Abstract

Hospital acquired infections (HAIs) continue to be a threat to hospital admissions and workers thus contributing to mortalities and morbidities. Sophistication and type of services given by health facilities may determine health worker’s attitude towards combating these infections. The objective of this study is to compare knowledge, attitude and practice of HAIs among health workers at the three levels of health care in Nigeria, particularly the primary level that has to do with the resident as well as the health workers of Egor in Edo State. Nosocomial infections (Nls) are new localized or systemic infections that develop in patients receiving medical care in a hospital or other healthcare facilities. The infections are not incubating or present during a patient’s admission into the healthcare facility and are identified at least forty-eight to seventy-two hours following the patient’s admission. Episodes of Nls are recognized in hospitalized patients world-wide and are prevalent in all age groups. They are caused by pathogens such as bacteria, viruses and parasites present in the air, surfaces or equipment and are often transmitted by indirect and direct contact. Some of the pathogens are resistant to antimicrobial agents. The burdens of Nls include prolonged duration of hospitalization for patients resulting in increased costs of healthcare and deaths. Implementation of safe patient care activities is the role of healthcare workers such as physicians, dental health care workers and nurses. Therefore these healthcare workers should be familiar with practices to prevent the occurrence and spread of Nls. It has been documented in the literature that at the time of their graduation from their professional education, healthcare professionals have sufficient knowledge to practice patient safety and infection control guidelines. However, the evidence suggests otherwise since healthcare workers including nurses are implicated in the transmission of nosocomial infections. With nurses having the most contacts with patients; understanding of their knowledge, attitudes and practice patterns with regard to the spread of Nls may provide one approach by which this health care issue would be addressed.

INTRODUCTION

1.1 Background of the study

Nosocomial or hospital acquired infections (HAIs) is a serious global public health issue, causing the suffering of about 1.4 million people across the world at any given time (WHO 2007). Susceptibility to these infections has been associated with use of invasive devices, extremes of age, immune status and infection control practices (Haley et al 1985, Emori and Gayness 1995, Vincent et al 1995).They often increase costs of health care both for patients and health services alike (Coello et al 1993, McCuckin et al 1999, Kim et al 2001). The World Health Organization offers several definitions of a nosocomial infection/ hospital –acquired infection:

An infection acquired in [a] hospital by a patient who was admitted for a reason other than that infection . An infection occurring in a patient in a hospital or other health care facility in whom the infection was not present or incubating at the time of admission. This includes infections acquired in the hospital but appearing after discharge, and also occupational infections among staff of the facility.

As a general timeline, infections occurring more than 48 hours after admission are usually considered nosocomial.  Nosocomial infections are also divided into two classes, endemic or epidemic. Most are endemic, meaning that they are at the level of usual occurrence within the setting. Epidemic infections occur when there is an unusual increase in infection above baseline for a specific infection or organism. Epidemiological studies report that nosocomial infections are caused by ubiquitous. pathogens such as bacteria (Lepelletier et aI., 2005), viruses (de-Oliveira et aI., 2005) and fungi(Trick et aI., 2002) present in air, surfaces or equipment. Nosocomial infections occur worldwide, both in the developed and developing world.  They are a significant burden to patients and public health.  They are a major cause of death and increased morbidity in hospitalized patients.  They may cause increased functional disability and emotional stress and may lead to conditions that reduce quality of life.  Not only do they affect the general health of patients, but they are also a huge burden financially.   The greatest contributors to these costs are the increased stays that patients with nosocomial infections require.  The increased length of stay varies from 3 days for gynecological procedures to 19.8 days for orthopedic procedures.  Other costs include additional drugs, the need for isolation, and the use of additional studies.  There are also indirect costs due to loss of work.

Nosocomial infections are most frequently infections of the urinary tract, surgical wounds, and the lower respiratory tract.  A World Health Organization prevalence study and other studies have shown that these infections most commonly occur in intensive care units and in acute surgical and orthopedic wards.  Infection rates are also higher in patients with increased susceptibility due to old age, underlying disease, or chemotherapy.

