2442 articles were identified through the systematic literature search. After removal of duplicates and title and abstract screening, 2146 articles were excluded and the number remaining was 136. After the full-text screening, a total of 34 articles remained and were included in the final review (Figure.1)
Location
Seven of the 34 studies were conducted in Nigeria [12]; [13]; [14]; [15]; [16]; [17]; [18], four in Ethiopia [19]; [20]; [21]; [22] three in Pakistan ([23]; [24]; [25]), four in Saudi Arabia KSA ([26]; [27]; [28]; [29], Two in India ([30]; [31]), Two in the USA ([32]; [33]), and one each in the UK [34], Ghana [35], Magnolia [36], Yemen [37] Tanzania [38] Afghanistan [39], Lebanon [40], China [41], Cameron [42] Canada [43] Kenya [44] Russia [45].
Study design
Thirty-one of the articles reported studies which were of cross-sectional design (quantitative studies) [12-18]; [20-35]; [37-44]; three were qualitative studies [36]; [19]; [45].
Assessment of quality
Thirty papers ([12-14]; [16-22]; [24]; [26-27]; [29-45] were considered to be of high quality. The remaining four were considered to be of low quality, mainly due to lower representativeness of inclusion/exclusion criteria of study participants, outcome measures and statistical analysis.
Knowledge, attitude and practice of infection control guidelines
For the purposes of this review KAP among the study participants refers to the level of compliance related to the implementation of IPC guidelines among laboratory staff and includes one of the following definitions [50;51]:
Knowledge: Information possessed on the IPC guidelines.
Attitudes: Opinion on and behavior towards the IPC guidelines.
Practices: Observable actions towards the IPC guidelines.
Of the 34 included studies, the KAP of infection prevention and control, and biosafety guidelines were identified and grouped into several themes, the specific definition of each theme was identified from the included studies (Table 4)
Table.4
Themes definitions
Theme
|
Specific definition
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(1) Awareness of IPC precautions
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Awareness of IPC precaution refers to the knowledge and understanding of the conditions the IPC guidelines should be followed.
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(2) Acceptability of IPC precautions
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Acceptability refers to determining how well IPC guidelines are adopted in everyday practice.
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(3) Application of IPC precautions
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Application refers to the actual exercise and use of measures that minimize the risk of physical harm in workplace.
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(4) Perception of risk
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Perception of risk refers to individual’s intuitive risk assessment, reflecting attitudes or beliefs about potential harm while working in the laboratory.
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(5) Exposure and post exposure prophylaxis (PEP)
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PEP refers to the participants’ exposure to injuries by a needle or any sharp instrument contaminated with blood or any body fluids including the administration of treatment following that exposure in order to block or reduce the injury or infection.
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(6) Immunisation against infectious diseases
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Immunisation against infectious diseases refers to the participants’ compliance with the recommended vaccination for laboratory staff such as HBV.
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(7) Training and association with IPC guidelines
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Training and association with IPC guidelines refer to any training undertaken on the IPC guidelines by laboratory staff to inform compliance with the guidelines.
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(8) Associations between knowledge and practice
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Associations between knowledge and practice refer to the extent to knowledge and understanding of the IPC guidelines associated with the participants’ attitude and their actual practice.
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(9) barriers and facilitators to poor practice and adherence
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Barriers and facilitators refer to factors the enable or inhibit the implementation of IPC guidelines.
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(1) Awareness of IPC precaution
There were no standardised criteria for classifying knowledge and awareness as poor, moderate or good across studies. However, it has been observed that the term ‘poor awareness’ was generally used when < 50% of participants had adequate awareness on the specific information about the IPC guidelines. Similarly, the terms ‘moderate’ and ‘good’ awareness were used when the participants with adequate specific information about the guidelines was between 50–70% and >70%, respectively, and this was also applied for the remaining themes below.
Awareness was examined in 17 studies. In Nigeria, three studies [15]; [13] and [12] reported poor knowledge and awareness of IPC precautions among laboratory personnel. In Fadeyi et al’s study [15] only 58.2% of the participants were aware of safety precaution principles, while in Ibeziako and Ibekwe study [13] about 50.4% of the respondents were aware of IPC precaution. Results of Izegbu et al’s study [12] showed that only 20.8% of the participants had heard of the IPC precautions and only 37.5% of these could define and state it’s objectives. These results may contradict with the results reported in one study conducted in Nigeria as well [18] which reported good results for awareness. Ndu et al’s study [18] attempted to differentiate between the knowledge among two groups of health care professionals: doctors and laboratory staff. Although the study found there were differences between the two groups on the knowledge and awareness of components of IPC, both showed a good level of knowledge (76.2% in doctors and 67.6% in laboratory staff).
