CHAPTER TWO

LITERATURE REVIEW

2.1 Introduction

This chapter deals with the review of related literatures based on the topic of the study using journals,
text books, as well as internet. However, literature review focus on the research questions, objectives,
conceptual review, theoretical review and empirical review

.2.2

CONCEPTUAL REVIEW2.2.1

Concept of infection Prevention and [Link] to the World Health Organization (WHO),
infection prevention and control (IPC) is a scientific approach and practical solution designed to prevent
harm caused by infection to patients and health workers. It is a subset of epidemiology, but also serves
an essential function in infectious diseases, social sciences and global health (WHO, 2020).Cross-
infection of patients by health care workers with contaminated hands is a major source of infection.
Despite educational efforts, health care workers continue to fail to adhere to standards for hand
hygiene, which is universally considered the single most important method for infection control. The
average level of compliance has varied among hospitals from 16 percent to 81 percent (Gilboy &
Howard, 2008).Effective IPC is a public health issue that is fundamental in patient safety and health
system strengthening. The prevention of healthcare-associated infections (HAI), epidemics (including the
2013-2016 Ebola virus disease outbreak), and pandemics of international concern (For Example; 2009 flu
pandemic and the corona virus disease 2019) are rooted in effective IPC measures. A guiding principle
on WHO's Core Components of IPC is that "access to health care services designed and managed to
minimize the risks of avoidable HAI for patients and health care workers is a basic human right" (WHO,
2016).The additional measures such as adherence to the use of Personal Protective Equipment (PPE)
and following aseptic techniques during the invasive procedures are found to be useful in protecting the
patient as well as Healthcare Professionals (HCPs) from infection (Khan, Ahmad & Mehboob, 2015). Non-
compliance to adhere to the infection control guidelines has resulted in various out-breaks. Though
hand hygiene is considered very important in preventing infection, the global adherence to it among
healthcare workers is poor and the overall compliance rate is less than fifty percent (Biswal et al. 2014)

2.2.2 Epidemiological Triad

In humans, infections occur when an infectious microorganism enters the body, multiplies, and leads to
a reaction in the body and potential infectious disease. The

spread of infectious disease requires three variables, known as the epidemiological triad:

The Agent - The microorganism that causes the infection and can be in the form of bacteria, viruses,
parasites or fungi
The Host - The target of the disease

The Environment - The surroundings and conditions (these are external to the host) (US DHHS,
2020)

2.2.3 Modes of Infection Transmission

An infection is defined as the successful transmission of pathogenic microorganisms, such as bacteria,

viruses, parasites or fungi that are spread. There are five main modes of infection transmission: (Center
for Disease Control, 2020

[Link] transmission

Direct contact transmission involves contact between the infectious agent and the susceptible host.
Indirect contact transmission involves contact between a susceptible host and a contaminated
intermediate object such as a needle, instrument or other equipment (CDC, 2020)

2. Droplet transmission

Droplet transmission involves contact of the conjunctivae or mucous membranes of the nose or mouth
of a susceptible host with large particle droplets (larger than five microns) that contain an infectious
agent. Droplets are released through talking, coughing or sneezing, and during procedures such as
suctioning and bronchoscopy. Large particle droplets do not remain suspended in the air and generally
travel less than one meter through the air. (CDC, 2020)

3. Vehicle transmission

Food, water or medication contaminated with an infectious agent can act as a vehicle for transmission
when consumed. Contaminated instruments or devices that come in contact with body tissue or the
vascular system can also act as a vehicle for transmission. (CDC, 2020).

4. Airborne transmission

Small particle residue (five microns or smaller) of evaporated droplets may remain suspended in the air
for long periods of time, or dust particles may contain an infectious agent. Infectious agents carried in
this manner can be widely dispersed by air currents and can become inhaled by, or deposited on, a
susceptible host in the same room or over a longer distance, depending on environmental factors. (CDC,
2020)

5. Vector borne

Vectors such as insects may harbor an infectious agent and transfer it to humans through bites (for
example, West Nile virus) (Infection Prevention and Control 2009)

2.2.4 Infection Spread in Healthcare

Healthcare facilities, whether hospitals or primary care clinics are an area with an elevated risk of
disease transmission due to the presence and relative ratio of susceptible individuals. One in ten
patients get an infection whilst receiving care yet effective infection prevention and control reduces
health care-associated infections by at least 30%. In a healthcare setting, the three components required
for infection spread are the following:

Source - places where infectious agents survive (e.g. sinks, hospital equipment, countertops, medical
devices).

