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Year : 2016  |  Volume : 29  |  Issue : 4  |  Page : 984-990

Effect of an educational health program on the knowledge, attitudes and practices of healthcare workers with respect to nosocomial infections in the National Liver Institute, Egypt

1 Department of Public Health and Community Medicine, Faulty of Medicine, Menoufia University, Shebin Elkom, Egypt
2 Department of Microbiology, National Liver Institute, Menoufiya University, Menoufia Governorate, Shebin Elkom, Egypt
3 Department of Environmental Health of Liver, National Liver Institute, Menoufiya University, Menoufia Governorate, Shebin Elkom, Egypt

Date of Submission02-May-2014
Date of Acceptance04-Jul-2014
Date of Web Publication21-Mar-2017

Correspondence Address:
Marwa F Youssef
Department of Environmental Health of Liver, National Liver Institute, Menoufia University, Gamal Abdel Nasser Street, Shebin Al-Kom, Menoufia, 32111
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/1110-2098.202486

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The aim of the study was to assess the knowledge, attitudes, and practices (KAP) among different healthcare workers (HCWs) with respect to nosocomial infections in the National Liver Institute.
Healthcare-associated infections (HAIs) are infections that patients contract while receiving treatment for medical or surgical conditions. They are considered a serious problem in the healthcare services as they are common causes of illness and mortality among patients. HCWs are at high risk for acquiring HAIs and for transmitting to their patients and close contacts.
Participants and methods
A total of 100 HCWs, including physicians (n = 20), nurses (n = 60), and housekeepers (n = 20), were included in the study. A questionnaire was administrated to them to assess their KAP with respect to nosocomial infections. A scoring system was devised to grade the KAP scores. They were further subjected to another similar questionnaire after an interval of 2 months based on an education module.
Comparison of the preintervention and postintervention scores for the total study population showed a significant increase in the postintervention cumulative KAP score, as well as in the KAP scores. Housekeepers, compared with nurses, showed the best response to the health education intervention with a significantly higher percentage change in the KAP score (P = 0.005).
Nurses had higher levels for attitude and practice with respect to HAI control measures compared with physicians and housekeepers. Continuous education and in-service training on prevention of HAIs is mandatory to protect HCWs, especially housekeepers.

Keywords: healthcare-associated infections, health education, knowledge, attitudes, and practices

How to cite this article:
Abdel-Rasoul GM, Al Bahnasy RA, Mohamed OA, Abdel-Aziz AM, Mourad WS, Youssef MF. Effect of an educational health program on the knowledge, attitudes and practices of healthcare workers with respect to nosocomial infections in the National Liver Institute, Egypt. Menoufia Med J 2016;29:984-90

How to cite this URL:
Abdel-Rasoul GM, Al Bahnasy RA, Mohamed OA, Abdel-Aziz AM, Mourad WS, Youssef MF. Effect of an educational health program on the knowledge, attitudes and practices of healthcare workers with respect to nosocomial infections in the National Liver Institute, Egypt. Menoufia Med J [serial online] 2016 [cited 2022 Jul 5];29:984-90. Available from: http://www.mmj.eg.net/text.asp?2016/29/4/984/202486

  Introduction Top

Healthcare-associated infections (HAIs) produce negative impact on both healthcare providers and patients. They increase the incidence of work absenteeism, consumption of healthcare resources, and patient morbidity and mortality [1].

According to the Ministry of Health and Population of Egypt, there is little to no surveillance of infection, which leads to misconceptions about the incidence of hospital-acquired infections among healthcare workers (HCWs) [2].

Infection control is a very pertinent issue within clinical circles, in public health, and among health service consumers. A number of reports on poor hospital hygiene have been published, including reports about patients' fears about safety in hospitals [3].

A few patients have sued healthcare facilities and providers for perceived infection stemming from treatment received at these centers. This should raise concern among healthcare personnel, both qualified and in training, and among administrators and educators [4]. Infection control is necessary to reduce the high levels of HAIs and curb the proliferation of antibiotic-resistant bacteria [5].