Three studies in Ethiopia [22]; [20]; [21] showed that between 55.4%- 84.7% of laboratory staff had a good level of awareness. It should be clarified that the number of laboratory staff included in these studies was very low compared to other healthcare workers (13/150; 29/49; 58/605), respectively.
Similar results were reported in two Saudi studies [29]; [26]; [28] (84%; 66%; 81.97). As a small number of laboratory staff (10) participated in study [26], it may not be a good representative of laboratory staff as well. The Rabaan et al’s study [28] assessed the awareness of, infection prevention and control policies and guidelines, but it is considered to be a study of low quality because of no information regarding the inclusion/exclusion criteria of its study sample.
In Pakistan, one study examined awareness regarding IPC precautions and reported only 51% of participants knew that the standard method of discarding needles is without recapping [25]. However, this study has flaws in its quality assessment tool, because no information regarding the inclusion/exclusion criteria of its study sample was reported. Furthermore, the instrument used for data collection was not pretested to check its validity and reliability.
Both Indian studies included in this review examined the laboratory staff’s awareness of IPC precautions, one found a good level (75%) [31], and one found a poor level (32%) [30]. This difference in the results may be due to the awareness and knowledge present among the included staff and the level of training they have received.
Studies conducted in Lebanon [40] and Yemen [37] showed a good and poor level of awareness, respectively. Almost all the technicians were knowledgeable about the IPC precautions (100%) in [40]. In contrast, only 38% of respondents had good level of awareness in the Yamani study [37]. All studies considered to be high quality studies have ensured that an adequate number of laboratory staff participated.
One study shows good level of awareness (82%), this was Chalya et al’s study [38] in Tanzania. In contrast, the only Akagbo et al’s study that was conducted in Ghana and included in this review reported poor awareness (37.0%) of IPC precautions among laboratory staff [35]. It is important to highlight that the findings of this study were drawn from only 5 laboratory members of staff out of 100 healthcare workers.
The participants of a qualitative study in Mognolia included in this review claimed that many infection control decisions are made by those who have a non-medical background or non-knowledgeable in infection control. In addition, all the study participants acknowledged their poor knowledge of infection control and reported that IPC is not well taught at the under- and post-graduate levels of education. Poor knowledge on disinfection and sterilization were also reported as the standards and guidelines for disinfection and sterilisation have not been updated in the laboratory [36] (see table.5).
Another qualitative study which conducted in Russia showed that laboratory staff were most knowledgeable about Tuberculosis IPC guidelines as they believed wearing hospital-laundered lab coats and disposable shoe coverings was protective against TB transmission. Participants also described the necessity of showering and changing clothes so they did not carry the bacillus home [45] (see table.5).
Finally, the findings regarding awareness level of these studies may be subjected to recall bias as they used self-administered questionnaires for data collection.
(2) Acceptability of IPC precautions
The attitude and acceptability of laboratory staff toward IPC were examined in 9 studies.
Two studies in Nigeria reported different findings of acceptability, moderate [15] and poor [12]. In Fadeyi et al’s study [15] 60.0% of participants were willing to eat and drink in the laboratory, while in Izegbu et al’s study [12] 45.6% of the participants eat in the laboratory and 47.0% of them stored food and water in the refrigerators meant for the storage of body fluids and chemicals, attitudes which indicate a disregard toward IPC and safety precautions.
Different situations appear in Ethiopian studies ([20]; [21]) where both found moderate level of acceptability among laboratory staff (66.2%; 66.1%), respectively.
In India, one study reported good acceptability level [31] while the other reported the opposite [30]. Good acceptability level in [31] were observed in three departments in the laboratory: 83.3% in the pathology department, 75% in the biochemistry department and 100% in the microbiology department. Yet the results in Zaveri et al’s study [30] surprisingly matched in an exact way the findings from Izegbu et al’s study [12] conducted in Ethiopia (45.6% of the participants eat in the laboratory, 47.0% of them store foods and water in the refrigerators).
The studies [40] conducted in Lebanon and [27] and [29] in Saudi Arabia observed good and positive acceptability and behavior among laboratory staff. Only 8 of the 73 (11.0%) technicians showed some behavioural lack inside the laboratory: eating, drinking, smoking or pipetting with their mouths [40]. In Khan et al [27], although the majority of respondents demonstrated good behaviours towards the use of IPC protective measures (58.8), they displayed poor behaviours towards their active participation in infection control program (24.2). Meanwhile, in Khabour et al [29] only 24.2% of participants were willing to eat, drink or use gum, 18.3% used cosmetics and 24.6% used their mobile phones in the laboratory.
