key: cord-301085-tk2vvxj7
authors: Askarian, Mehrdad; McLaws, Mary-Louise; Meylan, Marysia
title: Knowledge, attitude, and practices related to standard precautions of surgeons and physicians in university-affiliated hospitals of Shiraz, Iran
date: 2006-07-11
journal: Int J Infect Dis
DOI: 10.1016/j.ijid.2006.01.006
sha: 
doc_id: 301085
cord_uid: tk2vvxj7

OBJECTIVE: To measure levels of knowledge, attitudes, and practice toward standard precautions (SP) in medical practitioners of Shiraz University of Medical Sciences affiliated hospitals in Iran. METHOD: In this cross-sectional study, knowledge, attitude, and practice related to SP among four medical staff groups – surgeons, surgical residents, physicians and medical residents – were assessed using a questionnaire. RESULTS: Across the four medical staffing groups the median levels of knowledge ranged from 6 to 7 (maximum score 9), median attitude scores were high ranging from 35 to 36 (maximum score 45), while median practice scores were low, ranging from 2 to 3 (maximum score 9). A moderate relationship between knowledge and attitudes was found in surgical residents and medical residents (r = 0.397, p = 0.030 and r = 0.554, p = 0.006, respectively). No significant correlation was found between knowledge and practice between the groups. A significant but poor (r = 0.399, p = 0.029) relationship between attitude and practice was found in surgical residents. CONCLUSION: Specific training programs may have to target newly graduated medical practitioners to establish acceptance of appropriate practices that will enable them to adopt and adhere to SP while their older counterparts may require more intense continuous assistance.

Objective: To measure levels of knowledge, attitudes, and practice toward standard precautions (SP) in medical practitioners of Shiraz University of Medical Sciences affiliated hospitals in Iran. Method: In this cross-sectional study, knowledge, attitude, and practice related to SP among four medical staff groups -surgeons, surgical residents, physicians and medical residents -were assessed using a questionnaire. Results: Across the four medical staffing groups the median levels of knowledge ranged from 6 to 7 (maximum score 9), median attitude scores were high ranging from 35 to 36 (maximum score 45), while median practice scores were low, ranging from 2 to 3 (maximum score 9). A moderate relationship between knowledge and attitudes was found in surgical residents and medical residents (r = 0.397, p = 0.030 and r = 0.554, p = 0.006, respectively). No significant correlation was found between knowledge and practice between the groups. A significant but poor (r = 0.399, p = 0.029) relationship between attitude and practice was found in surgical residents. Conclusion: Specific training programs may have to target newly graduated medical practitioners to establish acceptance of appropriate practices that will enable them to adopt and adhere to SP while their older counterparts may require more intense continuous assistance. # 2006 International Society for Infectious Diseases. Published by Elsevier Ltd. All rights reserved.

A heightened understanding of transmission of blood-borne diseases in the mid-1980s [1] [2] [3] [4] [5] [6] to healthcare workers (HCWs), including surgeons, physicians, and residents in training, and the importance of adherence to standard precautions (SP) is well accepted. Adherence to SP is even more important with the emergence of infectious diseases, such as avian influenza, severe acute respiratory syndrome, and the threat of bioterrorism. 7 The problems of containing drugresistant organisms such as methicillin-resistant staphylococcus 8-10 and vancomycin-resistant enterococci from colonizing patients give a continuous reminder to HCWs that adherence to SP is also pivotal to patient safety in terms of healthcare-associated infections. In 1996, the Centers for Disease Control proposed Guidelines for Isolation Precautions in Hospitals, as new, two-tiered best practice of infection control precautions that are standard for all patients who are to be regarded as potential carriers of pathogenic microorganisms. 1,10 Strict adherence to SP guidelines is necessary to prevent exposure to potentially life-threatening infections, 3,11-15 yet a high level of compliance with SP has been reported to be problematic worldwide. 3, 4, [16] [17] [18] [19] [20] Medical practitioners, especially surgeons, are among high-risk healthcare workers for exposure to blood-borne or other infections during direct patient contact. [2] [3] [4] The purpose of our study was to measure the level of knowledge, attitude, and practice in surgeons and physicians in Shiraz University of Medical Sciences affiliated hospitals.

