C:\Users\User\Documents\39 no 3 199 ABSTRACT UNIVERSA MEDICINA Assessment of compliance to standard precautions among nurses using the Health Belief Model Noer Triyanto Rusli*@, Muchtaruddin Mansyur**, Aria Kekalih***, Astrid Sulistomo**, and Retno Asti Werdhani*** BACKGROUND The application of Standard Precautions (SP) has become a significant challenge for healthcare workers, especially in developing countries, endangering their safety and increasing their exposure to blood-related pathogens. This study was aimed at exploring the factors related to nurses’ compliance with the practice of SP. METHODS A cross-sectional study was conducted on 120 nurses working at a hospital in Palembang. Health Belief Model components of the subjects were recorded through questionnaires. A 12-point observation form assessed the nurses’ SP compliance. Multiple logistic regression models were used to explore factors associated with nurses’ compliance. RESULTS The results showed that 56.7% of participants had good compliance, although the five moments of hand hygiene still needed to be improved. The study revealed that the proportion of the operating room and emergency room nurses who complied with the SP was larger than the proportion of those who worked at the other wards (OR=2.57, 95% CI 1.51- 4.36). The nurses who had received training also showed a larger proportion of compliance with SP than those who had not been trained (OR=2.70, 95% CI 1.07-6.79). CONCLUSION Nurses’ behavior to SP was significantly associated with the adequacy of the training and work unit. It is suggested that the practice of SP was also influenced by enabling factors and subjective norms. Adequate training of nurses, provision of infection prevention equipment, and assessment of occupational exposures need to be introduced. Keywords: Standard precautions, compliance, health belief model, nurses ORIGINAL ARTICLE pISSN: 1907-3062 / eISSN: 2407-2230 DOI: http://dx.doi.org/10.18051/UnivMed.2020.v39.199-206 September-December 2020 Vol.39- No.3 Cite this article as: Rusli NT, Mansyur M, Kekalih A, Sulistomo A, Werdhani RA. Assessment of compliance to stan- dard precautions among nurses using the Health Belief Model. Univ Med 2020;39:199-206. doi: 10.18051/ UnivMed.2020. v39.199-206. *Occupational Medicine Specialist Program, Faculty of Medicine, Universitas Indonesia **Occupational Medicine Division, Department of Community Medicine, Universitas Indonesia ***Epidemiology Division, Department of Community Medicine, Universitas Indonesia Correspondence: @Noer Triyanto Rusli Occupational Medicine Specialist Program, Faculty of Medicine, Universitas Indonesia, Jakarta, Indonesia E-mail: noer@u.nus.edu ORCID ID : 0000-0002-8585-7438 Date of first submission, May 18, 2020 Date of final revised submission, December 13, 2020 Date of acceptance, December 17, 2020 This open access article is distributed under a Creative Commons Attribution- Non Commercial-Share Alike 4.0 International License 200 Rusli, Mansyur, Kekalih, et al Standard precautions and Health Belief Model INTRODUCTION Standard precautions (SP) are a series of infection control practices that are used to prevent transmission of diseases that can be acquired through contact with body fluids, blood, injured skin (including rashes), and mucous membranes.(1)The components of SP include hand hygiene, injection safety, use of personal protecti ve equipmen t and envir onmental cleanliness, as well as waste management, and respiratory hygiene and cough etiquette.(2) Healthcare workers (HCW) are exposed to needle stick injuries, c ontact with blood secretions, hepatitis B or C, and AIDS / HIV infections through occupational exposure to blood and other body fluids.(3) It is estimated that each year, 35.7 million healthcare workers and related professionals throughout the world are at risk o f c o n tr a c t i ng d is e a s e s c a us e d b y microorganisms in the bloodstream through percutaneous contact.(4) Healthcare workers, most specifically nurses, pose the greatest risk of cross-infection among patients and fellow healthcare workers, because of their high visibility and their direct interaction with patients while performing their nursing activities.