Environment - patient care areas, sinks, hospital equipment, countertops, medical devices.

People - patients, healthcare workers, or visitors.

Susceptible Person - Someone (Patient, Healthcare Worker, or Visitor) who is not vaccinated or immune
to a particular infectious disease, or an individual with a compromised immune system /
immunodeficient

In addition, susceptibility can be heightened in individuals due to underlying medical conditions,

medications, and necessary treatments and procedures that increase the risk of infection (For Example;
Surgery) (CDC, 2020)

.2.2.5 Controlling Infectious Diseases within Communities

Infection control and prevention is a global issue and there are many protocols and guidelines that can
be followed to minimize the spread of infection between people, within a population and globally.
Identifying at-risk groups such as children, older people and those with chronic conditions can also help
guide relevant strategies to protect these vulnerable groups. The first step when looking at infection
control can start at the community level by changing behaviour, including:

.Regular hand washing

.Appropriate use of Face-masks (Protect from and Prevent spread of Respiratory Infections)Using insect
repellents

.Ensuring up-to-date routine vaccinations and participating in immunization programs

.Taking prescribed medications, such as antibiotics, as directed by health professionals

.Social Distancing - avoiding contact with others

Using condoms when having sex, especially with a new partner

Other steps that can be taken to control the spread within communities include environmental
measures such as:

Modifying Environments
Surveillance of Diseases

Food Safety

Air Quality(WHO, 2016)

2.2.6 Medical Interventions

As well as simple steps to prevent and control infections, there are biochemical interventions that can
be implemented to speed up the recovery process and in some cases prevent viral infections
completely. The development of antibiotics, antivirals and vaccinations have been shown to speed up
recovery, slow down the progression and in some cases eradicate infectious diseases from entire
populations. (Drexler, 2010, McBride, 2018)

Antibiotics

Antibiotics are prescribed for bacterial infections and support the body's natural defence system to
eliminate the disease-causing bacterial agent. They are designed to either kill bacteria or stop them from
reproducing, however poor use of antibiotics, over-prescribing and the mutation of bacteria has led the
development of resistant bacteria. In these cases, either stronger doses are required or the combination
of one or more antibiotics (Drexler, 2010, McBride, 2018)VaccinationsVaccinations are designed to
improve immunity to a particular disease. Vaccines work by introducing small amounts of the disease-
causing virus or bacteria into the host, allowing them to build up natural immunity. The introduction of
regular vaccines have slowed down and in some cases eradicated certain diseases such as polio,
measles, mumps, whooping cough and rubeola (measles). There are also vaccinations for chickenpox but
this is not given routinely and is reserved for those at risk of spreading the disease to those with a
weakened immune system. This is due to the fact that it is prevalent in children under 10 years of age
and symptoms are usually mild; this method allows them to build up natural immunity and contributes
to improving the immunisation of a community. This type of protection is known as herd immunity
(Drexler, 2010, McBride, 2018)Antivirals

For infectious diseases that are caused by viral agents such as influenza, HIV, herpes, and hepatitis B,
antibiotics provide no defence and in these cases, antiviral medications are the most effective at slowing
down the progression of the disease and boosting the immune system. Unfortunately, as with
antibiotics, viruses can mutate over time and become resistant to these antiviral drugs (Drexler, 2010,
McBride, 2018).

2.2.7 Infection Control in Healthcare Facilities

Another important factor in controlling and preventing infection is by improving practices in healthcare
facilities. It is the duty of healthcare professionals worldwide to ensure they develop strategies and
implement policies that protect those who may be immunocompromised in order to keep susceptible
patients safe from healthcare-associated infections (HAIs) (Borg, 2014)

.2.2.8 Forms of Infection Control Measures

There are two tiers of recommended precautions by the Center of Disease Control and and Prevention
(CDC) to prevent the spread of infections in healthcare settings:

Standard Precautions:

.Hand hygiene

.Personal protective equipment

Transmission-Based Precautions

.Sterilization,

Cleaning and Disinfection

Safe use and disposal of sharps

(Rathore, and Jackson, 2017)

[Link] Hand Hygiene

Hand hygiene is defined as hand washing or washing hands and nails with soap and water or using a
waterless hand sanitizer (American Journal of Infection Control 2007). Hand hygiene is central to
preventing spread of infectious diseases. Independent studies by Ignaz and Semmelweis in 1847 in
Vienna and Oliver Wendell Holmes in 1843 in Boston established a link between the hands of health
care workers and the spread of hospital-acquired disease. The Centers for Disease Control and
Prevention (CDC) has stated that “It is well documented that the most important measure for preventing
and controlling the spread of pathogens is effective hand washing.” (CDC, 2020)

Hand Hygiene Moments

Moments' or opportunities for hand hygiene are based on those defined by the World Health
Organization Guidelines on Hand Hygiene. A 'moment' is when there is a perceived or actual risk of
pathogen transmission from one surface (or patient) to another via the hands.

