Knowledge, Attitude and Practice of Standard Infection Control Precautions among Health-care Workers in a hospital in Qassim, Saudi Arabia: a Cross-sectional Survey

： Hospital-acquired infections (HAIs) contribute to increased length of hospital stay, high mortality and higher health-care costs. Prevention and control of HAIs is a critical public health concern . We conducted a cross-sectional survey of 213 hospital health-care workers in Qassim, Saudi Arabia. We assessed Knowledge, Attitude and Practice (KAP) of standard infection control precautions using a structured questionnaire. Predictors of KAP were investigated using multivaraible logistic regression analyses and independent sample t tests. Prevalence of good (≥80% correct response) knowledge, attitude and practice were 67.6%, 61.5% and 73.2%, respectively. Predictors of good knowledge included age over 34 years (adjusted odds ratio: 30.5, p <0.001), and receiving training (13.3, p <0.001). Predictor of positive attitude was having >6 years of experience (5.5, p <0.001). While, the predictors of good practice were having >6 years of experience (2.9, p <0.01), previous exposure to HAIs (2.5, p <0.05) and training (3.5, p <0.01). However, being female (0.22, p <0.001) and older (>34 years) (0.34, p <0.01) were negatively associated with knowledge. Results indicate that older academic programs might not have adequately covered infection crontrol. Ar-ranging training for HCWs might be useful in improving their knowledge of standard infection control precautions and is also expected to facilitate positive attitude and practice.


Background
The infections acquired in, or associated with, hospitals that were absent or not incubating at the time of hospital admission are defined as hospital-acquired infections (HAIs) [1]. The burden of HAIs is on the rise globally despite advancements in medical care and technologies [2]. According to the World Health Organization (WHO), the prevalence of HAIs ranges between 5.7% and 19.1% in hospital seetings globally [3]. Recent studies estimated the prevealnce of HAIs in Europe [4] and the USA [5] at 6.5% and 3.2%, respectively. The burden of HAIs is strikingly higher in low-resourced countries compared to high-income countries [6][7][8]. A WHO-led systematic review revealed that the prevalence of HAIs varies between 7.6% and 15.5% in high-income and low-and middle income countries, respectively [3]. HAIs contribute to increased length of hospital stay, high mortality, higher health-care costs, and economic burden on families, communities, and countries at large [3,9]. Hence, prevention and control of HAIs appear as a critical public health concern [10].
The contaminated hands of health-care workers (HCWs) and healthcare equipments have been identified as the primary sources of HAIs [7,11]. The pathogens of HAIs are commonly transmitted from one patient to another when HCWs do not perform hand hygine properly following caring for one patient and contacting another patient [12]. The incidence of HAIs varies in different types of clinical departments. A study in Norway reported that the greatest infection rate is in the intensive care units followed by neonatal and burns units [13].
The WHO reported that improper environmental hygiene and waste disposal procedures, poor infrastructure, inadequatre equipment and manpower, overcrowding, limited knowledge and poor practices of basic infection control measures, and lack of national guidelines are the key determinants of HAIs [14]. The Center for Disease Control and Prevention (CDC) developed 'Standard Precautions' describing detailed procedures that need to be followed in order to prevent transmission of disease-causing agents and thereby preventing HAIs [15]. The standard infection control precautions warrant a uniform protocol to be followed for all patients at all times in all settings [2]. The principle of this guideline is all patients carry infectious agents even when they are asymptomatic [15]. The standard precautions include hand hygiene, use of gown, cleaning and disinfection of equipment, facial protection (e.g. masks and goggles), disposal of sharp objects, management of medical waste and coughing etiquette [2]. However, Hein and colleagues [16] reported that adherence to hand hygiene recommendations among HCWs is below standard, with a 30% compliance rate in Burkina Faso. It was found that about 42% of Corona Virus Disease-2019 among HCWs is associated with improper personal protective equipment (PPE) use [17]. Hefty workload, prolong clinical methods and skin status have been reported as key barriers in maintaining hand hygiene recommendations [18,19].
In some urban hospitals in the Kingdom of Saudi Arabia (KSA) recorded 2.2% hospital infection monthly, and other reports confirmed that hospital infection is still one of the most common health problems in the KSA [20]. Al Ra'awji et al. [21] observed that more than one quarter (37%) of HCWs in the KSA had poor knowledge on hand hygiene and there is a high need of training for the HCWs in this country. The KSA has been trying to activate all infection control guidelines to improve the activities in the field of infection control in high standards [22].
According to WHO, poor knowledge, attitude and practices (KAP) are among the key predictors of HAIs [14]. While narrating the KAP theory, Kelman argued that knowledge is essential to change practice and a positive attitude is a key instigator to bring a change [23,24]. Therefore, assessment of KAP among the HCWs is crucial to explore the reasons for non-compliance and identify the measures that should be undertaken to improve infection control practice and prevent HAIs [12]. Our literature search revealed a few studies reporting the KAP of hand hygiene and infection control mesures in the KSA. Among the published studies, one focused on hand hygiene of HCWs [21], three studied infection control among dental students [25][26][27], one assessed infection control measures among HCWs in dental clinics [28], one investigated cross-infection and infection control in dental patients [29], one incorporated health science students to assess standard precautions and infection control [30] and one evaluated prevention and control of HAIs among HCWs and non-HCWs [22]. Although, Al Ra'awji et al. [21] studied KAP of hand hygiene among HCWs but the authors did not report practice aspects. To the best of our knowledge, no study has examined the KAP on standard precautions of infection control among HCWs in the KSA. In this context, we aimed to assess the current status of KAP regarding infection control standard precautions among HCWs in the Qassim University Medical City, KSA.