(5,6) They are at additional risk for a cquiring bloodborne pathogens (BBP) when compared to any other occupational group.(7) Although occupational HIV and hepatitis seroconversion is relatively rare, the risks and associated costs of a blood exposure are serious and real. These costs include initial and follow-up treatment of the exposed health care personnel, fear and anxiety about the possible consequences of an exposure, drug toxicities and absence from work.(8) The use of personal protective equipment (PPE) such as gloves and sterile surgical gowns, and sterile equipment, hygiene practices such as washing hands with antiseptic, and the instrument safe waste disposal procedures as descr ibed in the SP guidelines can keep healthcare workers safe from infections caused by blood.(9-11) Standard precautions are supposed to be adopted by all healthcare workers. Physician compliance with SP is extremely important.(12) In many studies, compliance with SP among healthcare professionals was reported to be inadequate with regard to eye protection, avoidance of needle recapping, glove use when required, washing hands before and after patient contact, use of face masks, and avoidance of a used needle that is disassembled from a syringe and the implementation of precautions for all pa tients.(13) The low adhesion to standard precautions is linked to individual aspects of wo r ke r s , e mp lo ye r s a nd e du c a t i on a l institutions.(14) A study in a tertiary referral center i n No r th -We st er n Niger i a fou nd ga ps i n identification of knowledge and practice of infection control among doctors and nurses in the study; hence, it will be beneficial for all HCW to rec e ive f or mal and peri odic r ef resh er trainings.(15). One study in Jamaica showed that compliance with SP in the operating department is low (17%).(16) The study conducted by Aung (1 7) in M ya n ma r c o n c l ud e d t ha t th e r e wa s inconsistency in some aspects of compliance with SP among Myanmar nurses. Among Health Belief Model variables, perceived susceptibility, benefits, and perceived barriers were statistically significant for the relation to compliance with SP except perceived seriousness. The Health Belief Model is a most commonly used model to explain and understand the factors that influence someone’s compliance, which may consequently contribute to the adoption of certain behaviors. The difference of the present study with previous studies is found in the fact that nurses’ compliance with SP was objectively assessed by a direct observational approach by an observer. We therefore aimed at exploring the factors related to nurses’ compliance with the practice of SP at a hospital in Palembang based on the Health Belief Model. 201 METHODS Research design A cross-sectional study was conducted in a hospital at Palembang, Indonesia, from September to December 2019. Research subjects Sample size was determined by total sampling.The study population were all nurses who were on duty in the Isolation Room, Intensive Care Unit (ICU), Emergency Department, and Operating Room of the hospital at the time of the study. Those who were off-duty were excluded. Other medical and nonmedical personnel were also excluded. Study participants were recruited by convenience sampling. A total of 120 eligible nurses were included in this study. Data collection This study used a questionnaire adapted from Aung(18) with content validity (index range 0.306 – 0.756) and reliability (Cronbach α range 0.671 – 0.807).The questionnaire was an adaptation of the original questionnaire from a study in Myanmar, because it has the similar aim of explaining the predictors of compliance with SP using the Health Belief Model. The following i nf or ma ti o n wa s re c o r d e d : s ub j e c t ’s demographies, HBM components, age, gender, education, nurse group, work unit, infection control training, history of blood exposure, history of needle stick injury, history of hepatitis B vaccination, and history of post-exposure prophylaxis. Instruments The He alth Belief Model consists of perceived threats, perceived benefits, and perceived barriers. The scores of