Hand hygiene by healthcare staff has been reported to be of vital importance in the control of infection. Other protective measures such as masks, gloves, and vaccinations are useful in ensuring that healthcare personnel are not exposed unnecessarily to occupation-related infections, nor do they pass them on to patients [6].

Several effective evidence-based interventions for reducing the occurrence of HAIs have been proposed, and the Centers for Disease Control and Prevention has developed specific guidelines aimed at preventing the transmission of pathogens within the hospital setting [7].

National infection control guidelines in hospital practice published by the Egyptian Ministry of Health and Population have been renewed periodically to reduce contamination and cross-infection in different medical aspects [8].

To benefit from these available protective measures, it is recommended that a strong emphasis be placed on infection control in the undergraduate and postgraduate curricula of medical and other healthcare programs [9].

Several authors have reported that nonadherence to infection control behaviors such as putting on and changing gloves for every patient is typically multifaceted and extends beyond a lack of knowledge or forgetfulness [10]. Therefore, it is important to promote an educational approach that emphasizes behavioral change and maximizes the personal freedom of HCWs to choose to adhere, yet maximizes the potential healthcare and social costs. The National Liver Institute (NLI) is a place where the potential risk is most imminent for transmission of HAIs to patients or to HCWs who treat them.

Indeed, these HCWs are in the forefront of assisting critically ill patients before a diagnosis, who have life-threatening conditions. To this end, there has been limited attention paid to investigating the knowledge, attitudes, and behavior of HCWs with regard to control policies within this setting [11],[12].

Therefore, the objectives of this study were to provide an assessment of the level of knowledge, attitudes, and practices (KAP) regarding standard precautions for HAIs among HCWs in different departments at the NLI. We had applied interventions in the form of an education module designed to suit the need of each of these categories of HCWs (doctors, nurses, and ward aides). We studied the impact of the intervention on the level of KAP at different intervals. It was hypothesized that participants who are more knowledgeable perceive a lower risk of acquiring an HAI from patients and perform their medical duties with better compliance to standard precautions. This study aimed to highlight the shortcomings in KAP so as to recommend areas in which infection control training could be improved.

  Participants and Methods Top

This study was conducted from 1 August 2012 to 31 July 2013. It was carried out at the NLI. Hepatobiliary surgery, hepatology, intensive care, liver transplantation, and endoscopy departments were chosen for this study as they are expected to acquire a higher rate of hospital infections and thus those participants were at highest risk. The Menoufia Faculty of Medicine Committee for Medical Research Ethics reviewed and formally approved the study before it began. The target study population comprised the auxiliary healthcare personnel (physicians, nurses, and housekeepers) at the selected departments. All potential study participants were contacted and invited to participate in the study. Those who agreed to participate gave informed verbal consent.

Sample size calculation

A total of 111 participants were recruited for this study. They were selected from the total number of HCWs during this phase of the study (NLI record, 2011). To achieve a power of 80% and assuming an error level of P equal to 0.05, the calculated sample size was 111 HCWs (Power and Sample Size Calculation version 3, software program, Creative Commons Attribution-NonCommercial-NoDerivs 3.0 United States License, Chicago, USA).

Sampling technique

Using a random sampling method 111 HCWs were selected. They had graduated from nursing schools, technical health institutes, and faculty of nursing. Out of 69 housekeepers, 23 were randomly chosen and their ages ranged from 16 to 45 years and their work experience was 1–20 years. They had graduated from primary and technical schools.


The study was conducted as follows.

Preintervention phase

A self-administered questionnaire was constructed for assessment of the KAP of HCWs with respect to infection control measures. Form A was constructed for physicians and Form B for nurses and housekeepers. It included the following items: basic principles and facts about the most common HAIs — for example, chest infection, MRSA, and VERSA; hand hygiene — for example, good handwashing steps before clinical rounds; wearing personal protective equipment (gloves, gowns, masks, etc.); environmental cleaning — for example, cleaning of surfaces, floor coverings, bed edges, and door locks with soap and water before disinfection; and sterilization of instruments, such as cleaning and disinfection of equipment after use for each patient. Coding of KAP items was as follows for each answer: 2 for true, 1 for incomplete, and 0 for false or no. The total score was the sum of scores for all questions; KAP was considered good if the total score was 75–100%, average if it was 50–75%, and poor if less than 50% of the optimal score.