Study Design and Setting
We conducted a cross-sectional survey of the HCWs in the Qassim university medical city, Saudi Arabia between November 2020 and February 2021. Qassim university medical city is the first specialized academic medical city in the Qassim region, KSA. It has 278 HCWs including physicians of different disciplines, dentists, nurses and pharmacist and medical technologists [https://qumc.edu.sa/].

Instrument
We assessed Knowledge, Attitude and Practices (KAP) of standard infection control precautions using a self-administered structured questionnaire. We developed our KAP questions on infection control standard precaution based on the guideliens of the CDC [31] and WHO [32]. The questionnaire was divided into four parts: the first part included questions on demographic and professional information of the HCWs; the second, third and fourth parts respectively focused on knowledge, attitude and practices regarding infection control standard precautions.
We assesed knowledge using a 20 item-scale. We provided 1 point for each right answer and 0 point for each wrong answer. The maximum possible score was 20 points with a range from 0 -20 points. Overall level of knowledge were classified as poor (<10 points, <50% right answer), moderate (10 -15 points, 50 -79% right answer) and good (16 -20 points, 80 -100% right answer). For logistic regression analysis knowledge was recoded into two groups -good (16 -20 points, 80 -100% right answers) and moderate to poor (<16 points, <80% right answers).
We assesed practice of infection control standard precautions using 15 questions on practicing standard precautions. Participants were given 1 point for each activities they were always practicing and 0 point for not practicing. The maximum possible score was 10 points with a range from 0 -50 points. Overall level of practice were classified as poor (<8 points, <50% score), moderate (8 -11 points, 50 -79% right answer) and good (12 -15 points, 80 -100% score). For logistic regression analysis practice was recoded into two groups -good (12 -15 points, 80 -100% score) and moderate to poor (<12 points, <80% score).

Data collection
Data was collected between November 15, 2021 and February 15, 2021. We have dissiminated our online questionnaire through our professional network using emails and WhatsApp. Participants were requested to avoid multi-registration. Before starting data collection we have pretesed our online questionnaire on 20 HCWs from different facilities. Pretesting feedback was used to improve wording of the questions and response options.
A total of 213 HCWs participated in the survey out of a total of 278 HCWs in the Qassim univerity medical city with a response rate of 76.62%.