Patients are exposed to a variety of microorganisms during a hospital stay, but contact between a patient and an organism does not necessarily guarantee infection.  Other factors influence the nature and frequency of infections.  Organisms vary in resistance to antimicrobials and in intrinsic virulence.  Bacteria, viruses, fungi, and parasites can all cause nosocomial infections.  There are multiple ways of acquiring such an organism.  The organisms can be transferred from one patient to another (cross-infection).  They can be part of a patient’s own flora (endogenous infection).  They can be transferred from an inanimate object or from a substance recently contaminated by another human source (environmental transfer).  The organisms that cause most hospital acquired infections are common in the general population, in which setting they are relatively harmless.  They may cause no disease or a milder form of disease than in hospitalized patients.  This group includes Staphylococcus aureus, coagulase-negative staphylococci, enterococci, and Enterobacteria.  Factors that increase a patient’s susceptibility to nosocomial infections include young or old age, decreased immune resistance, underlying disease, and therapeutic and diagnostic interventions.

The organisms that cause nosocomial infections are often drug-resistant.  The regular use of antimicrobials for treatment therapy or prophylaxis promotes the development of resistance.  Through antimicrobial-driven selection and the exchange of genetic resistance elements, multi-drug resistant strains of bacteria emerge.  Antimicrobial-sensitive microorganism that are part of the endogenous flora are suppressed, while the resistant strains survive.  Many strains of pneumococci, staphylococci, enterococci, and tuberculosis are currently resistant to most or all antimicrobials which were once effective.

Health care workers (HCWs) are at a high risk of needle stick injuries and blood-borne pathogens as they perform their clinical activities in a hospital.3  They are exposed to blood borne pathogens, such as human immunodeficiency virus (HIV), hepatitis B (HBV) and hepatitis C (HCV) viruses, from sharp injuries and contacts with blood and other body fluids.

Many nosocomial infections are caused by pathogens transmitted from one patient to another, by way of healthcare workers who have not washed their hands, or who don’t observe simple hospital hygiene measures, and also between patients (Horn et al 1988). Consequently, it is important to note that approximately one-third of hospital-acquired infections may be preventable (Comptroller and Auditor General 2000)

1.2  Statement of the Problem

Healthcare workers (HCWs) are at menace of occupational hazards as they carry out their clinical activities in the hospital.  Nosocomial infections have been acknowledged as a problem disturbing the quality of health care and a principal source of adverse healthcare outcomes. It has been recognized in the literature that within the realm of patient safety, these infections have serious impact. Increased hospital stay days, increased costs of healthcare, economic destitution to patients and their families and even deaths, are among the many negative outcomes (Emori et aI., 1991; Starfield et aI.,2000; Angus et aI., 2001; Zhan &Miller, 2003; CDC, 2005; Engemann et aI., 2005; Elward, et aL, 2005: Klevens et aL, 2007; Kaye et aL, 2009; Edwards et aI., 2009; Scott II, 2009). $26 million (Anderson et aI., 2009). These findings are indicative of the enormous economic burden associated with nosocomial infections.

Epidemiological studies report that nosocomial infections are caused by ubiquitous pathogens transmitted, at least in part, by healthcare workers through direct and indirect contact.

In 1938, Price established that microorganisms recovered from human body could be divided into two categories: the resident Hora (microbiota), or transient flora (Price, 1938). The resident

microbiota, also commonly referred to as normal flora consists of bacteria mostly found in the

superficial cells of the skin and mucous membranes; and in linings of the orifices of digestive, respiratory and reproductive systems (Black, 2012). It has been demonstrated in several immunological studies that resident microbiota exhibits protective functions against invasion, or

outgrowth, of pathogenic microorganisms and its depletion or aberration may lead to opportunistic infections (Fujimura et aI., 2010). However, these bacteria may cause infections in non-intact skin.

The most overriding species of resident microbiota is Staphylococcus epidermidis.