(3) Application of IPC precautions
The majority of studies (23) in this review examined laboratory staff application of IPC precautions.
Six studies were Nigerian and those included in this review assessed how IPC precautions were practiced in laboratories. Poor application results were reported in two studies [12] (43%) and [17] (45.6%). Moderate findings were reported in Fadeyi et al [15] as about 69.2% of participants wore gloves when handling samples and in Sadoh et al [14], 63.8% of participants always used personal protective equipment. The findings in Ndu et al’s study [18] demonstrated that laboratory staff reported good application and greater use of personal protective equipment such as gloves and coveralls than doctors (100% and 35%, respectively). The same good practice and application level was reported in Ibeziako and Ibekwe’s study [13] as gloves were used by 86.6% of respondents while only 43.9% of them practiced appropriate hand washing.
One Ethiopian study reported good level of application [21] (66.1%). On the other hand, [22] and [20] show poor (57.3%) and moderate (77.4%) results.
In KSA, it had been revealed that only 27% of participants were using gloves all the time while 48 (69%) were doing so only occasionally [26]. It was furthermore documented that 10%-25% injuries in laboratory occurred while recapping a used needle [26]. Nevertheless, Khabour et al’s study [29] demonstrated good application level among laboratory staff and the majority (> 80%) of participants followed guidelines for disposal of medical waste, decontamination of sample spills, and use of protective lab coats and gloves, among other measures.
Indian studies reported good application levels [30] and [31]. All the participants wore gloves during laboratory work [30], and 66.7%, 81.5% and 100% of participants in the pathology, biochemistry and microbiology departments, respectively, had correct answers to the practice questions in the study questionnaire [31].
All three studies conducted in Pakistan demonstrated a poor level of application and practice. There was a lack of awareness of good laboratory practices reported in Nasim et al’s studies [23] (as 46.2% of the participants did not use any kind of PPE, and almost 39.5% recapped used syringes regularly) and (33.6%) in [24]. Qazi et al’s study [25] yielded poor results, as 80.3 % of 208 participants were recapping needles, which meant that 31.3 % had experienced a needle stick injury while recapping.
The studies conducted in Lebanon [40], Kenya [44] and Tanzania [38] reported good levels of application. 93.2% of participants wear gloves while working in the laboratory [40], 97.8% of participants used personal protective equipment (PPE), gloves, overalls, gumboots, mouth masks and other protective equipment when handling medical waste [44] and 77.0% of participants applied the universal precautions [38].
Conversely, the studies from Afghanistan [39], Yamani [37] and Ghana [35] revealed poor application level. 57.8% of respondents reported that they always recapped the needle after giving an injection in [39], only 32% of respondents had good practice of IPC precautions in [37]. Only 50% of respondents always protect themselves from injections and about a quarter of the respondents do not recap needles after use as reported in [35].
The participants of Ider et al’s study [36] conducted in Mognolia perceived that hand-hygiene practice among health professionals of Mongolia is low. They also wonder that, despite most hospitals conducting staff hand-hygiene training once or twice a year, hand-hygiene practice remained poor. The main reasons behind that may be due to unavailability of hot water and sinks and a poor supply of soap, poor supply of alcohol-based hand sanitizers, skin care products and high workload of health professionals [36] (see table.5).
One study conducted in China aimed to assess the infection control practices among COVID-19 infected healthcare workers [41]. Before the COVID-19 outbreak, 53.4% of respondents always followed the procedure for wearing and removing PPE, 66.0% always wore masks and 51.5% wore gloves in their routine work. However, approximately 41.8% of participants thought their infection was related to protective equipment and utilisation of common equipment (masks and gloves), either due to inadequate provision of PPE or to insufficient protection provided by the PPE they had.
Poor application of tuberculosis IPC guidelines was reported in Woith et al’s study [45] in Russia. Poor application was on the use of respirators and masks because they are uncomfortable especially during hot weather and wearing respirators interfered with using microscopes in the lab and the quality of the respirators available at their facilities is poor (see table.5).
It is important to clarify those discrepancies between studies might be due to a difference in knowledge of IPC guidelines, the sample size, methodological and sociodemographic differences, lack of training and supplies and the professionals’ nonadherence to IPC precautions.
(4) Perception of risk
Only three studies in this review reported risk perception among laboratory staff.