perceived threats (8 items), perceived benefits (8 items), and perceived barriers (8 items) were rated on a Likert scale (1=strongly disagree, 2=disagree, 3=agree, 4=strongly agree). The total number of items was 24. In determining the cut-off score for the HBM component, considering that the number of question items is eight and the respondent answers a score of 3 or 4 (agree/ strongly agree) for the good HBM component, the total score is 24. For this reason, the good HBM component was defined as a total score of 24 and poor HBM component as a total score of <24. These categories were determined by mutual agreement between the researchers prior to the start of the study. Nu r s e s ’ c o mpl i an c e t o wa r d s t he implementation of SP was measured by using a 12-point observation form. The observer was the head of the work unit of the 120 subjects from the Emergency Department, Intensive Care Unit (ICU), Isolation Room, and Operating Room. The observation was made once without the subjects knowing that they were being observed. The categories for compliance with SP were: poor = <12, good = 12 (if participants comply with all 12 points in the observation form). These categories were also determined by mutual agreement between the researchers prior to the start of the study. Data analysis Statistical analyses were performed using the Statistical Package for the Social Science (SPSS) program, version 20. Initial bivariate analyses were done using simple logistic regression to determine the associations between potential variables and nurses’ compliance with SP. Variables with p-values of <0.20 in the simple logistic regression were selected for multivariate analysis. Multiple logistic regression analysis was used to calculate the odds ratio (OR) of each selected independent variable on nurses’ compliance. Ethical clearance Ethical clearance was obtained from the Faculty of Medicine Universitas Indonesia - Cipto Mangunkusumo National Hospital (FKUI- RSCM) Research Ethics Committee under No. KET-453/UN2.F1/ETIK/PPM.00.02/2019. Univ Med Vol. 39 No.3 202 Rusli, Mansyur, Kekalih, et al Standard precautions and Health Belief Model A B C RESULTS In this study, 120 subjects were obtained. Data in this study showed that there were more females (82 or 68.3%) than males. The age of the subjects ranged from 26 years to 54 years. The education of the subjects varied with the largest proportion being found at the diploma program level (71.7%). Research subjects who had attended infection control training were 80 in number (66.7%). Information was also obtained that 81 subjects (67.5%) had been exposed to blood or body fluids and that 52 people (43.3%) had been exposed to a needle stick/ sharp object. Detailed information on the basic characteristics of the subjects can be seen in Table 1. De t e r m i na nt f a c t or s o f nur s e s ’ SP compliance Table 2 shows the results of simple logistic regression and multiple logistic regression a na lysi s o f co mpl ia nc e w ith SP an d the associated independent variables. Based on the multiple logistic regression analysis, this study found that work unit and infection control training had a statistical relationship with behavior after being controlled for age, gender, education, nurse group, history of blood/body fluid exposure, history of needle stick injury, history of hepatitis B vaccination, and history of receiving post-exposure prophylaxis (PEP). The proportion of the operating room and emergency room nurses who complied with SP was larger than the proportion of those who worked at the other wards (OR=2.57, 95% CI 1.51-4.36). The proportion of nurses who had received training also showed a larger proportion in compliance with SP than those who had not been trained (OR=2.70, 95% CI 1.07-6.79). DISCUSSION In this study, the overall compliance of nurses with SP practices was 56.7%. This figure showed that the compliance was low because Characteristics n (%) Age (years) ≥30 <30 80 (66.7) 40 (33.3) Gender Male Female 38 (31.7) 82 (68.3) Highest education High school Diploma Bachelor 3 (2.5) 86 (71.7) 31 (25.8) Nurses’ group Clinical nurse II Clinical nurse III Clinical nurse IV 43 (35.8) 75 (62.5) 