Intervention phase

After the questionnaire was answered, all participants were given a series of 10 training lectures of 120 min each. Lectures were conducted in slang Arabic language addressing the types, transmission, and prevention of hospital-acquired infections. At the end of each lecture, an applied practical session was carried out.

Postintervention phase

About 2 months after the intervention, an assessment of the effectiveness of the introduced health education intervention was carried out by measuring the change in the KAP using the same self-administered questionnaire of the pretest.

Data processing and statistical analysis

Data were transferred to a personal computer, classified, and analyzed with statistical package of social science version 20 (SPSS Inc., Chicago, Illinois, USA). Descriptive statistics was determined as number and percentage. Continuous variables were expressed as X ± SD and used for analysis. Comparison of preintervention and postintervention KAP scores was carried out using a paired t-test for analysis of normally distributed data. A P-value less than 0.05 was considered significant.

  Results Top

Out of 116 physicians, 23 were randomly chosen and their ages ranged from 26 to 35 years, with work experience of 1–9 years; 16 of them had a Bachelor's degree and four had a Master's degree. Out of 316 nurses, 65 were randomly chosen and their ages ranged from 16 to 45 years, with work experience of 0.5 to more than 10 years. They had graduated from nursing schools, technical health institutes, and faculty of nursing. Of 69 housekeepers, 23 were randomly chosen and their ages ranged from 16 to 45 years and had work experience of 1–20 years. They had graduated from primary and technical schools [Figure 1],[Figure 2],[Figure 3]).
Figure 1: Effect of training on nurses' knowledge, attitudes, and practices.

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Figure 2: Effect of training on doctors' knowledge, attitudes, and practices.

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Figure 3: Effect of training on housekeepers' knowledge, attitudes, and practices.

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A total of 211 questionnaires were distributed, of which 200 were completed and returned. The response rate was 94.7%, and 77% of the responders were female. Most participants (71%) had a Bachelor's degree, 8% had a nursing diploma, and 21% had education lower than high school level. Almost 43% had been working for more than 10 years. Approximately 57% of the healthcare providers had not received any specific education with regard to hospital infection; however, 43% had undergone previous training ([Table 1]).
Table 1 General characteristics of the healthcare workers

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With regard to the nurses' knowledge before intervention, the majority of nurses (96.7%) gave correct answers to questions about the main infection control measures: that standard precautions can prevent transmission of infection and isolation precautions can decrease transmission of infection. In 43.3% of respondents there were shortcomings in knowledge with respect to identifying the most common hospital-acquired infection ([Table 2]).
Table 2 Nurses' knowledge about hospital-acquired infections before the intervention program

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There were some positive attitudes toward many precautions for preventing nosocomial infections, such as cleaning and disinfection of equipment after use for each patient and safe disposal of hospital waste (90.2%) and vaccination of the entire healthcare team against hepatitis B )85.2%) ([Table 3]).
Table 3 Nurses' attitudes about infection control measures before the intervention program

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Many precautions to prevent nosocomial infections had poor practice levels, such as washing hands before clinical rounds (30%) and wearing clean gloves on drug injection or catheter insertion (11.7%). However, there were good practice levels for cleaning equipment with soap before sterilization (91.4%) and informing the doctors if edema or inflammation occurs around the catheter opening (95%) ([Table 4]).
Table 4 Nurses' practices about infection control measures before the intervention program

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On comparison of the preintervention and postintervention scores among nurses, a significant increase was seen in the postintervention mean KAP score and in the attitude and practice scores by about 42 and 35%, respectively (P < 0.001) ([Table 5]). However, in physicians the postintervention scores did not show any significant difference in their KAP (P = 2.19, 1.67, and 2.43, respectively) ([Table 6]).
Table 5 Preintervention and postintervention knowledge, attitudes, and practices scores of nurses toward nosocomial infections and infection control measures

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Table 6 Preintervention and postintervention knowledge, attitudes, and practices scores of physicians toward infection control measures

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For the housekeepers a significant increase by 28 and 23% was detected in the postintervention mean knowledge and practice scores, respectively (P < 0.01). However, their attitude scores did not differ from pretraining to post-training (P = 2.28) ([Table 7]).
Table 7 Preintervention and postintervention knowledge, attitudes, and practices scores of housekeepers toward infection control measures

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  Discussion Top

Overall, the results from this study are well in line with outcomes of previous studies.