The 5 Moments for hand hygiene are:

Moment 1: Before touching a patient

Moment 2: Before a procedure

Moment 3: After a procedure or body fluid exposure risk

Moment 4: After touching a patient

Moment 5: After touching a patient’s surroundings (WHO 2005).In a study conducted by (Smith &
Lokhorst 2009) on the topic “Infection control: can nurses improve hand hygiene practice?” they
provided salient tactics to promote effective infection control practices in hospitals by presenting three
(3) major strategies that can be used to promote effective hand hygiene practices for infection control in
hospital.

Three strategies are as follows:

(1) Education that promotes the “why and how to” of washing hands properly.

(2) Intervention strategies to promote clean hands in a hospital environment

(3) Evaluation tools used to monitor the practice of hand washing.

[Link] Personal protective equipment

Personal protective equipment is the barrier that aims at protecting skin and mucous membranes from
exposure to potentially infectious materials thus minimize the risk of being infected. The primary role of
personal protective equipment is to protect staff and reduce opportunities for transmission of
microorganisms in hospitals.

The decision to use or wear personal protective equipment must be based upon an assessment of the
level of risk associated with a specific patient care activity or intervention and take account of current
health and safety legislation. According to the occupational safety requirement, managements are
responsible for ensuring appropriate personal protective equipment is provided to staffs. Staffs should
learn how to select and use appropriate personal protective majors according to the risk assessment of
nursing procedures and the infectious diseases situations (Rathore and Jackson, 2017)

Components of personal protective equipment

Gloves

Gowns/Aprons

Facemask, Respiratory and Eye protection

(Rathore and Jackson, 2017)

Gloves

Since the mid-1980s the use of gloves as an element of personal protective equipment has become an
every-day part of clinical practice for healthcare workers. Expert opinion agrees that the two main
indications for the use of gloves in preventing health care acquired infection are to protect hands from
contamination with organic matter and microorganisms, and to reduce the risks of transmission of
microorganisms to both patients and staff (Rathore and Jackson, 2017)

Precautions when using gloves

Gloves must be worn for invasive procedures, contact with sterile sites, and non-intact skin or mucous
membranes, and all activities that have been assessed as carrying a risk of exposure to blood, body
fluids, secretions and excretions; and when handling sharp or contaminated [Link] must be
worn as single use items. They are put on immediately before an episode of patient contact or
treatment and removed as soon as the activity is completed. Gloves are changed between caring for
different patients, or between different care/treatment activities for the same [Link] must be
disposed off as clinical waste and hands decontaminated, ideally by washing with liquid soap and water
after the gloves have been removed (Rathore and Jackson, 2017)

Gowns/Aprons

National and international guidelines recommend that protective clothing should be worn by all
healthcare workers when close contact with the patient, materials or equipment may lead to
contamination of uniforms or other clothing with microorganisms, or when there is a risk of
contamination with blood, body fluids, secretions, or excretions. Disposable plastic aprons are
recommended for general clinical use. However, unused aprons need to be stored in an appropriate
area away from potential contamination. Full body gowns need only be used where there is the
possibility of extensive splashing of blood, body fluids, secretions or excretions and should be fluid
repellent (Rathore and Jackson, 2017)

Precautions when using gowns/aprons

Disposable plastic aprons must be worn when close contact with the patient, materials or equipment
are anticipated and when there is a risk that clothing may become contaminated with pathogenic
microorganisms or blood, body fluids, secretions or excretions, with the exception of [Link]
aprons/gowns should be worn as single-use items, for one procedure or episode of patient care, and
then discarded and disposed of as clinical waste. Non-disposable protective clothing should be sent for
[Link]-body fluid-repellent gowns must be worn where there is a risk of extensive splashing of
blood, body fluids, secretions or excretions, with the exception of perspiration, onto the skin or clothing
of healthcare workers (for example when assisting with childbirth) (Rathore and Jackson, 2017)