2 (1.7) Work unit Isolation room Intensive care unit Emergency department Operating room 8 (6.7) 39 (32.5) 43 (35.8) 30 (25.0) Total duration of working as nurse (years) ≥15 <15 59 (49.2) 61 (50.8) Infection control training Yes No 80 (66.7) 40 (33.3) Exposure to blood/ body fluids Yes No 81 (67.5) 39 (32.5) Needlestick injury Yes No 52 (43.3) 68 (56.7) Hepatitis B vaccination Yes No 73 (60.8) 47 (39.2) Post exposure prophylaxis (PEP n=52) Yes No Compliance Good Poor 29 (55.7) 23 (44.3) 56.7 43.3 Table 1. Distribution of demographic characteristics and clinical features of nurses (n=120) * There were no subjects in the group of Clinical Nurse (PK) I and Clinical Nurse (PK) II the Indonesian hospital accreditation board requires compliance of more than 85% for SP practices. This finding is almost identical with the study conducted by Beyamo et al.(18) which s howe d th a t 65 % of h e a l thc a r e wo r ke r s complied with SP practices. In the present study, when each of the specific components of non- compliance with SP practices was analyzed, the p r o po r t i on of ha n d h ygi e n e c omp l ia nc e 203 Univ Med Vol. 39 No.3 according to the 5 moments was the highest (17.5%). Washing hands is one of the most important procedures in preventing nosocomial infections. According to the WHO, it is necessary t o wa sh h a n ds t o r e d uc e t h e nu mbe r o f nosocomial infections through the 5 moments, namely before touching a patients, before clean/ aseptic procedures, after contact with body fluids Table 2. Simple and multiple logistic regression of determinants associated with SP compliance *and † In the data analysis group merging was carried out; ‡ Variables with p<0.20 were included in the multiple logistic regression; @Significant at p<0.05 on multivariate analysis Simple Logistic Regression Multiple Logistic Regression Independent Variables Crude OR (95% CI) p-value Adjusted OR (95% CI) p-value Age (years) ≥ 30 2.38 (1.09-5.17) 0.027 3.89 (0.72-20.82) 0.113 < 30 1 Gender Male 1.26 (0.58-2.76) 0.561 Female 1 Education Bachelor 1 0.055 0.66 (0.18-2.38) 0.657 Diploma III* 0.45 (0.19-1.03) High school* Nurses’ classification Clinical nurse IV* Clinical nurse III* Clinical nurse II 1.64 1 (0.77-3.49) 0.196 0.52 (1.22-2.22) 0.377 Work unit Operating room* Emergency department* 9.61 (4.10-22.5) <0.001@ 2.57 (1.51-4.36) <0.001@ Intensive care unit† 1 Isolation room† Work duration (years) ≥ 15 2.15 (1.03-4.49) 0.040 1.16 (0.34-4.01) 0.817 < 15 1 Infection control training Yes 2.79 (1.28-6.09) 0.009‡ 2.70 (1.07-6.79) <0.001@ No 1 Exposure to blood/ body fluids Yes 1 0.723 No 0.87 (0.40-1.89) Needle stick injury Yes 1.64 (0.78-3.43) 0.189 1.46 (0.52-4.07) 0.469 No 1 Hepatitis B Vaccination Yes 2.24 (1.06-4.73) 0.034 1.56 (0.58-4.20) 0.381 No Post exposure prophylaxis (n=52) Yes 1.99 (0.82-4.84) 0.163 1.66 (0.47-5.92) 0.432 No 1 Perceived treats Yes 1.23 (0.48-3.18) 0.663 No 1 Perceived benefits Yes 1 No 0.93 (0.45-1.91) 0.853 Perceived barriers Yes 1 No 0.75 (0.32-1.76) 0.50 204 Rusli, Mansyur, Kekalih, et al Standard precautions and Health Belief Model exposure/risk, after touching a patients and after touching patient surroundings.(19) The finding in the present study seems to reflect the Indonesian situation which is that hand hygiene has seldom been adopted and encouraged in Indonesia. Logistic regression analysis was used to identify determinants of compliance with SP. This study found that nurse working unit and previous inf ect ion control tra ini ng a re asso ciat ed significantly with and are determinants of the compliance with SP. This finding is consistent with the study conducted by Luo et al.(20) In terms of nurse working unit, the compliance of nurses in the medical departments was lower than that in the surgical departments. This d if f e r e nc e w a s f o u nd to be s t at i st i c a l l y significant, and is probably the result of the greater numbers of chronic internal medicine and elderly patients in the medical departments. Also, there is no obvious presence of blood in the medical de partment, which may result in protection being neglected. These results indicate that the administration departments should focus on comprehensive monitoring, especially the monitoring of hospital infections in primary level hospitals. Training is also factor that continues to play an important role in the compliance with SP. Motaarefi et al.