Statistical analysis
Data was analysed using the SPSS version 20. Descriptive analyses were carried out to analyze participants' demographic information, mean knowledge, attitude and practice score of the HCWs. Descriptive analyses results were presented in tables reporting percentages and frequencies. To investigate association between KAP and socio-demographic variables, we conducted multivaraible logistic regression analyses and independent sample t tests. A p value of <.05 were considered statistically significant for both tests. For multivariable logistic regression analyses, we reported odds ratio (OR) with 95% confidence interval (CI). To compare mean knowledge, attitude and practice between different socio-demographic and professional groups we did independent sample t test. For these tests we reported mean knowledge, attitude and practice score of different groups and reported mean differences with 95% CI.

Results
A total of 213 health-care workers (HCWs) participanted in this study. Among them, 67.1% were aged 30 -34 years ; 56.3% of were males ; 67.6% had more than 6 years of experience as a HCW; 30.5% were previously exposed to infection while working and 84.5% received training in infection control practices (Table 1).  Table 2 depicts the number of the participants with the correct responses in each knowledge statement. We found that 67.6% of the HCWs had good knowlege (≥80% correct response) about infection control standard precautions. The mean score for knowledge was 15.7 (±2.7) with a range from 9 -20.
We found that majority of the HCWs correctly responded to the knowledge statments related to using standard precautions for all patients regardless of their diagnosis and perceived infection status (96.2%) and isolation precaution (76.1%), performing hand hygine after contact with the patient's environment (95.8%), before and after patient care (96.2%) and before and after handling potentially infectious materials (93.9%). Moreover, they correctly responded to the knowledge statments related to wearing (98.1%) and changing gloves (95.8%) for each patients ; using surgical masks (86.1%) and gown or apron (85.4%) to block contaminants and segregation of clinical and non-clinical waste for preventing spread of infection and (96.2%). All participants stated that mask must be placed on coughing patients to prevent potential dissemination of infectious respiratory secretions from the patient to others. While fewer participants correctly responded to statments related to linen from an infectious patients (45.5%), throwing of ampoules injection that has been used in the clinical waste bin (37.1%) and only 10.3% of them considered stationary, telephones kept in wards, and doorknobs as sources of infections.  Table 3 showed that 61.5% of study participants had positive attitudes twords infection control standard precaution. The mean score for attitudes was (55.5±5.7) with a range 35 -65. The Majority of the HCWs had a positive attitude towards performing hand-hygiene before and after any intervention with patients (91.5%), effectiveness of standard precautions in preventing the spread of infections (87.8%), ensuring adequate disinfection of medical equipment (85.0%), reducing the transmission of infectious organisms by adhering to standard and contact precautions (78.4%) and considered stationeries, telephones, and doorknobs are sources of infections (74.2%).
However, only 38.5%, 16% and 12.7% respectively strongly disagreed to the statements that standard precautions is not easy to follow, it is not logical to assume all patients contagious unless their infection has been confirmed and it is difficult to work wearing PPE. Therefore, demonstrated negative attitudes in these regards (Table 3).  Table  4 shows that 73.3% of participants had good practice of infection control standard precaution (≥80% score). Mean practice score (14.2) was closer to the maximum attainable score (15). Among the participants, 84.4% reported always wearing gloves when handling saliva or sputum culture ; 82.2% reported always wearing mask when performing operations / procedures that might induce spraying of blood, body fluid, secretions, and excretions. Moreover, majority of them reported always wears gloves when comes in contact with blood or handling the patient's mucosa (79.8%), dressing wounds (79.3%), disposing of stool or urine (77.9%), handling impaired patient-skin (75.1%), performing parenteral injections of medications (72.8%) and drawing blood samples (68.5%).