Facemask, Respiratory and Eye protection

Healthcare workers (and sometimes patients) may use standard surgical facemasks to prevent
respiratory droplets from the mouth and nose being expelled into the environment. Facemasks are also
used, often in conjunction with eye protection, to protect the mucous membranes of the wearer from
exposure to blood and/or body fluids when splashing may occur. Facemasks are also used to protect the
wearer from inhaling minute airborne respiratory particles. As surgical facemasks are not effective in
filtering out such small respiratory particles, specialized respiratory protective equipment (sometimes
called ‘respirators’) is recommended for the care of patients with certain respiratory diseases, such as
active multiple drug-resistant pulmonary tuberculosis (National Collaborating Centre for Chronic
Conditions for the National Institute of Health and Clinical Excellence, 2006), Severe Acute Respiratory
Syndrome (SARS) and pandemic influenza. In order to protect the wearer effectively from inhaling small
respiratory particles, they masks must fit closely to the face to minimize leakage. Although the advice to
use particulate filter masks is based on expert opinion, one study found that staff exposed to patients
with SARS acquired the infection when they did not use particulate filter masks (Rathore and Jackson,
2017). Another study demonstrated a lack of knowledge about guidance on using particulate respirator
masks among staff caring for patients with SARS and suggests that focused training on the use of
personal protective equipment and the transmission risk of SARS is required (Chia, 2004).

Precautions when using face mask, respiratory and eye protection

Face masks and eye protection must be worn where there is a risk of blood, body fluids, secretions or
excretions splashing into the face and [Link] protective equipment, i.e., a particulate filter
mask, must be correctly fitted and used when recommended for the care of patients with respiratory
infections transmitted by airborne particles (Rathore and Jackson, 2017).

[Link] Sterilization, Cleaning and Disinfection

Sterilization is a process intended to kill all microorganisms and is the highest level of microbial kill that
is possible. Sterilizers may be heat only, steam, or liquid chemical (Miller & Chris 2010). Effectiveness of
the sterilizer (e.g., a steam autoclave) is determined in three ways. First, mechanical indicators and
gauges on the machine itself indicate proper operation of the machine. Second heat sensitive indicators
or tape on the sterilizing bags change color which indicate proper levels of heat or steam. And, third
(most importantly) is biological testing in which a highly heat and chemical resistant microorganism
(often the bacterial endospore) is selected as the standard challenge. If the process kills this
microorganism, the sterilizer is considered to be effective. It should be noted that in order to be
effective, instruments must be cleaned, otherwise the debris may form a protective barrier, shielding
the microbes from the lethal process. Similarly care must be taken after sterilization to ensure sterile
instruments do not become contaminated prior to use (Miller & Chris 2010). Sterilization, if performed
properly, is an effective way of preventing bacteria from spreading. It should be used for the cleaning of
the medical instruments or gloves, and basically any type of medical item that comes into contact with
the blood stream and sterile tissues. There are four main ways in which such items can be sterilized:
autoclave (by using high-pressure steam), dry heat (in an oven), by using chemical sterilants such as
glutaraldehydes or formaldehyde solutions or by radiation (with the help of physical agents). The very
high temperatures needed to perform sterilization in this way are able to melt the instruments that are
not made of glass or [Link] sterilization is done at a temperature of 121 C (250 F) with a pressure
of 106 kPa . In these conditions, unwrapped items must be sterilized for 20 minutes, and wrapped items
for 30 minutes. The time is counted once the temperature that is needed has been reached. Steam
sterilization requires four conditions in order to be efficient: adequate contact, sufficiently high
temperature, correct time and sufficient moisture. Sterilization using steam can also be done at a
temperature of 132 C (270 F), at a double pressure. Dry heat sterilization is performed at 170 C (340 F)
for one hour or two hours at a temperature of 160 C (320 F). Dry heat sterilization can also be
performed at 121 C, for at least 16 hours (Miller & Chris 2010).Chemical sterilization: also referred to as
cold sterilization, can be used to sterilize instruments that cannot normally be disinfected through the
other two processes. The items sterilized with cold sterilization are usually those that can be damaged
by regular sterilization. Commonly, glutaraldehydes and formaldehyde are used in this process, but in
different ways. When using the first type of disinfectant, the instruments are soaked in a 2-4% solution
for at least 10 hours while a solution of 8% formaldehyde will sterilize the items in 24 hours or more.
Chemical sterilization is generally more expensive than steam sterilization and therefore it is used for
instruments that cannot be disinfected otherwise. After the instruments have been soaked in the
chemical solutions, they are mandatory to be rinsed with sterile water which will remove the residues
from the disinfectants. This is the reason why needles and syringes are not sterilized in this way, as the
residues left by the chemical solution that has been used to disinfect them cannot be washed off with
water and they may interfere with the administered treatment. Although formaldehyde is less expensive
than glutaraldehydes, it is also more irritating to the eyes, skin and respiratorytract and is classified as a
potential carcinogen (Miller & Chris 2010).

