Knowledge and Practice of Standard Precautions for Infection Prevention and Control among Health Care Workers in Public Primary and Secondary Health Facilities in Edo State: A Reﬂection of the Neglect of First and Second Levels of Care in Infection Prevention in Nigeria

Standard precautions (SP) refer to the minimum infection prevention practice applied whenever providing patient care, irrespective of the diagnosis. SP is applied to all patients all the time to prevent unprotected contact with body ﬂuids so that bloodborne infections and the risks of infection transmission are unlikely. It involves various components that when consistently practised, prevents the spread of infection to health care workers, patients, and visitors. This study assessed the knowledge and practice of standard precaution among health care workers in public primary and secondary facilities in Edo State. A Cross-Sectional study design was used to study 217 HCWs in both public primary and secondary health facilities. Respondents were selected using the cluster sampling technique. The study was carried out between April and October 2019. Most of the HCWs (94.5%) were aware of SP with their source of awareness, mainly from their colleagues. Their knowledge of SP was generally poor. Only 23 (10.6%) of the respondents had good knowledge, others either had fair 153(70.50%) or poor [41(18.90%) knowledge of SP with a statistically signiﬁcant relationship between knowledge of SP and the HCWs level of completed education (p-value 0.019) as well as with the professional group they belong to (p-value 0.002). The practice of SP was generally abysmal, with only 3(1%) having good practice. The knowledge and practice of standard precaution among health workers at both the primary and secondary levels of care in Edo State were abysmally poor. There is an urgent need to organise sustained infection prevention and control (IPC) training as well as implement strategies to improve IPC competence among the HCWs in the primary and secondary facilities in Edo State.

| pg. 436 Osagiede EF, et al. to and among patients they care for. It is generally known that health care workers often come in contact with bloodborne pathogens and other microorganisms, and this exposure commonly occurs during major or minor surgical procedures, routine clinical and nursing services and disposal of sharps, as well as during lifesaving 2 emergency procedures. Health care workers are at risk of various occupational hazards in the hospital, including exposure to bloodborne infections such as human immunodeficiency virus (HIV), hepatitis B and C (HBV and HCV) infection from sharps 2,3 and contact with body fluid. The World Health Organization (WHO) in 2005 estimated that about 2.5%of HIV infections and 40% of HBV and HCV infections among healthcare workers worldwide were as a result of 3,4 exposure, following a needlestick injury. Occupational exposure of health workers to bloodborne infections, mainly through needlestick and other sharp injuries, has become a significant concern in developing countries. In Africa, the incidence of sharps injuries among HCWs is 3,4 estimated to be about 2.1% per year. Due to this concern, the Center for Disease Control (CDC) and Occupational Safety and Health Administration (OSHA) introduced "Universal Precautions" in 1985, to protect health care workers who come in contact with patients' blood and body fluids from infections. In 1996, this concept was further expanded and changed to the term Standard Precautions which is a set of measures formulated to prevent transmission of bloodborne diseases when providing health care regardless of the diagnosis or 2,5 infectious status of the patient. The components of standard precaution include hand hygiene, use of personal protective equipment (e.g. gloves, masks, goggles), respiratory hygiene/cough etiquette, sharps safety (engineering and work practice controls), safe injection practices (i.e., an aseptic technique for parenteral medications), sterile instruments and devices, clean and disinfected environmental 6 surfaces, waste management, education and training. The knowledge and adherence with these set of practices by HCWs vary from region to region and by the level of health care services involved. It has been observed that attention to capacity building of HCWs on SP is disproportionately skewed in favour of those practising at the tertiary facilities compared to those at the primary and secondary healthcare facilities. For instance, a crosssectional survey conducted in 2012 to assess the knowledge, attitude and practice of standard precaution of infection control among healthcare workers in two tertiary hospitals in Nigeria, revealed a percentage median knowledge score of 90%, with 97% of the respondents knowing that standard precautions should be practised on all patients and laboratory specimen irrespective of 5 diagnosis. Conversely, a study carried out among HCWs in Primary Health Care levels in Enugu, Southeast Nigeria revealed that there were serious knowledge deficits on the meaning, aim and components of SPs especially those related to hand hygiene, sharps disposal, and the 7 management of sharps injuries. Similarly, in another study conducted at Mizan-Aman General Hospital, Southwest Ethiopia, the researchers concluded that the majority of health care workers' knowledge, attitude and practice toward standard precaution were not sufficient, favourable 8 and safe enough to the expected standard. Generally, most of the studies on the practice of standard precaution are commonly conducted in tertiary health facilities in Nigeria and other developing countries without attempts to ascertain what the situation is at the primary and secondary levels of health care deliveries. Findings from one of these few studies in Nigeria carried out at the secondary level of healthcare by Johnson et al., in the South-south region of Nigeria revealed that there were poor practices among the HCWs in the area of needle 9 recapping (54%) and faulty sharps disposal (13%). They concluded that there were several gaps in the practice of SP among health workers in the secondary level of health care deliveries and that regular training of these health workers was critical in optimising infection control and 9 prevention in that level of healthcare delivery. To further worsen the matter of poor knowledge as revealed above, further study has shown that even in settings were the knowledge level was found to be high, the compliance level with standard precaution was poor. In a survey carried out among nurses working in Primary Health Facilities in Saudi Arabia, an acceptable level of knowledge was seen. Still, they had poor compliance with standard precaution, especially in observation of 10 compliance. The authors concluded that there were needs to commit more resources for education and monitoring of the implementation of standard precaution 10 among nurses in primary care centres. Suffice to say that the forgoing has alluded that generally, the poor compliance to the standard precaution of infection control is not entirely due to inadequate knowledge of the subject SP alone but maybe as a result of insufficient resources for infection prevention and control 5 , 11 or a complex mix of both and other factors. Implementing standard precaution in the lower levels of healthcare has been a significant challenge, especially in developing countries like Nigeria, where non-compliance 12 with standard precautions is often understudied. This situation has become worse at the primary and secondary levels of health care delivery due to lack of political will, human resources, materials, training, and motivation of the few health care workers who are engaged at that level of healthcare service delivery. This study was therefore carried out to ascertain the level of awareness, knowledge, and practice of standard precaution by healthcare workers in public primary and secondary health facilities in Edo State with a view of identifying the gaps and make a