(21) stated that training was the most important factor related to the prevention of needle sticking behavior among nurses. Nurses who did not participate in any training session regarding the prevention of needle stick injury in their workplaces faced a higher risk of suffering from these injuries compared to those who participated in several types of training. The suboptima l compliance with SP hightlights the need for interventions to enhance the occupational safety of nurses. To improve compliance of nurses with SP, we suggest to also include other factors, such as enabling factors and subjective norms. Enabling factors can be in the form of availability and affordability of facilities such as safety boxes and personal protective equipment (PPE), while subjective norms can be in the form of norms that apply in both work units that encourage subjects to conduct SP. The study of Balozi et al.(22) in Tanzania showed that subjective norms had a positive influence and a significant mediating effect on knowledge sharing behavior among healthcare workers. Their study showed that the higher the subjective norms, the higher the knowledge sharing behavior among healthcare workers. The main strength of the current study is the use of a direct observational approach where nurses are observed objectively by an observer to deter mine their SP complia nce. Some limitat ions sho uld be a ckno wled ged and considered. First, the study was of cross- s e c t i on a l de s i gn t ha t do e s not a l l o w a n examination of the temporal nature of the association. Second, the use of self-filled questionnaires may cause self-reported bias, while observation bias may also have occurred in this study. However, this limitation has been taken into consideration and overcome. The significant implications of this study were for nursing practice and education because it can explore the factors related to nurses’ compliance with the pr actice of standard practices. In addition, to the extent of our knowledge, this is the first study assessing compliance with standard practices which is available in Indonesia. This can help to plan and evaluate new interventions in order to increase and ensure stringent compliance with standard practices. Further research is needed to better explain the determinants of nurse compliance with standard practices in a better research design namely a cohort study. CONCLUSIONS Nurses’ behavior to SP was significantly correlated with the adequacy of the training and work unit. It is suggested that the practice of SP is also influenced by enabling factors and subjective norms. Health authorities in the study area need to improve the training of nurses and provision of infection prevention equipment. 205 CONFLICTS OF INTEREST All authors declare that there is no conflict of interest in this research ACKNOWLEDGEMENTS We would like to thank the staff of the Department of Community Medicine, Universitas Indonesia for the support for this publication. CONTRIBUTORS NTR contributed to conceptualization and methodology. NTR and MM contributed to preparing and writing the original draft. MM, AK, AS, and RAW contributed to supervision. NTR contributed to review and editing. All authors have read and approved the final manuscript. REFERENCES 1. Sadeghi R, Hashemi M, Khanjani N. The impact of educational intervention based on the health belief model on observing standard precautions among emergency center nurses in Sirjan, Iran. Health Educ Res 2018;33:327-35. doi: 10.1093/her/ cyy020. 2. Ogoina D, Pondei K, Adetunji B, Chima G, Isichei C, Gidado S. Knowledge, attitude and practice of standard precautions of infection control by hospital workers in two tertiary hospitals in Nigeria. J Infect Prev 2015;16:16-22. doi: 10.1177/ 1757177414558957. 3. Musa S, Peek-Asa C, Young T, Jovanović N. Needle stick injuries, sharp injuries and other occupational exposures to blood and body fluids among health care workers in a general hospital in Sarajevo, Bosnia and Herzegovina. Int J Occup Saf Health 2015;4:31–7. doi: 10.3126/ijosh.v4i1. 