Transient microbiota are microorganisms present, under definite conditions, in any of the

locations where resident microbiota are found. Some of these microorganisms take possession of the superficial layers of the skin. They are more amenable to removal by routine hand hygiene and such microorganisms are often acquired by healthcare workers during direct contact with patients or contaminated environmental surfaces, within the patient’s surroundings. The most common types of transient bacteria are the Staphylococcus aureus, Escherichia coli, {3eta-hemolyticStreptococci, Serratia mercescens, Klebsiella pneumoniae, Pseudomonas aeruginosa,

Enterobacter species, Candida albicans and Clostridium difficile (Black, 2012). These are the

organisms frequently implicated in nosocomial infections (Monarca et aI., 2000; CDC 2002;

Lepelletier, 2005; Ribby et aI., 2005 &Hayden et al., 2006) and some of the strains are resistant to antibiotics (Lodise et aI., 2002; Conly et aI., 2004; Abba et al., 2005).

Epidemiological studies have demonstrated that transient bacteria are often acquired by

healthcare workers during direct contact with patients, or contaminated environmental surfaces,

within the patient’s surroundings (Monarca et aI., 2000; Lepelletier, 2005; Ribby et aI., 2005 &

Hayden et aI., 2006). Epidemiological studies suggest that nosocomial infections can be transmitted through direct person-to- person contact between infected patient. healthcare workers, non-infected patients and by indirect contact through equipment, supplies, medical procedures, or air (CDC, 2000; WHO 2002). The affected body systems depend on the virulence of the pathogens, accessibility of the pathogen to the patient and susceptibility of the patient to the pathogen (CDC, 2000). The most common types of nosocomial infections affect the urinary tract, surgical wounds, respiratory system and blood stream (WHO, 2002). Studies that have examined the impact of nosocomial infections caused by antibioticresistant pathogens at a single center in Egor L.G.A  and some laboratories that served hospitals in Edo state, showed that infections caused by antibiotic challenging pathogens were associated with amplified mortality rates, increased lengths of hospital stay and higher healthcare costs compared to the nosocomial infections caused by pathogens susceptible to antibiotics.

These findings sustain the notion that nosocomial infections present massive economic encumber to the public and the healthcare system.  In response to the realization of the degree of the problem, various agencies including federal and state governments, and professional societies – both nationally and internationally, have devised measures aimed at reducing the incidence of nosocomial infections. For example, Center for Infection Control and Epidemiology developed guidelines for hand-hygiene in healthcare settings and made recommendations for infection control practices which were based upon the obtainable evidence surrounding the best practices for patient care (Boyce at aI., 2002).

Furthermore, the Centers for Disease Control and Prevention (CDC), in cooperation with

government and non-government organizations throughout the world, has synchronized efforts and resources to help minimize the occurrence of nosocomial infections; and recommend activities that increase quality of patient care. In this regard, healthcare workers have been fostered to implement strategies that would call attention to measures aimed at prevention of the transmission of nosocomial infections. For that reason, healthcare professionals have been encouraged to participate in in-service continuing education on topics related to measures deemed necessary to reduce the transmission of nosocomial infections.

The World Health Organization (WHO), in conjunction with CDC, set prevention of nosocomial infections as main concern by developing a practical guide (manual) for the prevention of nosocomial infections globally (WHO, 2002). Some recommended strategies included in the manual were: the use of hand decontamination, personal hygiene, exploitation of masks and gloves; and proper methods of handling soiled clothing when healthcare workers perform patient care activities. The manual also recommends methods for preventing environmental transmission

including cleaning the hospital environment, use of hot  superheated water, disinfection of patient equipment, sterilization, and prevention of transmission of pathogens (for example, HIV, Hepatitis- B, Hepatitis-C viruses, and M. tuberculosis) to staff. Above a/l, the manual recommends that hospitals provide sufficient resources by training staff in infection control programs such as appropriate patient isolation and sterilization techniques and yearly work-plans and manuals for infection control practices that are approved by infection control committees (WHO, 2002). Such initiatives by the CDC suggest the importance with which nosocomial infections should be addressed (http://www.cdc.gov/ncidodlhip/prevention). Conversely, despite the development of the above policies and recommendations, the incidence of nosocomial infections and their collision on healthcare costs, morbidity and mortality stay unabated (Anderson et aI., 2009 &Scott II, 2009)  and healthcare workers are concerned in the transmission. The centers for Medicare and Medicaid Services instituted a“payment reform” program  where the eventual reimbursement system will not cover costs for preventable infections (nosocomial infections) acquired in the course of treatment (Johnson, 2009). Moreover, the federal government requires that healthcare institutions’ statistics on nosocomial infections be made available to the public and hospitals with highest rates of nosocomial infections will be penalized (DHHS, 2009). Furthermore, the Healthcare Reform Law has instituted measures that incentivize hospitals and other healthcare facilities to improve their programs for reducing nosocomial infections. Findings from several epidemiological studies divulge that healthcare workers such as physicians, dentists and nurses are implicated in the transmission of nosocomial infections.