Only 23% of laboratory workers in the UK thought they were at some risk of HIV infection in their occupational setting; this low percentage may relate to the high knowledge of safe working practice and practical working experience or they worked in a safe lab using safe practices [34]. A Canadian study assessed prion disease risk perception among laboratory staff and found that 18% believed that they were at risk of prion transmission when processing prion associated specimens and 81% would be more comfortable processing specimens if safety guidelines existed and were used in their laboratory [43]. One qualitative study in Ethiopia [19] explored healthcare workers’ perceptions on occupational risk of HIV transmission. The study of Alemie [19] reported that all the participants were aware of the risk of acquiring HIV in healthcare settings and all of them were worried about the inadequacy of protective materials required to prevent HIV transmission, which was mentioned as the main reason for perceived high risk (see table.5).
(5) Exposure and post exposure prophylaxis
Ten articles reported exposure to injuries and post exposure prophylaxis (PEP) following injuries.
In Nigeria, 53.23% of the participants had had cuts or punctures from needles and were treated in the laboratories [12]. Although 94% of the laboratories have first aid boxes, only 28.78% of the staff make use of these [12]. In Fadeyi et al’s study [15], despite the fact that 79.2% of respondents were aware of the availability of Post Exposure Prophylaxis for HIV and HBV (hepatitis B virus), only 1.5% positively responded to presenting themselves and did Post Exposure Prophylaxis follow any laboratory accidents [15]. 50.0% of the laboratory workers who participated in the study [16] had experienced needle pricks, and only 25.7% of exposures were reported to the staff clinic.
Four of the seven participants in Alemie‘s study [19] in Ethiopia had experienced accidents: needle stick injuries, exposure to blood or other body fluid and their explanations of the incidents indicated the accidents were frequent. Many of the injuries/accidents were followed by commencement of post exposure prophylaxis which, however, was mentioned by some to be less practiced although they were well aware of post exposure prophylaxis [19] (see table.5).
In Pakistan, no percentages of accidents were reported according to studies [23] and [24], but 83.4% and 89.3% of laboratories did not maintain any accident records, respectively. In Rabaan et al’s study [28], about 31.3 % of participants had experienced a needle stick injury while recapping, however, only 24.2 % of participants who experienced an injury were aware that they should take post exposure prophylaxis.
A similar situation was noted in a Saudi study, where 74% of participants had a history of needle stick injuries, and only 21% of the 74% reported the injuries to the hospital authority [26].
In India, 53.23% of the participants had been injured by needles and sharp instruments. However, only 28.78% of them made use of first aid supplies after their injury [30].
A Cameroonian study [42] reported exposure and Post Exposure Prophylaxis and agreed with the findings of [30]. It showed that a high proportion of participants (58%) had poor knowledge on PEP and 60.6% had a positive attitude towards PEP. About 50.9% of all participants had at least one occupational exposure, but only 19.1 % of Post Exposure Prophylaxis incidents were recorded among exposed participants.
The reported data on occupational accidents/injuries relies on the participants’ memories of past exposure, which may therefore be prone to recall bias.
(6) Immunisation against infectious diseases
The assessment of the immunisation status of laboratory staff has been reported in 8 studies.
In KSA, 60% of respondents who worked on laboratory had been vaccinated against hepatitis B [26], and 87% had received a smallpox vaccination in their lifetime [33].
However, in Nigeria, the situation is different. The findings revealed that the awareness about HBV vaccine is not good enough, as only 46.2% were aware of the availability of HBV vaccination in their workplace even though 72.3% of participants were willing to be vaccinated [15]. It was furthermore found that 91.5% of participants were not immunised against the Hepatitis B virus [12].
In India, the results were similar, as 91.5% were not immunised against HBV [30]. Meanwhile, in Pakistan, 90.9 % of participants were vaccinated against the Hepatitis B virus [25].
A Kenyan study found that all the staff participated in the study were aware of the importance of the vaccination, but since it is optional in their institution, they chose to remain unvaccinated [44]. While in Afghanistan, 78.0% of participants were vaccinated despite the fact that vaccination against HBV is not covered by the government and healthcare workers have to pay from their own funds to receive this vaccination [39].
The main barriers to vaccination may be fear associated with possible adverse effects of the vaccine and thus a greater willingness to risk accidental infection rather than be vaccinated [33]. Moreover, low compliance with vaccination might be due to the fact that staff could not remember the vaccination under reference and they may confuse this vaccination with others they had received before [44].
(7) Training on IPC guidelines
Twelve studies reported the results of training on IPC precautions.
