CHAPTER TWO
2.0 LITERATURE REVIEW
2.1 UNIVERSAL PRECAUTION: A CONCEPTUAL OVERVIEW
Healthcare
literature, especially those on preventive measures, are replete with issue
relating to universal precaution, which has gained prominence since its
documentation. Issues relating to preventive guideline date back to the 1970s.
In 1970, according to Eftrathiou, Papastavrou, Rasfsaplous and Merkouns (2011)
the first set of preventive guideline was issued by the CDC to help healthcare
professionals protect themselves and patients from the transmission of
microorganisms. It was followed by a review in 1983.
In 1987, the universal precautions were
released, they among other things, required health care professionals to treat
every patient as potentially infectious (see Efstathious et al., 2011; Diaz, Mc Growder, Alexander- lindo, Gordon, Brown and
living, 2010, Okoro Eze and Ohagwu, 2010;
Bissonnette, 2008; Twitchell, 2003; and uwakwe, 2000). Efstathiou et al., (2011) re-echoing the
conceptualization by CDC stated that universal precautions refer to a set of
guidelines to prevent exposure to infection. In their analysis, Hesse, et at., (2006) wrote that the term
universal precaution (up) is the prevention of transmission of transmission of
blood-borne pathogens like HIV through strict respect by healthcare workers of
rules concerning care and nursing. “Anibue et
al, (2010) here conceived universal precaution as “the routine use of
appropriate barriers and techniques to reduce the likelihood of exposure to
blood, other body fluid and tissues that may contain blood- borne pathogens”.
According to the guidelines, up assumes anybody in a hospital, especially,
patients are potent carriers of blood borne pathogens, therefore all patients
are treated in the same way as though they were infected (Hesse et al., 2006; Jarvid, et
al., 2009; and Anibue et al., 2010).
In the same vein, Ofili, Asuzu and
Okejie (2010) view up as a series of procedures proposed by CDC for preventing
occupational exposures and for handling potentially infections materials such
as blood and body fluids. Cichoki (2006) views it as “the protocols used to
maintain an aseptic field and to prevent cross – contamination and cross-
infection between healthcare providers, between healthcare provider and
patients, between patients and patients” Obi (2010) held that “universal
precaution refers to the practice in medicine of avoiding contact with patients
body fluids and blood”.
The documentation and issuing of up were
borne out of the realization of the fact that blood and other body fluid from
patients are becoming increasingly hazardous to those who provide care for
them. UP encompasses a wide range of step taken during regular work day by
healthcare workers and must be adhered strictly to in order to protect self,
patient and co- workers from infections (Okoro, Eze and Ohagwu, 2010). Izegbu, Anide
and Ajayi (2006) have reiterated that UP apply to blood, other body containing
visible blood, semen, and vaginal secretions. Up also apply to tissues and to
the following fluids; cerebrospinal, synovial pleural, peritoneal, pericardial
and amniotic fluids. But they do not apply to faces, nasal secretions, spectrum
sweat, tears urine, and vomitus unless they contain visible trace of blood. Up does not apply to saliva except
when visibly contaminated with blood or in the dental setting where blood
contamination in saliva is predictable (Izegbu et al., 2006; and Bamigboye and Adesanya, 2006).
Anibue, et al (2010) wrote that the recommendation of up include; wearing
gloves, gowns and aprons when collecting or handling blood and body fluid
contaminated with blood wearing face shields
when there is danger of blood splashing on mucous membranes. Others include
disposing of all needles and sharp objects in puncture – resistant containers.
Cichocki (2006) analyzed UP to include but not limited to the sterilization of
instrument and goods, the isolation and disinfection of the immediate clinical
environment; the use of disposable, scrubbing, masking, growing and gloving;
and the proper disposal of contaminated waste. Aniebue, et al., (2010) emphasized that this recommendations are for
doctors, nurses, patients and healthcare support workers who are required to
come into contact with patient or body fluids (see also http:llen.wikepia.org/wiki).
Remarkably UP require the sustained provision of protective materials proper
training of health care providers and strict adherence to sterilization and
disinfection protocols.
