water 140 (30.5)
Used only an alcohol‑based hand sanitizer 56 (12.3)
Washed off fluid with only water 19 (4.2)
Nothing 4 (0.9)
PPE always worn by health workers when working
Gloves or coveralls 420 (66.8)
Gloves only 336 (53.4)
Gown only 274 (43.6)
Gloves and coveralls 215 (34.2)
Reasons for not always wearing both gloves and coveralls while working* (n=414)
Do not have regular access to PPEs 239 (57.7)
Do not have time to wear them 175 (42.3)
Wearing them make it difficult for me to do my work 104 (25.1)
Do not believe they are really protective 88 (21.3)
Can work safely without them 23 (5.6)
Disposal of used needles and syringes among doctors, nurses and laboratory scientists (n=569)
Recap needle and discard both syringe and needle 301 (52.9)
Discard both syringe and needle into the safety box without recapping 242 (42.5)
Disconnect and discard needle and replace with new needle for another drug administration on the same 26 (4.6)
patient
Nurses and cleaners who ensure that manufacturers’ instructions are followed while diluting disinfectants used in 223 (63.7)
cleaning hospital surfaces (n=350)
*Some gave more than one response. PPEs=Personal protective equipment; SPs=Standard precautions

diseases (78.5%), and not associated with stigma and Practice of standard precautions
discrimination (28.9%). The total knowledge score was Most of the respondents wash or decontaminate
65.8% (fair) [Table 2]. hands after removal of gloves (73.6%) and before
Attitudes to standard precautions leaving patient’s care area (33.1%). More than 70%
In general, there a positive attitude toward use SP: has been exposed to patient’s blood or body fluids
Over 90% agreed that SPs are useful in protecting and washing the exposed part with water, soap, and
against biohazards in the workplace and that employers disinfectant was the most frequent action (52.1%).
should provide SP training for their workers. On Gloves were the most commonly used PPE (53.4%)
the other hand, over 90% disagreed that SPs are not and the major reason for inconsistent use was
necessary in hospitals and that they are meant for only unavailability (57.7%). Over 50% recap needles before
theater workers [Table 3]. discarding [Table 4].

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Arinze‑Onyia, et al.: Standard precautions among health care workers

Table 5: Association between demographic variables/training and exposure to patient’s serum/use of personal
protective equipment
Variables Skin has been exposed to patient’s serum while working Always wear PPEs (gloves or coveralls)
while working
Yes (n=457), n (%) No/cannot remember (n=172), n (%) Yes (n=420), n (%) No (n=209), n (%)
Doctor 114 (79.7) 29 (20.3) 84 (58.7) 59 (41.3)
Nurse 221 (76.2) 69 (23.8) 193 (66.7) 97 (33.3)
Laboratory scientist 92 (67.6) 44 (32.4) 112 (82.4) 24 (17.6)
Health attendant/orderly 30 (50.0) 30 (50.0) 31 (51.7) 29 (48.3)
χ2; P 22.65; <0.01 25.22; <0.01
Years of service
1‑5 184 (68.4) 85 (31.6) 181 (67.3) 88 (32.7)
6‑10 120 (71.0) 49 (29.0) 113 (66.9) 56 (33.1)
11‑15 59 (71.1) 24 (28.9) 54 (65.1) 29 (34.9)
16‑20 49 (89.1) 6 (10.9) 38 (69.1) 17 (30.9)
21‑25 22 (84.6) 4 (15.4) 19 (73.1) 7 (26.9)
26‑30 17 (89.5) 2 (10.5) 10 (52.6) 9 (41.4)
31‑35 6 (75.0) 2 (25.0) 5 (62.5) 3 (37.5)
χ2; P 45.37; <0.01 2.52; 0.87
Trained on the use of
protective equipment
Yes 342 (73.4) 124 (26.6) 325 (69.7) 141 (30.3)
No 115 (70.6) 48 (29.4) 95 (58.3) 68 (41.7)
χ2; P 0.49; 0.48 7.15; <0.01
Trained on SP
Yes 286 (73.3) 104 (26.7) 276 (70.8) 114 (29.2)
No 171 (71.5) 68 (28.5) 144 (60.3) 95 (39.7)
χ2; P 0.24;0.63 7.39; <0.01
PPEs=Personal protective equipment; SP=Standard precaution

Association between demographic Detailed knowledge of SP was fair high in the present
variables/training and exposure to patient’s study. A similar level of knowledge has also been
serum/use of personal protective equipment reported.[15] This shows the degree of interest on SP by
Exposure to patients’ serum was significantly higher HCWs which is most likely associated with their hope in
among doctors and nurses P < 0.05, while the use of PPEs SP as key to infection control in public health settings.
was highest among the laboratory scientists (82.4%). In line with previous findings, most of the respondents
Those who were trained on SP (70.8%) and PPE (69.8%) in the present study were positively disposed to SP.[13,16]
were significantly more likely to always use PPEs, Again, the displayed positive attitude could be as a result
P < 0.01 [Table 5]. However, training had no significant of their faith in SP because the SP policy is indeed a good
effect on respondents’ exposure to patients’ serum. package designed to prevent the spread of nosocomial
infections and ensure safety of HCWs while at work.
Discussion Hand hygiene was suboptimally practiced which is not
Almost half of the respondents in the present study good because aside from being an important component
were nurses. This is similar to a previous study of SP, regular hand hygiene is very crucial in infection
conducted in France where nurses constituted 44% control. Present finding is significantly lower than the
of the group of HCWs studied and another study in previous report from south India in which the practice
Nigeria in which nurses were 50.7% of all the hospital of hand hygiene was 95%.[17] The probable reason for
workers studied and this appears to be a reflection of the poor practice could be irregular access to materials
the proportion of nurses among HCWs in general.[12,13] for hand hygiene. On the other hand, it could be due to
Awareness of SP was quite high which is not surprising nonchalance on the part of HCWs who may believe that
since the policy on SP was introduced a long time ago. hand hygiene before patient’s care is irrelevant.
A slightly higher level was reported in the United Arab As has been reported previously, most of the respondents
Emirates where 97% of the respondents were familiar who came in contact with patient’s blood or body fluids
with the concept.[14] washed off the exposed part immediately.[18] Doctors

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Arinze‑Onyia, et al.: Standard precautions among health care workers

and nurses were more likely to be exposed to patient’s Financial support and sponsorship
body fluids. This could be because they work in close Nil.
proximity with the patients than lab scientists but it could
Conflicts of interest
also be as a result of the less likelihood to use PPEs by
the doctors and nurses. Thus, strict compliance to SP is There are no conflicts of interest.
of utmost importance in the prevention of health workers’
contact with patients’ body fluids.
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