Disinfection: refers to the use of liquid chemicals on surfaces and at room temperature to kill disease
causing microorganisms. Disinfection is a less effective process than sterilization because it does not kill
bacterial endospores (Miller & Chris 2010).

2.2.9 The Safe Use and Disposal of SharpsThe safe handling and disposal of needles and other sharp
instruments forms part of an overall strategy of clinical waste disposal to protect staff, patients and
visitors from exposure to blood borne pathogens (Health Services Advisory Committee, 1999). In 2003
the National Audit Office found that needle stick injuries ranked alongside moving and handling, falls,
trips and exposure to hazardous substances as the main types of accidents experienced by health care
workers (National Audit Office, 2003). In 2001 the Royal College of Nursing (RCN) launched its Be Sharp
Be Safe campaign aimed at reducing sharps injuries. Nurses were the group with the highest proportion
of sharps injuries, accounting for 41.2% of all reported injuries.A report in 2006 from the Health
Protection Agency confirms that healthcare workers are still being exposed to blood borne virus
infections, even though such exposures are largely preventable. The number of reported occupational
exposures increased by 49% in three years, from 206 in 2002 to 306 in 2005, with almost half of all
exposures occurring in nurses (Health Protection Agency, 2006). The average risk of transmission of
blood borne viruses following a single percutaneous exposure from an infected person, in the absence
of appropriate post-exposure prophylaxis has been estimated (Health Protection Agency, 2006; CDC,
2006):Hepatitis B virus (HBV) 33.3% (1 in 3)Hepatitis C virus (HCV) 1.8 -1.9% (1 in 50)Human
immunodeficiency virus (HIV) 0.3 % (1 in 300)As with many infection prevention and control policies, the
assessment and management of the risks associated with the use of sharps is paramount and safe
systems of work and engineering controls must be in place to minimize any identified risks, such as
positioning the sharps bin as close as possible to the site of the intended clinical procedure. Any
healthcare worker experiencing an occupational exposure to blood or body fluids needs to be assessed
for the potential risk of infection by a specialist practitioner, such as a physician or occupational health
nurse, and offered testing, immunization and post-exposure prophylaxis if appropriate (Expert Advisory
Group on AIDS, 2000).

Precautions for safe use and disposal of sharps

Sharps must not be passed directly from hand to hand and handling should be kept to a
[Link] must not be recapped, bent broken or disassembled before use or [Link]
sharps must be discarded into a sharps container at the point of use by the user. These must not be
filled above the mark that indicates the bin is [Link] sharps bins should be positioned out of the reach of
children at a height that enables safe disposal by all members of staff. They should be secured to avoid
spillage (Miller & Chris 2010).