9847. 4. Reis LA, Gómez La-Rotta EI, Diniz PB, Aoki FH, Jorge J. Occupational exposure to potentially infectious biological material among physicians, dentists, and nurses at a university. Saf Health Work 2019;10:445-51. doi: 10.1016/j.shaw.2019. 07.005. 5. Cruz JP, Bashtawi MA. Predictors of hand hygiene practice among Saudi nursing students: a cross- sectional self-reported study. J Infect Public Health 2016;9:485-93. doi: 10.1016/j.jiph.2015.11. 010. 6. Mani A, Shubangi AM, Saini R. Hand hygiene among health care workers. Indian J Dent Res 2010;21:115. doi: 10.4103/0970-9290.62810. 7. Gorar ZA, Butt ZA, Aziz I. Risk factors for bloodborne viral hepatitis in healthcare workers of Pakistan: a population-based case-control study. BMJ Open 2014;4:e004767. doi: 10.1136/ bmjopen-2013-004767. 8. Mohammadi N, Allami A, Malek Mohamadi R. Percutaneous exposure incidents in nurses: knowledge, practice and exposure to hepatitis B infection: percutaneous exposure incidents in nurses. Hepat Mon 2011;11:186-90. 9. Timilshina N, Ansari MA, Dayal V. Risk of infection among primary health workers in the Western Development Region, Nepal: knowledge and compliance. J Infect Dev Ctries 2011;5:18–22. doi: 10.3855/jidc.782. 10. Ferreira LA, Peixoto CA, Paiva L, Silva QCG, Rezende MP, Barbosa MH. Adherence to standard precautions in a teaching hospital. Rev Bras Enferm 2017;70:90-7. doi: 10.1590/0034-7167- 2016-0138. 11. Akinboro AA, Adejumo PO, Onibokun AO, Olowokere AA. Community health care workers’ risk perception of occupational exposure to HIV in Ibadan, South-west Nigeria. Afr J Prm Health Care Fam Med 2012;4:1–9. doi: 10.4102/phcfm. v4i1.338. 12. Carvalho MJ, Pereira FM, Gir E, Lam SC, Barbosa CP. Investigating compliance with standard precautions during residency physicians in gynecology and obstetrics. Clinics (Sao Paulo) 2016;71:387-91. doi: 10.6061/clinics/2016(07)06. 13. Haile TG, Engeda EH, Abdo AA. Compliance with standard precautions and associated factors among healthcare workers in Gondar University Comprehensive Specialized Hospital, Northwest Ethiopia. J Environ Public Health 2017;2017: 2050635. doi: 10.1155/2017/2050635. 14. Porto JS, Marziale MH. Reasons and consequences of low adherence to standard precautions by the nursing team. Rev Gaucha Enferm 2016;37:e57395. doi: 10.1590/1983-1447. 2016.02.57395. 15. Alice TE, Akhere AD, Ikponwonsa O, Grace E. Knowledge and practice of infection control among health workers in a tertiary hospital in Edo state, Nigeria. Dir Res J Health Pharmacol 2013;1: 20–7. 16. McGaw CD, Tennant I, Harding HE, Cawich SO, Crandon IW, Walters C. Healthcare workers’ 206 Rusli, Mansyur, Kekalih, et al Standard precautions and Health Belief Model attitudes to and compliance with infection control guidelines in the operating department at the University Hospital of the West Indies, Jamaica. Int J Infect Control 2012;8. doi: 10.3396/ijic.v8i3. 023.12. 17. Aung SS, Nursalam, Dewi SY. Improving compliance with standard precautions among Myanmar nurses using health belief model. Malaysia J Nurs 2016;8:21-8. 18. Beyamo A, Dodicho T, Facha W. Compliance with standard precaution practices and associated factors among health care workers in Dawuro Zone, South West Ethiopia, cross sectional study. BMC Health Services Res 2019;19:381.doi: 10.1186/s12913-019-4172-4. 19. World Health Organization. Save lives – clean your hand. Geneva: World Health Organization; 2019. 20. Luo Y, He GP, Zhou JW, Luo Y. Factors impacting compliance with standard precautions in nursing, China. Int J Infect Dis 2010;e1106–14.doi: 10.1016/ j.ijid.2009.03.037. 21. Mootarefi H, Mahmoudi H, Mohammadi E, Hasanpour-Dehkordi A. Factors associated with needlestick injuries in health care occupations: a systematic review. J Clin Diagn Res 2016;10. doi: 10.7860/JCDR/2016/17973.8221. 22. Balozi M. Mediating effects of subjective norms on the relatioship between career advancement and job characteristics and knowledge sharing behavior among Tanzanian healthcare professionals. Gadjah Mada Int J Business 2018;20:187-203. doi: 10.22146/gamaijb.23740.