2.2 Theoretical
framework
It would be worthwhile in a study of
this magnitude to carry out an overview of the theoretical underpinning that
underlies human behavior, especially in the healthcare field. Indeed they are
many motives for observed behaviors. As postulated by behaviorist theorists,
human beings adopt behavior they believe will result in the attainment of their
desire goals, e.g. the operant conditioning human behavior can also be adjusted
by modeling, i.e. the social learning theory (Omebe, 2005). Like every other discipline
that involves Behavioural adjustment, the medical field in general, and
universal precautions practice in particular, has underlying theories or models
that explain the way human beings adjust their behaviors with respect to a
particular concept.
Writing on standard precautions, Garcia-
Zapata, et al., (2010) explained that
“prompting compliance with UP measures implies behavioral changes”. They
explained that the dynamics of this
change is complex and multifaceted, and involves many factor such as education,
motivation and re- organization of the context of the working environment.
Analysis on UP practice among healthcare
workers is anchored on the health belief model (see Glanz, Rimer and levis, 2002; Conner and Norman, 1996; and
www.utwente.nl/cw/theoreenover zich/theory). The health belief model (HBN) is a
psychological model that attempts to explain and predict health behavior. This
is done by focusing on the attitudes and belief of individuals (Glanz, Rimer,
and Levis, 2002). The model was first developed in the 1950s by social
Psychologists, Hochbaum, Rosentock, Kegel and levanthal, working in the U.S
public health service. The model was developed in response to the failure of a
free tuberculosis (Tb) health screening programme. Since then the HBM has been
adopted to explore a variety of long and short- term health behaviors,
including sexual risk behavior and the transmission of HIV/AIDS, which features
prominently on analysis involving universal precautions (Conner and Noman,
1996; and Glanz, Rimers and Levis, 2002).
Health belief model (HBM), according to
Efstathiou et al., (2010), has been
widely used and is considered as one of the most useful models in health care
prevention and promotion, it offer the ability to understand the different
behavior or attitudes people may develop under the same condition by following
or not following certain guidelines or requirement (see also Roden, 2006, and
Kartal and Ozsoy, 2007). The original model had four constructs, supplemented
later by more (Becker, Janz, et al.,
1990; and Vaz et al., 2011). The HBM is based on two axes: (1) the perceived
threat for acquiring a disease, which incorporates the perceived susceptibility,
the perceived severity constructs. This axis creates a pressure to an individual
for action, nevertheless, this action may not necessarily take place; and (2)
the enabling factors that trigger the behavior, which include the perceived
barriers &benefits(Negad, werthein and Green wood, 2005). The additional
constructs that supplemented the earlier four were self – efficiency and cues
for action (Efsathiou, 2011).
In practical terms, the HBM suggests
that the seriousness of a disease as perceived by an individual (perceived
susceptibility) will prompt a behavior geared towards reducing the threat of
the disease. This will lead to action that will be determined by the level of
education attained, symptoms of the disease, media information, and other
determinants, such as social and demographic factors. The individual will
evaluate his action based on the benefits to be derived and the barriers that
constrain his/her actions. The level of risk as perceived by the individual and
the benefits of an action will result in a likelihood behavioral change.
The
health Belief model (HBM)
(source:
http://www.utwente.nl/cw/theeorieenoerzicht/theory )
The relevance of the HBM to our study on
UP is that healthcare providers, patient and other clients attending healthcare
facilities would readily adopt the precautions and adhere to the guild lines on
UP if they perceived the disease to be serious and life – threatening, the risk
of contacting the disease high, and the compliance with up guidelines a sure
measure to reduce the risk of infection. Here, their action would be based on
the their level of knowledge, the threat they face, the information they have,
availability and convenience of protective equipment, the actions of colleagues
and superiors (i.e. significant others), and the desire to reduce the
prevalence of the disease and remain healthy and free from threats.