It has as well been reported that transmission frequently occurs during the performance of medical procedures, when these healthcare workers fail to follow aseptic precautions. Thus, noncompliance with recommended guidelines by healthcare workers expose patients to an abundance of pathogens (Monarca et aI., 2000; Boyce et aI., 2002; Cohen et aI., 2003; Harrel et aI., 2004; Pittet et aI., 2004; Miner et aI., 2004; Szymanska, 2004; de Oliveira et aI., 2005; Lam et aI., 2004; Kurita et aI., 2006; Rautemaa et aI., 2006; Racco et aI., 2009; Eriksen et aI., 2009 &Costello et aI.,2010).

A study conducted by Casewell and Philips (1977) demonstrated that nurses could contaminate their hands with colonies of bacteria during clean patient care activities such as lifting patients, taking pulse, blood pressure, oral temperature or touching patients’ hands, shoulder or groin (Casewell and Phillips, 1977). Stone (2001) documented that patient contacts result in 18

contamination of hands by pathogens and that washing hands significantly reduces hand

contamination and infection rates (Mortimer et al., 1966; Stone, 2001). In a controlled trial study at a neonatal unit, Mortimer and colleagues (1966) found only 10 %acquisition rate of Staphylococcus aureus by babies where nurses washed their hands between patient contacts; and a 14% acquisition rate of the same pathogen by babies during the first 20 days when the nurses

washed their hands between patient contacts. The rate increased to 43% when the nurses

washed their hands only when they felt that the practice was clinically indicated (Mortimer et aI., 1966). These findings affirmed the ease with which healthcare workers could transmit

microorganisms and consequently, the spread of nosocomial infections.

Price (1938) and Lepelletier et al. (2005) observed that transient bacteria that colonize the

superficial layers of the skin are easily acquired by healthcare workers during direct contact with

patients or contaminated environmental surfaces (Price, 1938 &Lepelletier et aI., 2005). likewise, McBryde et al. (2004) and Michalopoulos et al. (2006), recognized that healthcare workers contaminate their hands or gloves with various pathogens, including resistant strains. While performing procedures that involve touching hospitalized patients’ intact skin or their immediate environment. Exclusively, 17% of transmission of Methicillin Resistant Staphylococcus aureus(MRSA) to the healthcare workers’ gloves occurred after get in touch with patients, patients’ clothing or patients’ bed (McBryde et aI., 2004). additional studies that investigated the modes of transmission of nosocomial infections in neonatal intensive care units showed that each hospitalized neonate or its immediate environment was touched 78 times during a 12-hour shift. Explicitly, more than half of the contacts were carried out by nurses (Cohen, et aI., 2003). In the light of these statistics, it is incumbent upon healthcare workers to enhance their knowledge of options as regards the alleviation of the transmission of nosocomial infections. It has been documented in the literature that at the time of their graduation from their

professional education programs, nurses should have acquired sufficient knowledge to practice

patient safety and infection control guidelines (Smith et aI., 2007; Cronenwett et aI., 2007).

Besides, their expertise with regards to knowledge, attitudes and practice to control the spread

of infection is also well evidenced by their success in licensure exams and other significant

assessments, which test their knowledge of infection control practices and the application of skilled safe patient care activities, over the course of their academic journey (Sherwood et aI., 2007; Smith, 2007). hence, the continued presence of nosocomial infections raises an enigma which may only be explained by other factors. fascinatingly, studies that investigated the responsibility of institutional support and the spread of nosocomial infections showed that low staffing levels lead to high workload and increased healthcare workers’ non-compliance with recommended hand hygiene practices (Huggonet et aI., 2007). Furthermore, existing studies show that the lack of proper equipment and surveillance systems for the monitoring of infections further increased the episodes of nosocomial infections (Monarca et aI., 2000; Chen et aI., 2003, Garretson et aI., 2004; Lo et aI., 2008 & Saint et aI., 2008). Thus, it is plausible that this paradox could be explained through a thorough examination of socio-cognitive perspectives with regards to knowledge; or behavioral aspects such as attitude that could affect the healthcare workers’ on-the- job practice; or ecological factors that include organizational support or architectural design of healthcare facility.