Nurses and doctors showed a significantly higher preintervention knowledge score compared with housekeepers. This is somehow expected as the education level of the former two groups is higher than that of housekeepers. Surprisingly, practice scores showed almost no difference between the three categories. This is alarming for the risk of spread of HAIs, as it indicates that safety measures are hardly followed by the studied categories.

The health education intervention was successful in raising the knowledge about transmission and prevention of HAIs, improving the risk perception and increasing to some extent compliance with universal and safety precautions. This positive impact of the health education intervention was also previously demonstrated by studies conducted elsewhere. In India, an education module had effectively elevated the KAP score of HCWs; the proportion of workers who had excellent/good KAP scores increased from 14% before the intervention to 94% thereafter [13]. In Korea, it was also found that the group of nurses and medical students who had received education on HAIs showed significantly higher knowledge (P = 0.036) and performance (P < 0.01) levels than the group that had not received similar training [13].

In our study, physicians had the best level of knowledge in the preintervention phase, followed by nurses, but their practice score was almost less than that of nurses. However, the practice scores of the nurses and ward aides significantly increased following the intervention. The marked improvement in the practice score by 32% (from 54.3 to 86.1%) indicates the value and successful uptake of continuing education to improve compliance with general safety measures. This was also demonstrated by a study conducted in Pakistan, which pointed to the need of refresher courses in infection control [14].

Thus, continuous education, efficient in-service training, and monitoring and evaluation of HCW practices play a pivotal role in the sustainability of application of UP and infection control practices. Finally, a study conducted in Pakistan showed that, out of knowledge about safety precautions, mode of transmission, risk perception, and perception about disease severity, the only factor that predicted the practice of universal precautions was knowledge about mode of transmission [15].

The causes of lack of compliance to universal precautions identified in the current study were mainly work overload and lack of training on universal precautions and safety practices. Other studies conducted in Egypt and the USA also agreed that lack of knowledge, training, equipment and postexposure prophylaxis at healthcare facilities are major determinants for noncompliance to UP and safety practices [16],[17]. A review assessing the contribution of nurses' working conditions to risks for occupational injuries concluded that poor organizational climate and high workloads were associated with 50–200% increases in the incidence of needlestick injuries among hospital nurses [18].

There is a need for health education campaigns for health workers so that they can understand the risks that they are exposed to and the importance of practicing control measures.

  Conclusion and Recommendations Top

We can conclude that there is good knowledge and attitude, but poor practice characterizes physicians and nurses among HCWs in the NLI. Healthcare authorities should strive to create an organizational atmosphere in which adherence to recommended universal precautions and safety practices is considered an integral part of providing high-quality care. For such an approach to be successful, healthcare settings must provide visible support and sufficient resources in the form of continuous education programs and necessary equipment for UP. These programs should be both educational and motivational, and tailored to specific categories of healthcare personnel.

  Acknowledgements Top

The authors are grateful to all participants who generously agreed to participate.

Conflicts of interest

None declared.