In relation to hand hygeine, 75.1% of the participants allways performed hand hygiene immediately after contacting blood, body fluid, secretion, excretion, and dirty substances. However, only 55.4% reported performing hand hygine when comes in contact with patients and 44.6% reported reported performing hand hygine after taking off gloves. While study participnats had allways wears protective suits or gown 66.2% and protective eye patch or goggle (62.9%) when performing operations/procedures that might induce spraying of blood, body fluid, secretions, and excretions. With regard to the waste disposal, 79.8% of the participants reported always disposing of single use needles, blades and other sharp objectes in a sharp disposal box after use. surprisingly HCWs with more than 6 years of work experience were less likely to had good knowledgel than those who have less work experince (OR : 0.14, 95% CI : 0.06 -0.34, p<0.001). While gender and previous exposure to infection while working did not have any statistically significant association with the level of knowledge about standard infection control precautions (p>0.05) With regard to the attiude of the HCWs towards standard infection control precautions, the results showed that there is no significant association with gender, age group, previous exposure to infection and reciving training (p>0.05). However, HCWs having more than 6 years of experience were more likely to have positive attitude compared to the HCWs with less experience (OR : 5.46, 95% CI : 2. 81 -10.59, p<0.001).
Regarding the practice of infection control standard precaution, the results showed that all characteristics of the participants are statistically associated with the level of practice of standard infection control precautions. HCWs who received training on infection control (OR : 3.54, 95% CI : 1.40 -8.98, p<0.01), who had more than 6 years of work experience (OR : 2.88, 95% CI : 1.38 -5.99, p<0.01) or exposed to infection while working (OR : 2.45, 95% CI : 1.08 -5.53, p<.05) were more likely to do good practice regarding standard infection control precautions. Gender and age were also associated with good practice. Female HCWs (OR : 0.22, 95% CI : 0.10 -0.49, p<0.001) and HCWs aged 35 years (OR : 0.34, 95% CI : 0.16 -0.75, p<0.01) were less likely to do good practice compared to their counterparts. The results in table 5 shows that HCW having less working experinces (1 to 6 years compared to more than 6 years) had significantly higher mean knowledge score (mean difference : 0.5, 95% CI: 0.04 -1.5, p<.05). In addition, mean knowledge score was significantly higher among the male HCWs than the females (mean difference : 0.7, 95% CI: 0.02 -1.5, p<.05).
In case of attitudes, we found that HCWs aged 35 years or more, female, having more than 6 years of working experience and being previously exposed to infection while working had significantly higher attitude score compared to the HCWs aged less than 35 years, males, having up to 6 years of work experience and not being exposed to infection while working respectively. Surprisingly, our results showed that the training had no statistically significant impact on attitudes of HCWs toward infection control standard precautions (p>.05).
In case of practice of standard infection control precautions we found that variables such as being younger (<34 years), male, having more experience (> 6 years ) and receiving training on infection control were associated with significantly higher mean practice score when compared to their counterparts (p<0.05).