1.3  Objectives of the Study

On the whole, accessible data show that needle stick injuries and blood borne pathogens are serious threats to patients, HCWs (Healthcare workers)  and to the host community.

Health workers , regardless of specialty, engage in the most direct contact with clients in healthcare settings. Also, existing literature has documented specific examples where nurses are implicated in the transmission of nosocomial infections {Casewell &Phillips, 1977; Ehrenkranz et aI., 1991; Lucent et aI., 2002; Waters et al., 2004; Lepelletier et al., 2005; de-Oliveira et aI., 2005;Pessoa-Silva et aI., 2007). A review of literature has shown that health workers educational programs incorporate courses and instructional approaches that include methods aimed at preparing the Health care practitioner in protocols designed for infection control and as such the reduction and transmission of nosocomial infections. Furthermore, their expertise with regards to knowledge, attitudes and practice to control the spread of infections is well evidenced by their success in licensure exams and relevant assessments over the course of their academic journey (Sherwood et aI., 2007; Smith, 2007). Paradoxically, the evidence highlights otherwise: that is, unabated levels of the spread of nosocomial infections (Anderson et aI., 2009; Scott II, 2009) and the role of healthcare workers including nurses, in the transmission of nosocomial infections (Pittet et aI., 2004; Miner et aI., 2004; Eriksen et aI., 2009; Racca et aI., 2009; Costello et aI., 2010). Additionally, there is some evidence that suggests that the spread of nosocomial infections could be related to a breakdown in knowledge, attitude and practices among healthcare workers (Godin 1996; Pessoa-Silva et aI., 2005; Pittet et aI., 2006). What has not been established is if thisbreakdown is prevalent in novice registered nurses, suggesting the novice registered nurses’ inability to apply their knowledge in awork setting, or that it is in the more experienced registered nurses, suggesting either adecrement of knowledge (Ribby et aI., 2005; Lam et aI., 2004; PessoaSilva et aI., 2007; Suchitra et aI., 2007; Sax et aI., 2007) or a change in attitude and or sloppy practices possibly associated with stressful behavioral interactions with colleagues, workload or other organizational factors (Godin, 1996; Larson et aI., 2000; O’Boyle et aI., 2001; Chenot & Daniel, 2010). With health workers having the most contacts with patients, understanding their knowledge, attitudes and practice patterns with regard to nosocomial infections may be an important mode by which this health care issue may be addressed.

This study will expose the level of awareness, attitude and practice of standard precautions among the HCWs and hence could be used as a baseline for intervention.  It will also identify gaps which would be recommended for correction through interventions.  This study could be used to monitor trends of events concerning knowledge, attitude and understanding among health care workers in Egor, Edo State, by reviewing from time to time, the incidence of needle stick injuries and the morbidity and mortality pattern.  It will also identify gaps in the standard precaution practices among these HCWs and the results from the study will be used for the planning of health education intervention programme.  It will also provide reference material for the academic society as well as further research.

The purpose of this study was seven· fold:

    a) To investigate the level of knowledge, attitudes and perception of health workers with regards to the spread of nosocomial infections in Egor, Edo States .

    b) To ascertain the attitude, knowledge and perception of health care workers in Egor, Edo towards standard precautions.

    c) To compare the knowledge and perception in novice and experienced healthcare workers with regards to the spread of nosocomial infections;

    d) To determine the level of practice of standard precautions among health care workers in Egor, Edo State.

    e) To investigate the level of organizational support as reported by the health workers;

    f) To examine if a relationship exists between organizational factors or support and the level of health workers’ knowledge, and understanding with regards to the spread of nosocomial infections.

    g) To determine the level of immunization of the health care workers against infectious diseases such as HBV.

    h) To describe the action taken by the health care workers when they are exposed to occupational hazards and injuries.