2.3 Factors
influencing compliance with universal precaution
The conceptual model adopted in this
study suggests that human behaviors are motivated and influenced by factors
that are directly or indirectly related to the situation under review. There are
records that explain that UP measures are not wholly adhered to by healthcare workers in spite of the fact that their own
safety depends on it. Ofili, Asuzu, and Okojie (2003) explained that studies
have extensively reported sub optional and non- uniform adherence to UP
guideline by healthcare workers in both developed and developing countries. The
following are some of factors suggested by analysts that could influence
healthcare workers’ adherence to universal precautions:
2.3.1 Availability:
Non-availability of equipment has been
reported as an obstacle for implementing up, as they cannot be followed if the
healthcare worker does not have direct and easy access to the them (Efsthiou et al, 2011, and Oliveira, Cardoso and
mascarenhas,2010) studies have revealed that some healthcare workers complained
that equipment are stored and even locked far away from the place nursing care
is provided, making their use impossible under certain situations (for example
under emerging situations). Gaidhane, Zahiruddin, khatib, shrivastar and
Johrapurkar (2009) concurred that the lack of protective materials is the main
reason for not applying UP in many healthcare facilities. In the same vein,
Anbue, et al., (2010) noted that the
inability of hospital and clinic administrators in resource – poor countries to
provide the required protective equipment especially sufficient new examination
gloves, remains a problem. It is therefore, vital for healthcare workers to
have the protective equipment at their disposal for use when necessary.
2.3.2 Knowledge:
Practice goes with knowledge. We are
familiar with the saying “how can the people know except they are tought?” healthcare
providers must have an appreciable level of knowledge on UP before one could
think of them practicing them. Anibue, et
al., (2010) noted that, “the concept of UP is however, not a very familiar
one, even among formal healthcare workers” (see also Janjua, et al., 2007; and Hesse et al 2006). Vaz et al (2010) are of the view
that: “it is very important that health care workers have good understanding
about the risk of blood borne pathogens at work place and about the preventive
measures for reducing risk. Jawaid, Igbal and Shahbaz (2009) stated that the knowledge,
attitude and compliance among health care workers towards UP are usually
inadequate. Garcir-Zapata et al
(2010) emphasized that, “in addition to the negative influence on the part of
the professional serving as a role model, some authors highlight that the
origin of the low compliance, especially regarding the hand hygiene, lies in
the academic training”.
2.3.3 Emergency Situations
Many participants in various studies
described an emergency as a major obstacle in following precaution. Some health
care workers were quoted saying “…. We had to rescue the patient, we neglected
our own safety” (Osborne, 2003). It was explained that an emergency situation
requires doing a lot of things at the same time, very fast and usually under
heavy pressure. This situation, according to Efstathiou et al (2011), may influence health care workers not to follow the
protective guidelines due to insufficient time (several conditions many be a
matter of life and death). Hence lack of time has also been widely described as
a factor not facilitating the implementation of precautions.
2.3.4 Patient’s discomfort:
Patients’ discomfort has been identified
as a factor in the compliance with UP. Some healthcare workers explained that
patients may experience distress, anxiety, or even sorrow when a nurse offers
nursing care while covering him/self with a mask or gown or while using gloves.
In addition, patients may anticipate these measures taken by nurses as an
indication that their health status is not good or is getting worse (Osborne,
2003; Bissonnette, 2008, Oliveria, cardso and Mascarenhas, 2010).
2.3.5 Busy Schedule
Often healthcare workers come across
many responsibilities to be fulfilled this leads nurses to avoid the use of UP,
even when it is anticipated they may be exposed to microorganisms. Some
healthcare workers also stated that following UP in many cases its time
consuming, e.g. putting on a gown (Osborne, 2003; and Efstathiou et al, 2011).
2.3.6 Significant others:
Various studies (e.g. Efstathiou et al., 2011, Garcia-Zapata, 2010;
Okaro, Eze and Ohagwu, 2010; Izegbu, Amole and Ajayi, 2006, and Osborne, 2003)
explained that when universal precautions are followed by colleagues with more
knowledge or by senior personal, the compliance will be high. (Izegbu, et al., (2006) emphasized that “a
potentially effective safety programme that is ignored by top management will
fail because others will certainly ignore it. They explained that the
perception of senior management support for safety programmes has been shown as
the most significant factor influencing compliance with universal precautions
practices.
2.3.7 Previous Exposure
Health exposure personnel who have once
been exposed to serious cases, e.g. HIV/AIDS as a result of their carelessness
usually learn their lesson and adopt preventive measure in subsequent cases.
