Universal precautions: compliance by health care workers at first level care facilities in rural areas of Swabi, in North West frontier provence of Pakistan

Date of Award


Document Type


Degree Name

Master of Science in Epidemiology & Biostatistics (MSc Epidemiology & Biostats)


Community Health Sciences


Background: Health care workers (HCW) are at risk of acquiring blood borne infections such as Human immune deficiency virus (HIV), Hepatitis B (HBV) and C (HCV) viruses. To reduce this risk they essentially have to follow universal precautions (gloving, gowning, hand washing, sharp disposal) recommended by Centers for Disease Control (CDC) USA. Significant reductions in occupational exposure to Blood-Borne Pathogens (BBP) are reported with use of universal precautions. A large number of injections are being administered in first level care facilities (FLCF) in Pakistan; many run by unqualified (non-licensed) practitioners in a rural setting. Risk to HCWs in such clinics also differ from those working in secondary or tertiary level care facilities based on lack of; availability of resources, infection control guidance, training, knowledge, and qualifications. These HCWs face a greater risk of occupational blood borne infections; especially when not complying with universal precautions practices. Aims: This study assessed the factors associated with compliance to universal precautions for blood borne pathogens using six constructs of health belief model (HBM) among Health Care Workers at clinics in a rural Tehsil Swabi in North West Frontier Province (NWFP) of Pakistan. Rationale: Large numbers of injections are being prescribed at FLCF. Given the high prevalence of HBV and HCV while little is known regarding needle stick/sharp injuries and compliance with universal precautions among HCWs at FLCF -HBM constructs are useful to study health behaviors; however, the model has not been applied fully for studying compliance to universal precautions in HCWs. Therefore, data on beliefs and behaviors of HCWs about UP and sharp injuries (SI) will provide rigorous framework to develop appropriate interventions. Methodology: A cross sectional study was conducted in HCW working at FLCF in Tehsil Swabi, NWFP Pakistan. A random sample of 370 clinics, stratified on type of clinic; i) Government based Public clinic (PC), Privately owned ii) Licensed Practitioners' clinic (LPC) and iii) Non-licensed practitioners' clinic (NLPC) were selected. A pre-tested questionnaire; determined the knowledge regarding modes of transmission of BBP, and responses (on likert scale) for constructs of HEM model (perceived susceptibility to BBP, disease severity, self efficacy, benefits of practicing UP, barriers to practicing UP, cue to action) and practice of UP. Analysis: Compliance with UP was assessed through validated eleven items likert scale having responses ranging from "never=0, rarely=1, sometimes=2, often=3, and always=4". HCWs who responded "often" or "always" to all the eleven items of UP scale were added together to calculate the overall compliance rate. Internal consistency of likert scales was confirmed by computing cronbach: As alpha score, used F test (Analysis of Variance "ANOVA") as tests of significance to assess the association between UP score and covariates. Scores on each likert item in a likert scale were added to calculate summative score for each scale. Adjusted Beta coefficients were obtained through multiple linear regression modeling to assess the relationship between compliance with UP and constructs of HBM. Results: From 365 clinics, 485 HCWs were interviewed; 7.9% facilities were PC, 15.9% were LPC, and 76.2% were NLPC; and 75% were prescribers and 25% were assistants. Mean age of HCWs was 38 (SD10.4) years, with median work experience of 10 years. Overall, "always or often" compliance with all the components of UP was 6.6%. Assistants were more compliant (9.8%) as compared to prescribers (5%). Cumulative knowledge regarding modes of transmission of BBPs, self efficacy, perceived benefits and susceptibility to BBPs were positively correlated with compliance to UP; adjusted Beta coefficient and 95% CI were 0.69(0.54,0.84), 0.6(0.28,0.93), 0.4(0.05,0.75) and 0.25(0.004,0.49) respectively. Barriers in practicing UP and perceived disease severity were negatively related with compliance to UP; Adj.B -0.28(-0.41,-0.15) and -0.37(-0.62,-0.11) respectively. At least one needle stick injury (NSI) in last one year among HCWs at clinics in Swabi was 20% (95% CI 16.4-23.6). Conclusion: Compliance of HCWs with UP was directly related to knowledge of transmission, and five constructs of health belief model (HBM). Compliance with UP among HCWs in rural clinics of Swabi can be improved by increasing modes of transmission knowledge of BBPs, self efficacy, perceived benefits, susceptibility to BBPs, and by minimizing the barriers in practicing UP.

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