1.4 Significance of the Study

It has been recognized in several epidemiological studies that healthcare workers such as physicians, dentists and nurses are caught up in the transmission of nosocomial infections.

Literature that has explored the knowledge, perception and practices of nurses and other health workers is limited. As a result, it is vital to further investigate the impact of knowledge, understanding and practices of novice and experienced graduate nurses with regard to the level of the spread of nosocomial infections. The findings from this study will add to the existing literature and may be used in developing interventions to reduce the spread of nosocomial infections.

1.5 Research Questions

There are six research questions for this study.

    a) What is the overall level of Knowledge, Attitudes and Perception among healthcare workers with regards to the spread of nosocomial infections?

    b) Is there significant difference in the level of knowledge between novice and experienced

healthcare workers with regards to the spread of nosocomial infections?

    c) Is there significant difference in attitude between novice and experienced healthcare workers

with regards to the spread of nosocomial infections?

    d) Is there significant difference in practice of safe patient care between novice and experienced

healthcare workers  with regards to the spread of nosocomial infections?

    e) What is the level of organizational support as reported by healthcare workers?

    f) What is the level of immunization of the health care workers against infectious diseases?

Theoretical Framework

Vacant social cognitive models propose that determinants that shape human behavior are acquired through socialization and may be susceptible to change. When reviewing the literature, three theories were found to offer a strong theoretical framework for research in this area: the social cognitive theory (SCT), the Health Belief Model (HBM) and Theory of Reasoned Action I

Theory of Planned Behavior (TRAlTPB) (Ajzen, 1980; Bandura,1989; Rosenstock et al. 1988).

The Social Cognitive Theory stems from the Social Learning Theory and was suggested by Alfred Bandura in 1986. This theory is based on the notion of a triad model that takes into account the communications between three factors: environment, personal cognition and behavior. A central belief of the Social Cognitive Theory asserts that behavior is uniquely determined by each of the three factors and that response penalty mediate behavior. Additional, the theory asserts that people are most likely to learn and model behavior observed in persons with whom they identify through a phenomenon commonly referred to as “vicarious capacity”. Vicarious capacity is defined as an observational leaning mechanism governed by attention span, retention process, motor facsimile development and motivational processes (Bandura, 1991 and Glanz et aI., 2002).Bandura asserted that people learn by modeling behaviors from significant others; and that behavior is determined by symbolizing capability, forethought, self-regulation, self-reflection, and vicarious capability. The theory also states that a bi-directional interaction occurs between the environment and personal characteristics and is thus central to the development of human prospect, beliefs, and cognitive competencies (Bandura, 1991 and Glanz et aI., 2002). In the context of Bandura’s Social-Cognitive theory, the healthcare facility would be the environment where directional and personal interactions between the healthcare workers such as the experienced health worker would interact with the novice health worker. It is therefore possible to postulate that the health worker with less experience will model the behaviors of the more experienced health worker. Some constructs of the Bandura’s Social Cognitive Theory are applicable to the Health Belief Model (HBM) – a psychological model that explains and predicts health behaviors by focusing on the attitudes and beliefs of individuals (Glanz et aI., 2002). Health Belief Model was first developed in the 1950s by social psychologists Hochbaum, Rosenstock and Kegels. The model uses constructs that represent perceived threats and net benefits such as perceived susceptibility, perceived severity, perceived benefits, perceived barriers, cues to action and self-efficacy. The model asserts that these constructs account for aperson’s “readiness to act” (Rosenstock, 1988). The literature reviewed suggests that it is possible to apply the constructs of the Health Belief Model to studies that explore health behaviors such as health prevention and promotion, and compliance with recommended guidelines for infection control. The behaviors of health care professionals, and in particular nurses, are also regulated by social and moral standards. Through foresight, the individual can think through the consequences of a behavior without actually performing the behavior oneself (Bandura, 1989). It is known in some studies that positive health behaviors by healthcare workers may decrease the occurrence of the unabated nosocomial infections (Aly et aI., 2005; Pittet et aI., 2004). For example, if a health worker internalizes the notion that prevention of nosocomial infections is essential he I she will take precautions in order to improve on the outcomes of the admitting disease or condition, and improve the delivery of quality standard of care.