  References Top

Hopf WH, Rollins DM. Reducing perioperative infection is as simple as washing your hands. Anesthesiology 2009; 110:978–985.  Back to cited text no. 1
Talaat M, Kandeel A, El-Shoubary W, Bodenschatz C, Khairy I, Oun S, et al. Occupational exposure to needle stick injuries and hepatitis B in Egypt: achievements and challenges. Am J Infect Control 2006; 34:193–200.  Back to cited text no. 2
Gould DJ, Drey NS, Millar M, Wilks M, Chamney M. Patients and the public: knowledge, sources of information and perceptions about healthcare-associated infection. J Hosp Infect 2009; 72:1–8.  Back to cited text no. 3
Cervia SJ, Ortolano AG, Canonica PF. A waterborne Hospital pathogen's 'Fantastic Voyage' – The Sequel. Reducing the incidence of hospital-acquired infections. Managing Infect Control 2009; 9:22–32.  Back to cited text no. 4
Weinstein AR. Controlling antimicrobial resistance in hospitals: infection control and use of antibiotics. Emerg Infect Dis 2001; 7:188–192.  Back to cited text no. 5
Borchert M, Mulangu S, Lefevre P, Tshomba A, Libande ML, Kulidri A, et al. Use of protective gear and the occurrence of occupational Marburg hemorrhagic fever in health workers from Watsa health zone, Democratic Republic of the Congo. J Infect Dis 2007; 196:168–175.  Back to cited text no. 6
Siegel JD, Rhinehart E, Jackson M, Chiarello LThe Health Care Infection Control Practices Advisory Committee. Guideline for isolation precautions: preventing transmission of infectious agents in healthcare settings; Atlanta, GA, USA: The Health Care Infection Control Practices Advisory Committee 2007. Available at: http://www.cdc.gov/ncidod/dhqp/pdf/guidelines/Isolation2007. [Last accessed on 2013 Sep 30].  Back to cited text no. 7
Talaat M, Kandeel A, Rasslan O, Hajjeh R, Hallaj Z, El-Sayed N, Mahoney FJ: Evolution of infection control in Egypt: Achievements and challenges. American Journal of Infection Control 2006; 34:193–200.  Back to cited text no. 8
Mann CM, Wood A. How much do medical students know about infection control? J Hosp Infect 2006; 64:366–370.  Back to cited text no. 9
Mears A, White A, Cookson B, Devine M, Sedgwick J, Phillips E, et al. Healthcare-associated infection in acute hospitals: which interventions are effective? J Hosp Infect 2009; 71:307–313.  Back to cited text no. 10
Ellison AM, Kotelchuck M, Bauchner H. Standard precautions in the pediatric emergency department: knowledge, attitudes, and behaviors of pediatric and emergency medicine residents. Pediatr Emerg Care 2007; 23:877–880.  Back to cited text no. 11
Sundaram RO, Parkinson RW. Universal precaution compliance by orthopaedic trauma team members in a major trauma resuscitation scenario. Ann R Coll Surg Engl 2007; 89:262–267.  Back to cited text no. 12
Suchitra JB, Lakshmi Devi N. Impact of education on knowledge, attitudes and practices among various categories of health care workers on nosocomial infections. Indian J Med Microbiol 2007; 25:181–187.  Back to cited text no. 13
Kim KM, Kim MA, Chung YS, Kim NC. Knowledge and performance of the universal precautions by nursing and medical students in Korea. Am J Infect Control 2001; 29:295–300.  Back to cited text no. 14
Janjua NZ, Razaq M, Chandir S, Rozi S, Mahmood B. Poor knowledge — predictor of nonadherence to universal precautions for blood borne pathogens at first level care facilities in Pakistan. BMC Infect Dis 2007; 7:81.  Back to cited text no. 15
Kabbash IA, El-Sayed NM, Al-Nawawy AN, Abou Salem Mel S, El-Deek B, Hassan NM. Risk perception and precautions taken by health care workers for HIV infection in haemo dialysis units in Egypt. East Mediterr Health J 2007; 13:392–407.  Back to cited text no. 16
McCoy KD, Beekmann SE, Ferguson KJ, Vaughn TE, Torner JC, Woolson RF, et al. Monitoring adherence to standard precautions. Am J Infect Control 2001; 29:24–31.  Back to cited text no. 17
Clarke SP, Sloane DM, Aiken LH. Effects of hospital staffing and organizational climate on needlestick injuries to nurses. Am J Public Health 2002; 92:1115–1119.  Back to cited text no. 18


  [Figure 1], [Figure 2], [Figure 3]

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7]


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