A cross-sectional survey was conducted in Shiraz University of Medical Sciences, Shiraz, Iran between May and November 2003 of four groups of medical staff; the questionnaire was to be answered by physicians, surgeons, surgical residents, and medical residents. The questionnaire was prepared by an infection control expert, a pediatrician certified in infectious diseases, and a psychiatrist, and reviewed by experts from the Iranian National Expert Group of Infection Control Specialists. It consisted of questions on knowledge, attitude, and practice of the guidelines with respect to standard isolation precautions as described by the CDC. The questionnaire was pre-tested on a random sample of participants to ensure practicability, validity, and interpretation of responses. The validity of the questionnaire was assessed using the Kuder-Richardson test for reliability and Cronbach's alpha internal consistency coefficient.

Items in the questionnaire included demographic data, specialty and status of medical practitioner (surgeon, physician, surgical, or medical resident), previous SP education, willingness to be trained, and nine questions pertaining to hand-washing, personal protective equipment,

M. Askarian et al. use of antiseptic solution, and disposal method for used syringes. Responses to items for knowledge were ''yes'', ''no'', or ''don't know''. The questions used to assess attitude were in the format of the Likert scale with responses that included ''very strong'', ''strong'', ''considerable'', ''weak'', or ''null'' and the five-point Likert scale response for practice questions (always, often, sometimes, seldom, never). All responses in accordance with CDC guidelines 1,10 were given a score value of 1 for correct answers to the knowledge questions and when answers for practice questions were ''always'', while a score zero was assigned to all other answers. The total scores ranged from zero to 9. For attitude questions, a score of 5 was equivalent to the answer ''very strong'' and a score of 1 to ''nil'', therefore, the total score ranged from 9 to 45 ( Table 1 ). The questionnaire was pre-tested on 21 randomly-selected members from the target population with high test-retest reliability (alpha = 0.73). Descriptive and inferential statistics including significance tests, Wilcoxon rank-sum test, Kruskall-Wallis test, and Spearman correlation coefficient were performed using SPSS version 10.0. Alpha was set at the 5% level.

Of the 250 questionnaires distributed, 155 (62%) were returned completed. Participants included 78 senior medical staff (42 surgeons and 36 physicians) and 77 residents (41 surgical residents and 36 medical residents) ( Table 2 ). There were more male, 73.8% ( p = 0.002) than female surgeons, while there was no significant ( p = 0.061) gender difference within the physicians, 54.8% males. Neither were there significant differences in the proportion of male surgical residents (56.1%, p = 0.435) and male medical residents (58.3%, p = 0.317). The median age of all senior medical staff was 34 years (range 26-70 years) and 31 years (range 24-39 years) for all residents ( Table 2) . Regardless of the status of medical practitioners, the majority (85.9% senior practitioners and 87.0% residents) reported no previous formal SP education and most (87.2% senior practitioners and 88.3% residents) were willing to receive SP training ( Table 2) .

The median scores for SP knowledge for all medical practitioners ranged from 6 to 7, while the range of median scores for attitudes was from 35 to 36 and that for practices from 2 to 3 ( Table 3 ). The median scores for knowledge and attitude were not significantly different ( p = 0.077 and p = 0.653, respectively) between surgeons (knowledge median 7.0 and attitudes median score 36) and physicians (knowledge median score 6.0 and attitudes median score 35); median scores for practices were less than half the possible total score of nine, although the median scores for surgeons, 3.0, and physicians, 3.0, were equal but differed significantly ( p = 0.036) ( Table 3) .