Discussion
Knowledge is essential to develop a positive attitudes therefore is a key instigator to bring a positive change in practice [23,24]. Evidence suggests that knowledge and positive attitudes are associated with improved compliance with infection control standard precautions among HCWs [33]. Here we report the current status of KAP regarding standard precautions of infection control among the HCWs in the medical city of the Qassim University, KSA.
We found that just over two third of the study participants had good knowledge (gave at least 80% correct answer) about infection control standard precautions. However, this rate is still higher than the rate reported by studies conducted in a hospital in Northern Cyprus [33], among nursing students in Jordon (49.64%) [34] and among the dental faculty members and students (3 rd -5 th year) in Riyadh, KSA (49 -49.6%) [35]. Gaps in knowledge of standard precautions among HCWs were also evident in studies conducted in Iran [36] and Nigeria [37]. This gap in knowledge among HCWs nessiseate giving more emphasis on infection control standard precautions in academic and continued professional development training curriculam.
Despite of average level of knowledge among the study participants. Most of the participants answered correctly to the knowledge statements related to using standard precautions for all patients regardless of their diagnosis, isolation precaution, and performing handhygine after contact with the patient's environment, and before and after patient care. Moreover, majority of them correctly answered the knowledge statements related to wearing and changing gloves for each patients. These finding are consistent with studies conducted in Nigeria [38] and India [39].
With regard to the attitude, our study found that the proportions of HCWs with positive attitude (≥80% score) were 61.5%, which is considerably higher when compared with studies conducted in Jordon [34] and Iran [40], but lower than the proportion reported in Ethiopia (64.2%) [41] and among the primary care professionals in Abha, KSA (88.2%) [42]. This differences between our study and the other study in the KSA is because of using different classification system, such as any score of ≥60% were classified as positive attitude in the Abha study, while the cutoff point for positive attitude in our study was 80%.
The majority of the HCWs had a positive attitude toward washing hands before and after any intervention with patients (91.5%); disinfection of medical equipment (85.0%); adhering to standard and contact precautions (78.4%); and believed that standard precautions prevent the spread of infections (87.8%). This is probably due to the fact that these activities became routine practice. Which probably got reinforced by a positive institution culture, policy introduced by the Ministry of Health on Infection Control.
Our study found that 73.3% HCWs had good practice (≥80% score). This rate is higher compared to the findings from studies conducted in Vietnam (46.1%) [43], Northern Cyprus (30.9%) [33], Ethiopia (60.2%) [44], Iran (42%) [40] and Singapore (66.3% ) [45], but lower than the rate reported among nurses in India (91%) [46]. These differences in the level of practice of infection control standard precautions in different countries may be due to the differences in education, training, organizational culture, policies, presence of infection control guidelines and monitoring of its implementation.
Our logistic regression analysis results suggest that older (≥35 years) HCWs were more likely to have good knowledge compared to the younger HCWs (<35 years). This is in contrast with the findings reported in Cyprus [33] and in Egypt [47]. These studies reported that younger HCWs (<34 years) were more likely to have good knowledge. However, another study reported no association between age and knowledge in Ethiopea [48].
Our results also suggest that HCWs who received training on infection control standard precautions were 13.3 times likely to have good knowledge than the HCWs without training. This indicates the importance of training in refressing and updating HCWs' knowledge on infection control standard precautions. Likewise, Elliott et al. argued that intensive teaching and self-learning can improve knwoldege of HCWs in preventing sharp injuries [49]. Surprisingly, we found that those with 6 years or more work experiences were less likely to have good knowledge than the less expericed HCWs. Perhaps recent academic programs give greater emphasis on topics about infection control or infection control guidelines developed recently by the health-care facility. Therefore, lower knowledge among more experienced HCWs may be partly related to limited training on infection control. Similarly, a study in the UK reported that current medical students demonstrated better knowledge of needlestick injuries than the previous cohort [49]. Regarding association between gender and level of knowledge, we found no evidence of association. While, a study among nurses in Iran found significant association between gender and knowledge of infection control [50].
Our results also showed that sociodemographic variables such as, age, gender and training was not associated with attitude towards infection control standard precautions. This in agreement with studies conducted in Nigeria [38], Turkey [51] and in the Estern province of the KSA [52]. On the contrary, we found that HCWs having more than 6 years of experience were more likely to have positive attitude when compared to the less experienced ones. This denote that the experience is an important influenceer of attitude. While a positive attitude is highly correlated with good practice and therefore are important public health issues because these will prevent spread of infection from the health-care facilities [53].
Regarding the practice of infection control standard precautions, our results showed that all characteristics of the participants like, age, gender, experience and training were statistically significantly associated with good practices. This is consistent with studies conducted by AlKhaldi et al. who reported that good practice was significantly associated with years of experience and training in infection control [42]. A similar study in Korea reported that gender, work experience, age and training course are significantly associated with practice [54]. Therefore, it is important that health-care facilities organize regular training programs on infection control standard precuations for the HCWs to refress and update their knowledge and promote positive attitude and good practice.

Conclusion
Having good knowledge, attitude and practice of infection control standard precautions are vital to prevent the spread of infections from health-care facilities. Our research highlighted the gaps in KAP of the HCWs practicing in a teaching hospital in Qassim, KSA. Years of experience was negatively associated with knowledge which might indicate that older academic programs did not adequately covered topics on infection crontrol in health-care facilities. We further found that receivng training on infection control standard precautions is positively associated with good knowledge and practice. Therefore, arranging training programs for HCWs might be useful in refressing and improving their knowledge of infection control standard precautions and is also expected to facilitate positve attitude and practice.

Institutional Review Board Statement:
The study was conducted according to the guidelines of the Declaration of Helsinki, and ethical approval was obtained from the Qassim Regional Ethics Committee (IRB number: 1442-4-228).

Informed Consent Statement:
Informed consent was obtained from all subjects involved in the study.
Data Availability Statement: Data used in this study are available from the corresponding author on reasonable request.