2.3

2.3.1EMPHERICAL MODEL

Knowledge of Nurses On Infection Control Measures.A study by Arinze-Onyia et. al (2018) on Knowledge
and Practice of Standard Precautions by Health-Care Workers in a Tertiary Health Institution in Enugu,
Nigeria, by which nurses forms the majority (46.1% of 629) showed that the respondents were mostly
females (64.4%), married (62.3%), Christians (94%), and within 20–59 years. Over 90% of respondents
had heard of Standard Precaution mainly from formal training (62%). Over 70% could define standard
precaution, 74.6% had knowledge of when SP is needed and >70% identified most components of SP.
Over 90% agreed that SPs are useful and that employers should provide SP training. Most respondents
washed hands after removal of gloves (73.6%) and before leaving patient’s care area (33.1%). More than
70% had been exposed to patient’s body fluids and washed the exposed part with water, soap, and
disinfectant (52.1%). Gloves were the most commonly used personal protective equipment (PPE)
(53.4%) and the major reason for inconsistent use was irregular access (57.7%). Over 50% recap needles
before discarding. Exposure to patients’ serum was significantly higher among doctors and
[Link] study conducted by Al Wehedy & Tarek (2009) on knowledge of infection control
components among healthcare workers at the primary healthcare level in Saudi Arabia revealed that
503 healthcare workers were assessed, out of which 195 were nurses and 24.5% had low level of
knowledge on components of infection control measures at the primary healthcare [Link] study
by Alrubaiee et. al (2017) on Knowledge and practices of nurses regarding nosocomial infection control
measures in private hospitals in Sana’a City, Yemen reveal that the highest percentage of nurses were
males (61.2%) and aging between 25 and above (71.8%) and had 3 years nursing diploma (60%), less
than 5 years of employment in the hospitals (56.5%), relatively high training course about nosocomial
infections (NIs) (64.7%), and working experience in infection control (78.8%). Most of the nurses (87%)
had a fair level of knowledge, while only 4% of them had a good level of knowledge of preventive
measures of nosocomial infections. The results also revealed that the majority of the nurses (71%) had
fair practices about nosocomial infections whereas 26% of them had good practices and only 3% of them
had poor practices.A recent descriptive study conducted by Eskander , Morsy, & Elfeky (2013) to assess
critical nurses' knowledge and evaluate their practice regarding infection control standard precautions.
The study revealed that, approximately two thirds (63.6%) of the studied sample had unsatisfactory
knowledge level, more than half (57.1%) of the studied sample had satisfactory performance
[Link], Ayed, Eqtait & Harazneh (2015) on Knowledge and Practice of Nursing Staff towards
Infection Control Measures in the Palestinian Hospitals revealed that, approximately half (53.9%) of the
studied sample had fair knowledge level (>80%). However, the majority (91.1%) of the studied sample
had Good practice (>80%). A descriptive study was conducted on nurses who worked at surgical wards in
in Azady Teaching Hospital in Kirkuk city to assess the practices of nurses towards standard precautions.
The study revealed that the majority (91.9%) of the nurses did not get training sessions regarding
infecton control and (83.4%) of them had not participated continuous learning about infection control.
According to the level of practices towards standard precautions, it has revealed that poor practices of
standard precautions by surgical wards nurses had shown in surgical wards (Mahmud and Abdul Sahib,
2011).

2.3.2 Perception Of Nurses Towards Infection Control Measures

.A study on attitude of nurses towards infection control by Ward (2012) in a primary health care facility
in the North of England revealed that 32 nurses were recruited for the study. Findings from the study
shows that nurses identified more positive attitude within their areas and organization, but their
comments did not always reflect this.

Another study on Knowledge, perception and practice of primary health care workers regarding health
care associated infections and infection control in Kuwait by Alnoumas, Enezi, Isaeed, Makboul & El-
Shazly (2012) revealed that out of 429 health care workers who participated, 277 were nurses and their
attitude regarding various infection control measures of hospital acquired infections were more or less
positive. It was also observed that proportions of nurses practicing infection controlmeasures were less
than that reported when describing their positive attitude towards hospital acquired infections. In
another study conducted by Georgios, Evridiki, Vasilios& Anastasios (2011) on factors influencing nurses'
compliance with infection control measures in order to avoid occupational exposure to microorganisms,
it was reported that factors related to noncompliance include lack of knowledge, skin irritation, lack of
time, forgetfulness, negative influence of the equipment on nursing skills, uncomfortable equipment,
lack of training, conflict between the need to provide care and self-protection and distance to necessary
equipment or [Link] study by Arinze-Onyia et. al (2018) on Knowledge and Practice of Standard
Precautions by Health-Care Workers in a Tertiary Health Institution in Enugu, Nigeria, by which nurses
forms the majority (46.1% of 629) showed that over 90% agreed that SPs are useful and that employers
should provide Standard precaution training while also most of the respondents washed hands after
removal of gloves (73.6%) and before leaving patient’s care area (33.1%). In another study by Timilshina,
Ansari &Dayal (2011) on knowledge and practice of infection control measures by primary health care
workers in the Western development region, Nepal; shows that irregular supply and availability of
materials, equipment and instruments prevents health care workers from using infection control
measures.