Although median scores for knowledge and attitudes were moderate to high, surgeons were the only group where a Knowledge, attitude, and practices related to standard precautions 215 moderate to strong (r = 0.748) relationship between knowledge and attitudes was significant ( p < 0.0001) while for other medical groups this relationship was poor ( Table 4 ). The relationship between knowledge and practices for all practitioners was not significant, as was the case for attitudes and practices, where correlations were not significant for all practitioners except surgical residents, where the relationship was significant but not strong, r = 0.399 ( p = 0.029) ( Table 4 ). All medical practitioners' levels of knowledge were high for the same six items that were answered correctly by at least three quarters of practitioners within each group (Table 5) . Few medical practitioners answered correctly that needles should not be bent before disposal with correct knowledge ranging from 27.8% (physicians) to 55.6% (medical residents). As few as 9.5% of surgeons and 9.8% of surgical residents correctly believed that betadine was not used as a hand washing antiseptic solution. Less than three quarters of practitioners correctly knew that they had to wash hands before glove use with proportions of practitioners answering correctly ranging from 52.8% (physicians) to 70.7% (surgical residents). Only two of nine attitudinal items were answered as ''very much'' by more than 75% of practitioners (Table 6 ). These two items indicating good attitudes related to SP activities do not require effort or much persuasion; the proportion of practitioners washing hands after touching blood, body fluids, excretions and contaminated items ranged from 91.7% to 95.2%, and glove use for touching mucous membranes, proportions ranged from 69.4% to 95.2%. Only one SP practice item, hand washing after touching contaminated items, was always practiced by 75.6% to 100% of practitioners (Table 5) .

A medical resident's knowledge towards SP was related to willingness to be trained ( p = 0.013) and a surgeon's practice of SP was related only to female gender ( p = 0.006). No other significant predictive relationships were found.

M. Askarian et al. 

Adherence to standard precaution guidelines has been problematic for HCWs universally. [2] [3] [4] This study was limited by its reliance on self-reporting rather than by observing compliance with SP by practitioners. However, self-reported attitudes towards SP and compliance were low. Our poor compliance with many SP practices is not unique to our teaching hospitals, with similar results published in other centers. 3, 4, [17] [18] [19] [20] [21] While principles of SP should be strictly observed by surgeons and physicians for their own safety as well as setting leadership roles for their residents, success in the implementation of SP guidelines depends on many factors such as optimal awareness and a positive attitude in all HCWs, and these goals are not reached without qualified personnel receiving continuing regular education, as has been repeatedly demonstrated in the literature. 4, [22] [23] [24] [25] [26] [27] [28] [29] [30] [31] [32] Our study revealed that more than 80% of all medical practitioners had not received previous SP education, and that more than 80% were willing to be trained. These findings illustrate that SP practices are not behaviors readily adopted, even by those aware of the SP issue and moderate to low levels of attitudes. A revision of current medical curricula offered in Iran may be required that mandates all medical students and hospital trainees attend infection control courses specific to their clinical terms. Although all our medical practitioners reported a willingness to be trained, compliance behavior is complex. 33 Some barriers to adherence observed internationally include inadequacy of equipment and facilities and difficulties of access to equipment, stressful working conditions, and the belief that practice of SP may interfere with patient care. 2, 23, [34] [35] [36] [37] [38] [39] [40] [41] Influencing the Iranian senior practitioner may require elements of other successful programs Knowledge, attitude, and practices related to standard precautions 217 and innovative approaches, such as improved hospital infrastructure that offers an infection control awareness week with infection control auditors to inform about correct practices at the time incorrect practices are observed, freely available personal protective equipment, such as gowns, gloves and masks, with reinforcing posters but also staff seminars launched on a platform of the importance of consistent SP practice for personal protection in times of emerging diseases.

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This article is the result of a research project (81-1412) approved by the Deputy of Research of Shiraz University of Medical Sciences and Health Services. We want to express our special appreciation to the respected research deputy who not only provided financial support, but also showed his interest in solving difficulties.Conflict of interest: No competing interest is declared.