2.4 Patients’
Personal Characteristics:
Patients appearance, according to
Osborne (2003), was believed to be a serious factor that may lead to healthcare
workers to comply with UP. Some healthcare workers have complained that when a
patient has tattoo in many places of his/her body, has low personal hygiene
status or low educational level, them he/she would be considered as a high risk
for carrying an infections disease (Efstathiou et al., 2011).
2.4.1 Severity
Fear of being infected on the part of
healthcare worker coupled with serious disease-death negative impact on life,
and the cost from being infected will always compel a healthcare worker to
implement safety measures while on duty (Okaro, Eze and Ohagwu, 2010).
2.4.2 Self-Efficacy
It has been established that it is
difficult for some healthcare workers to change their behaviour even though
they know that is not correct. Some would say “…… it is difficult to change
after so many years” and “I don’t think that after so many year of practicing
the way I do I will be able to change” (Oliveira, et al., 2010, Bissonnette, 2008, Izegbu, et al 2006, and Okoro, Eze and Ohagwu 2010).
2.4.3 Negative influence on healthcare workers
Some healthcare worker have
stated that the use of protective equipment reduces their skills e.g. to
perform venipuncture when wearing gloves. Some of them would say “……. Using
gloves to draw blood from a patient reduces my dexterity, I can’t feel the vein
because the gloves interfere.” Others would say “…. I cannot breathe normally
when I wear a mask, it has an awful smell. I prefer not to wear a mask even when its use is necessary (Osborne, 2003).
2.4.4 Influence on healthcare workers’ appearance:
Some female healthcare workers complain
that protective equipment have negative impact on their appearance. Some of
them stated “……my appearance is very important to me. If I wear a hair cap,
this will destroy the look of my hair. I spend a lot of time making my hair
look the way I want them to look. And I am not going to let anything damage
this.” Others would like say “…. The use of face mask damage my lipstick and
makeup. I prefer not to use it” (Efsthiou et
al, 2011).
Knowledge, Attitude and Compliance:
2.5 An
Empirical Review
There is the need for this study to
x-ray some of the results obtained in previous research works in this field. A
plethora of empirical findings exists in this area. This work will review some
of them.
In a study conducted by Okoro, Eze and
Ohagwu (2010) on awareness, knowledge, attitude and practice of blood and body
fluid precautions among radiographers in Enugu, the findings showed that many
radiographers practicing in the tertiary hospitals do not have knowledge of
some aspects of universal precautions. Only a small proportion (37.5%) was
right in their knowledge of not recapping needles. Anibue, et al ;(2010) also carried out a similar study on universal
precautions with particular emphasis on awareness and practice of patent
medicine vendor (PMVs) in Enugu metropolis they found that majority of the PMV(78%) are not aware so the
concept of universal precaution, a situation that could be explained by their
lack of formal education. Adinma, and Asuzu, et al.; (2009) studied the knowledge and practice of universal
precautions against blood borne pathogen among house officers and nurses in
tertiary health institutions in southeast Nigeria. They found that the
knowledge of UP measures was high for
both categories of respondents- 97.0% for doctors and 92% for nurses, although
practice was better for the nurses, 75.0% compared to the doctors 15.2%. The
study reported a lack of provision of adequate protective equipment. Another
study was carried out by Izegbu, et al; (2006)
on attitude, perception and practice of workers in laboratory the two colleges
of medicine and their teaching hospitals in Lagos state. The study revealed
that the knowledge, attitude, perception and compliance with UP among these
highly exposed laboratory workers are poor. They seem to have a poor perception
of the risk of infection and are not compliant with the basic principles of UP.
The study revealed that 47.0% of the laboratory workers stored foods water and
drinks in the refrigerators meant for the storage of body fluids and chemicals.
Sadoh & Fawole, et al; (2006) did
a research on the practice of universal precautions among healthcare workers in
Abeokuta metropolis. The result revealed that compliance with non- recapping of
used needles was high among trained nurses and worst with doctors less than
two- third (63.8%) of the respondents always used personal protective
equipment, and more than (56.2%) of the respondents had never worn goggles
during deliveries and at surgeries. The provision of sharps containers and
screening of transfused blood by the institutions studied was uniformly high.