2.3.3 Practice of Infection Control Measures Among Nurses

.A study conducted by Samuel, Hagos, Mutungi & Almedom (2005) on promotion of infection control
measures (hand washing) practice as a measure of quality of care and prevention and control of
hospital acquired infections in Eritrea revealed that the hospital has 142 health workers of whom 37 are
nurses and 7% had inadequate practice of measures for infection control. Another study conducted by
Georgios, Evridiki, Vasilios & Anastasios (2011) on factors influencing nurses' compliance with infection
control measures in order to avoid occupational exposure to microorganisms revealed that compliance
with precautions among nurses in order to avoid exposure to microorganisms is low. More specifically,
the study shows that compliance was inadequate concerning use of gloves when exposure to body fluids
was anticipated, eye protection, mouth and nose protection (mask use), wearing a gown when required,
hand hygiene guidelines and avoiding recapping the needle after it was used for a [Link]
study by Arinze-Onyia et. al (2018) on Knowledge and Practice of Standard Precautions by Health-Care
Workers in a Tertiary Health Institution in Enugu, Nigeria, by which nurses forms the majority (46.1% of
629) showed that Most respondents washed hands after removal of gloves (73.6%) and before leaving
patient’s care area (33.1%) and more than 70% had been exposed to patient’s body fluids and washed
the exposed part with water, soap, and disinfectant (52.1%). Gloves were the most commonly used
personal protective equipment (PPE) (53.4%) and the major reason for inconsistent use was irregular
access (57.7%). Over 50% recap needles before discarding. Exposure to patients’ serum was significantly
higher among doctors and [Link] by Alrubaiee et. al (2017) on Knowledge and practices of nurses
regarding nosocomial infection control measures in private hospitals in Sana’a City, Yemen reveal that
most of the nurses (87%) had a fair level of knowledge and majority of them (71%) had fair practices
about nosocomial infections prevention whereas 26% of them had good practices and only 3% of them
had poor practices.A recent descriptive study conducted by Eskander, Morsy, & Elfeky (2013) to assess
critical nurses' knowledge and evaluate their practice regarding infection control standard precautions.
The study revealed that, approximately two thirds (63.6%) of the studied sample had unsatisfactory
knowledge level, more than half (57.1%) of the studied sample had satisfactory performance
[Link] study carried out by Punia, Nair and Shetty (2014) on Health care workers Perceptions
and determinants of compliance to standard precaution in tertiary care hospital in south India with
regard to the use of PPE showed the use of hand sanitizers among doctors was 71.5% and nurses was
81.1%. Also, 82.6% doctors and 90.6% nurses were using gloves wherever needed. Use of masks
(doctors – 34.8%, nurses – 67.9%), eye protector (doctors –19.2%, nurses – 28.3%) and use of gowns
(doctors – 33%, nurses 18.85) was poor.A study conducted by Latha et. al (2019) on Compliance
Towards Infection Prevention and Control Practices in Orthopedic Department of a Tertiary Care
Hospital find out that Palm to palm rubbing was done more frequently (90.9%) in hand disinfection using
hand sanitizers. Hand disinfection after the procedure (69.4%) was twice more than before performing
the procedure (33.9%). Though, in more than 90% of the event, hand washing was done, all the steps of
hand washing were not performed. In more than half (54.4%) of events, hands were not disinfected
before the procedures, but in 75.5% of the events, hands were washed after the procedure. Performing
hand washing techniques was better with soap and water than hand disinfection with hand sanitizer.
Among 131 observations, disposal of gloves wasin 101 (75%) events, gloves were appropriately disposed
in 99 (76.7%) events and four (1.6%) events HCPs carried gloves in their pockets. Infection control
measures followed correctly during wound care was 92.9%, during the dressing was 97.7.% and during
different procedures such as medication administration, collection of samples, feeding, change of
positions, pre and post-operative care, etc. was 74.6% (Hand disinfection before the procedure was
54.4% and 75.5% after the procedure. Performing hand washing techniques was better with soap and
water than using a sanitizer. Use of personal protective equipment, personal factors and removal of
jewellery were good (above 80.8%). The compliance towards infection control practices during the
various procedures ranged from 74.6% to 97.7%.Fashafsheh, Ayed, Eqtait and Harazneh, (2015) On
Knowledge and Practice of Nursing Staff towards Infection Control Measures in the Palestinian Hospitals
revealed that, approximately half (53.9%) of the studied sample had fair knowledge level (>80%).
However, the majority (91.1%) of the studied sample had Good practice (>80%). A descriptive study was
conducted on nurses who worked at surgical wards in in Azady Teaching Hospital in Kirkuk city to assess
the practices of nurses towards standard precautions. The study revealed that the majority (91.9%) of
the nurses did not get training sessions regarding infecton control and (83.4%) of them had not
participated continuous learning about infection control. According to the level of practices towards
standard precautions, it has revealed that poor practices of standard precautions by surgical wards
nurses had shown in surgical wards (Mahmud and Abdul Sahib, 2011).