Furthermore, a study that examined fulfillment with hand-hygiene practices among medical staff showed that the frequency of healthcare workers’ hand-hygiene was greatly influenced by role models (Lankford et aI., 2001). In this observational study, the researcher noted that healthcare workers were less corn plaint with hand hygiene protocols when high ranking person such as physician or nurse did not carry out hand hygiene practices. This observation implied that the effect of role model is significant in negatively influencing healthcare workers’ compliance with recommended guidelines.

Another theory with tenets applicable to this area of study is the Theory of Reasoned Action /

Theory of Planned Behavior (TRArrPB) developed by social psychologists Ajzen and Fishbein in 1967. This theory explains how attitude and motivation influences human behavior. The theory proposes that “intent’ is the most important determinant of a person’s “behavior”; and furthermore, that an individual’s intention to perform a behavior is dependent upon the “attitude” toward the performance of the behavior. The theory also contends that behavioral beliefs and normative beliefs influence the individual’s motivation to comply with show of a certain behavior.

According to Ajzen (1991), behavioral beliefs link the behavior to an expected outcome while normative beliefs are considered as the perceived behavioral expectations of individuals within a group. Altogether these referents lead to actual behavior beliefs control and may drive the individual’s intention to perform the behavior (Ajzen, 2006). Another assumption of the TRAlTPB theory is that human beings are rational: they make systematic use of information available to them and consider the implications of their actions before they decide to engage or not engage in certain behaviors. They (human beings) have normative beliefs which arise from perceived behavioral expectations of individuals such as co-workers; for example, nurses. Therefore, the stronger a person’s intention to perform a particular task (behavior) is, the more likely the person will perform the behavior (Ajzen, 2006). In the context of this study, it is possible to think that health workers could be influenced by colleagues or friends and peers at the work settings. What is unclear is whether they are influenced in a positive or negative way. Additionally, it is possible to speculate that the health care workers would be influenced by cognitive factors such as decrement in knowledge. Any decrement in knowledge might lead to healthcare workers’ non- compliance with recommended guidelines and protocols while performing patient-care activities. What is also unclear from the literature is whether there is a decline in the knowledge and skills gained during their course of study or whether these workers become non-compliant over time due to modeling after other noncompliant colleagues during their performance of patient care activities. This non-compliance would lead to the spread of nosocomial infections.

1.6  Implications of the Study

The findings in this study suggest that the strong educational standards, set in place, should be continued and enforced. Furthermore, monitoring of adherence to and compliance with established guidelines set by the Centers for Disease Control and Prevention (CDC) by healthcare workers should be sustained. Additionally, the fundamental role of healthcare institutions to provide support in the form of adequate staffing and equipment should be intensified.

1.7 Limitations of the Study

As with many research projects, this study has several limitations. Even though some of the advantages of online surveys are the instantaneous data collection and savings, in both time and money, the approach may lead to many limitations. One of the primary limitations is the generalizability of the results to all heath workers. Cook and Campbell (1979) pointed out that people tend to report what they believe the researcher expects to read or report what reflects positively on their own abilities, knowledge, beliefs or opinions (Cook &Campbell, 1979). The questionnaire used in this study was constructed from emergent themes in the reviewed literature and established guidelines set by a task force committee on Infection Control Practices Advisory Committee. The knowledge and skills items related to information the respondents ought to have mastered during their academic joumey, or reinforced through work related experiences and continuing education. The items might not have been broad enough to capture all pertinent concepts related to reduction of the spread of nosocomial infections.

1.8  Scope of the Study

For the purpose of this study, the research work will be out in Edo State in Sixty three health care facilities, including all tertiary and secondary care facilities and selected Primary Health Centres and Private Clinics were sampled from 8 Local Government Areas from the three senatorial districts in Edo State. Three pre-tested tools were adapted to the local setting and used to interview key informants in the health facilities and to observe for practices and records relating to infection control and past experiences of puerperal sepsis. These included four LGAs in Edo South (Egor, Oredo, Ovia north-east and Ikpoba-okha), three in Edo Central (Esan Central, Esan North and Esan South-west), and one in Edo north (Etsako).