Ofili, Asuzu and Obi (2003) who conducted a similar research wanted to
ascertain the level of knowledge, and practice of UP among nurses in central
hospital, Benin city, Edo state. They found that nurses there had a poor
knowledge about universal precaution only 34.2% of them had heard about UP
there was also a poor observance of universal precaution.
In a related development, Hesse et al (2006) who sought to know the level of
knowledge, attitude and practice of universal basic precautions by medical
personal in a hospital in Ghana found that alleged knowledge did not match
actual tested knowledge (92% versus 71%). Knowledge of all forms of HIV
transmission was rather limited among medical personal. Practice of UP way also
not universal as 44% preferred to rely on pre-op HIV testing of patients and
knowledge of their status while 36% of the respondents admitted reluctance to
perform an invasive procedure of an HIV positive patient.
Away from Nigeria and African context,
Val et al (2010) carried out a study
to determine the level of knowledge, awareness and compliance with UP among
healthcare workers at the university hospital of the west Indies, Jamaica. The
study revealed that there was adequate knowledge and a fair level of awareness
among medical doctors, medical technologists and nurses towards up. More
respondents (92.9%) who were employed in the health factor for 16 years and
above reported high level of awareness of up than those who were employed for
less than five years. Again 28.6% of males and only 6.2% of females reported
that they do not use protective gear. Garcia-Zapata et al (2010) conducted a study on standard precautions with
emphasis on knowledge and practice among nursing and medical students in a
teaching hospital in Brazil. The result showed that, in spite of the fact that
the students knew that they had to wash their hands before and after caring for
a patient, 46.2% of nursing and 83.3% of medical students did not wash their
hands neither before nor after any procedure, although in 75.0% of these
instance, the necessary materials (water and soap) were available and ready to
be used. Jawaid, Iqbal and Shahbaz (2009) did a study to find out the level of
compliance with standard precautions in civil Hospital in Karachi, Pakistan,
and found out that the knowledge, attitude and compliance among doctors toward
standard precautions are inadequate. Majority of the doctors (52.5%) did not
know anything about CDC guidelines for standard precautions, while 40% of the
respondents had some idea and only 7.5% knew them all.
Here, 56.7% changed gloves for each
patient and only 39.2% wash their hands before and after examining a patient.
Most of the doctors (58.3%) said they always wear apron while dealing with
patients while 20% wear them only when dealing with high risk patients.
Protective goggles were not used by any of the respondents. The reasons given
for non-compliance includes non-availability of protective modalities by 58.3%
while 20% were of the opinion that it was not practical. Gaidhane et al., (2009) researched on the
occupation exposure to HIV and practice of universal safety precautions among
residents in Datta Meghe institute, medical science in India. They found that
of the 93 residents involved in direct patient care/ laboratory services, 54
(58%) were exposed to potentially infections materials. Here, 63 (67.7%) of
them were following dangerous procedures of either bending it against table/
wall or recapping (89.2%) used needles before disposal.
2.6 Summary
of Review Related Literature
Relevant literature on this study
explained universal precautions as a set of guidelines documented and issued by
the centre for disease control and prevention (CDC), which must be strictly
adhered to by healthcare workers in the course of discharging their duty of
caring for patients so as to prevent or reduce cross-contamination and
cross-infection between health care workers and patients, between patient and
patients and between health care workers and patient, and between healthcare
provider. It emphasized on the use of protective equipment which include
gloves, goggles, non-recapping and proper disposed of used needles, wearing of
grown, head gear, masks etc.
The health belief model (HBM) was
adopted to explain the relationship universal precautions and the behaviour of
health care workers with respect to compliance Here, health care workers
adherence or compliance with up is a function of factors such as the benefits
to be derived practicing safety precautions, the risky nature of a situation,
the likelihood of a patient being infections, level of education, attitude of
role models, the seriousness of the disease involved, etc
Findings obtained in previous research
were also reviewed and their major results highlighted. Most of the results
from these studies showed low level of knowledge, perception, awareness,
attitude and practice among healthcare workers across different areas and
countries. This study therefore seeks to unravel the situation as it is within
FETHA1