2.4

Theoretical Framework

2.4.1 HEALTH BLIEF MODEL (HBM)The health belief model (HBM) is a popular model applied in nursing,
especially in issues focusing on patient competence and preventive health care practices; it is a good
model for addressing problems behaviors that evoke health concerns (Croyle, 2005).

The health belief model proposes that a person’s health-related behavior depends on his perception of
four critical areas:

The severity of a potential illness

The person’s susceptibility to that illness

The benefits of taking a preventive action and

The barriers in taking that action

.HBM addresses the relationship between a person’s beliefs and behaviors. It provides away to
understanding and predicting how clients will behave in relation to their health and how they will
comply with the health care therapies.

2.4.2 CORE ASSUMPTIONS AND STATEMENTS

The HBM is based on the understanding that a person will take a health-related action if that person:

Feels that a negative health condition can be avoided

Has a positive expectation that by taking recommended action, he/she will avoid a negative health
condition

,Believes that he/she can successfully take a recommended health action (Rosenstock, 2000).

The HBM was spelled out in terms of four constructs representing the perceived threat and net benefits:
perceived susceptibility, perceived severity, perceived barriers. These concepts were proposed as
accounting for people’s ``readiness to act” (Hochbaum, 1952). Cues to action would activate that
readiness and stimulate overt behavior (Glanz, 2008). HBM has been applied to a broad range of health
behaviors and subject populations. The theory has been adopted to explore a variety of long-term and
short-term health behaviors. (Conner & Norman, 1996):
2.4.3 MAJOR CONCEPTS AND DEFINITIONS OF HEALTH BELIEVE MODEL

The model postulates that the health seeking behavior is employed by person’s perception of a threat
posed by a health problem and the value associated with actions aimed at reducing the threat. There
are six major concepts of HBM;

Perceived susceptibility: refer to a person’s perception that a health problem is personally relevant or
that a diagnosis of illness is accurate.

Perceived severity: Even one recognizes personnel susceptibility, action will not occur unless the
individual perceive the severity to have a serious organic or social complication. Perceived benefits;
Refers to client’s relief that a given treatment will cure the illness or help to prevent it.

Perceived costs: Refers to complexity, duration, susceptibility, and accessibility of the treatment.

Motivation: Include the desire to comply with a treatment and a believed that people should do what.

Modifying factors: Includes personality variables, patient satisfaction and socio – demographic factors.

The above mentioned components form a useful tool which will generate vital information from the
residents on their knowledge, attitude and practice of malaria prevention and treatment. When properly
done, it will help the residents to be active participants in all programs designed to prevent malaria in
the community.

2.4.4 Application of the theory to the Study

The application of the above theory to the study is that, in-depth knowledge of infection control
measures will most certainly influence the health related behaviors of the nurses or their perception
concerning the threat posed by infection spread in health facility and the value associated with the
nurses' action to reduce that threat. Based on the model, factors affecting knowledge and attitude of
infection control measures cannot be over emphasized as nurses' view of seriousness of the infection
spread combine with knowledge of prevention measures will influence them to perceive a threat of the
non practicing. This thereby will enable them to identify ways to help promote effective utilization of the
available protective equipment to reduce risk as well as adopting the appropriate infection control
techniques such as hand washing.

2.5 SUMMARY OF LITERATURE REVIEW

The literature review provided overview of concept of infection transmission, five modes of infection
transmission were reviewed as contact, droplet, vehicle, airborne and vector borne, requirements for
effective infection control was discussed and also the various forms of infection control measures such
as proper hand hygiene, use of personal protective equipment and safe use and disposal of sharps. The
theory of health believed model was adopted as the theoretical framework, the theory was considered
suitable because it explains and applies to the three parameters of the study which are the knowledge,
attitude and practice of infection control measures. Review of previous related studies showed that
earlier researchers in this area basically looked into only the knowledge, attitude and practice of
infection control measures which might be the reason for the poor and low level of practice of the
infection control measures by nurses in health care facilities.