Study Design
This study is a descriptive cross-sectional study conducted between April and October 2019.

Study Population
The study was carried out among selected participants including doctors, nurses, CHEWs, nurse assistants and health attendants in Edo State, South-South, Nigeria.

Inclusion and Exclusion criteria
All Health care workers who willingly gave their consent and had at least six months working experience in the facilities were included in the study, while those who did not give their consent to participate in the survey were excluded.

Sample size determination
The Sample size was determined using Cochran's formula 2 2 for cross-sectional surveys N = (z pq)/E with the prevalence (P) of 0.915 being the probability of standard precaution practice among health care workers in a 15,16 previous study. A minimum sample size of 132 participants was obtained with a non-response rate of 10%, thereby given rise to 147.

Sampling technique
The study was carried out using a cluster sampling technique to select HCWs. The state has 18 local government which was taken as clusters each. One local government (Esan West) was selected from the 18 LGAs of Edo State through simple balloting, and all consenting HCWs in the selected local government who met the selection criteria were recruited for the study.

Data Management
Data collection was done with the aid of a semi-structured interviewer-administered questionnaire designed by the  Data collected was then analysed using IBM SPSS (version 21) and presented in tables and charts. Scoring for knowledge and practice was done by allocating two marks for each correct answer while each wrong answer score zero. Knowledge score had a maximum of 22 marks, and the areas covered included the definition, measures, advantages, and applications of SP. The maximum score of the practice of SP was 14 marks. These scores were converted to percentages and graded as poor, fair and good for less than 50%, 50-69%, and at least 70%, respectively.

RESULTS
The results are summarised below in tables and charts.         There was a significant statistical association between level of education and knowledge of standard precaution, (p= 0.019), also observed was a significant statistical association between professional group and knowledge of standard precaution, (p=0.002). Only 1% of the respondents had a good practice; 63 % of the respondents had a poor practice of SP (Fig.3).

DISCUSSION
The majority 205 (94.47%) of respondents have heard of standard precautions, with over one third (43.41%) reporting that their sources of information were from colleagues and about one third 68 (33.17%) reporting hospital seminars as their source. This is similar to a There was a statistically significant association between respondents' knowledge and the health care professional group they belong to as it was noted that nurses (69.6%) had more knowledge of SP as compared to other health care workers in the study. This finding is similar to the 18 survey carried out in Jamaica. However, a more substantial portion (90.0%) of the nurses in the Jamaican study had good knowledge in contrast with the finding in this study. The majority (70.5%) of the respondents had a fair knowledge of SPs in this study, and this may be due to the erratic and irregular activities and attention given to the implementation of standard precautions at the primary and secondary levels of care by the relevant stakeholders in the health care industry. Also, contributory to this is the lack of training or seminars for health care workers in these facilities to enhance the knowledge of standard precaution.
There was a statistically significant association between respondents' level of education and knowledge of standard precautions. This association may also be related to the professional group as already elucidated in this study. HCWs in some professional groups like medicine, dentistry, nursing, and midwifery, pharmacy, and laboratory medicine are expected to have attained higher educational qualifications than their counterparts who are orderly, clerical, and security staff. This further underpins the fact that training and retraining of these HCWs at the p r i m a r y a n d s e c o n d a r y f a c i l i t i e s c a n n o t b e overemphasised. The training, especially in the form of hospital seminars and continuous professional education on topics like SP would afford all cadres of HCWs the opportunity to be equipped for better knowledge for safer health deliveries in the primary and secondary levels of care.
Regarding the practice of standard precaution, inadequate levels of practice were reported among two-third (63%) of respondents; these included the practice of handwashing, use of gloves during and after patients' point of care, and practice of needle recapping. There were reduced practices and the use of two-hand methods of recapping needles. This finding is similar to that conducted in Mizan- 8 Amam, SouthWest Ethiopia but in contrast to the findings 6 in Abuja, Nigeria, Hawassa City and Addis Ababa 19,20 Ethiopia where more than half of the respondents had good standard precaution practice. The lack of practice of standard precaution was due to lack of knowledge of SP as a result of the neglect for training and retraining of these HCWs. This may have been worsened with a possible lack of provision of personal protective equipment in these facilities as a further reflection of the neglect these levels of care had suffered.

CONCLUSION
Based on the findings of this study, the knowledge and practice of standard precautions for infection prevention and control among HCWs in public primary and secondary health care facilities in Edo State were abysmally poor. These have serious implications for the implementation of good infections prevention and control. Most of the HCWs sourced their information on standard precautions from sources that were not standardised for quality and mode of delivery as a means of filling the vacuum created by the neglect in training.