In Nigeria, only 13.8% had received training on universal precautions [13], and the study investigated how low and unequal levels of training among staff contributes to the poor knowledge of and compliance with the precautions. The training level was similar between medical doctors and laboratory staff (53.1% of medical doctors and 58.1% of laboratory staff). However, in Ndu et al’s study [18] 73.5% of the laboratory staff received training on wearing and removing PPE, this may contribute to the low use of PPEs among doctors compared to laboratory staff.
In the study of Desta et al [22], study participants who had undertaken IPC training amounted to 35.33% and there was an association between training and practice. Only 36.8% of the participants had taken biomedical waste management training, which led to the overall unsatisfactory level of knowledge, attitude, and practice scores in study [20].
Training status was reported in two Saudi studies. For instance, 68% of participants reported receiving training in laboratory safety either through a course during college education or through training workshops in their workplace [29]. However, the results showed that some of the unacceptable behaviors in laboratories were associated with lack of training IPC precautions. 23.06% of participants reported having received no training [28], and when the participants were asked to identify factors that contribute to the spread of infection in the hospital, 51.73% reported no infection control training program as a factor.
A Tanzanian study reveal that the percentage of the study sample who received training on universal precautions was 98.5%. and the previous training was significantly associated with good practice (P < 0.001) [38].
These findings match the results reported in Pakistan, as no formal biosafety training had been provided to 84.2% of the participants [24]. In Ghana it was reported that only 48% of participants had regular training in IPC precautions [35], and in Yemen 67% and 32% of private and public laboratory staff had received training, respectively [37]. No associations between training and practice were reported in [24], [35] and [37].
(8) Associations between knowledge, attitude and practice
Only four of the included studies examined the associations/correlations between knowledge, attitude and practice. A Tanzanian study found a significant correlation between knowledge and practice regarding IPC precautions (r=0.76, p<0.001) [38]. The same strong correlation was reported in KSA [23] and Ethiopia [22]. The correlation between knowledge and attitude was significant (r: 0.12; P <0.001) [27] and there was an association between adherence to IPC guidelines and the practice of infection prevention [22].
(9) Barriers and facilitators to poor practice and adherence
Four quantitative and two qualitative studies explored barriers and facilitators of poor adherence and practice.
As Nigeria is one of the middle-income countries, a study conducted there reported that the main reason for the poor practice was the unavailability of required resources and poor access to PPE [18]. In addition, some respondents found it difficult to use PPE during emergency situations in hospital [18]. The same results explored in Tanzania, where lack of PPE, emergency situations, and lack of knowledge accounted for the most frequently mentioned reasons for poor compliance [38].
Several reasons for poor compliance were given in Ghana. Participants thought that wearing PPEs such as gloves, gowns and goggles might cause patients to panic meaning that complying with the IPC precautions sometimes interferes with their ability to provide care. It was moreover the case that PPEs were not always available [35].
It is interesting to clarify that lack of availability and poor access to safety equipment was considered to be the most common reason for poor practice and adherence to IPC precautions in middle and lower and middle-income countries included in this review.
In the USA it has been found that the factors that positively promote consistent adherence were: education in standard precautions, providing facilities with personal protective equipment, and strong management support for safety. An increase in workplace demands and expectations negatively affected consistent adherence [32].
In Mongolia, a qualitative study assessed the perceptions of laboratory staff regarding the main barriers and challenges to implementation of effective infection control in the hospital. It found that poor IPC education, limited laboratory capacity, poor disinfection and sterilisation and low compliance with hand hygiene were the major barriers for implementation [36] (see table 5). Although this study examined issues from the participants’ perceptions, there were shortcomings with how this study was conducted, and that it could be improved using large-scale quantitative and mixed-method investigations.
A study was conducted in urban and rural regions in Russia to explore the barriers and facilitators affecting tuberculosis IPC practice using focus groups. It reported that the main barriers were knowledge deficits regarding the transmission of TB, negative attitudes related to the discomfort of respirators and practices with respect to the quality and care of respirators [45] (see table.5).
Table.5
Summary of the results with the original quotes (OQ) from the studies included in this review, which exemplify the themes of interest.
Theme
|
Original quotes
|
Awareness of IPC precautions
|
"“It is extremely difficult to convince people at the ‘top’ because they are non-medical” [Military hospital doctor]" [Ider et al., 2012] (OQ1)36
"“Are you really going to throw this money to garbage?” asked our hospital financial officer about the budget proposal for syringe boxes” [ICP]" [Ider et al., 2012] (OQ2)36
"“At the medical university I trained to be a hygienist. Most of our classmates now work as hygiene inspectors. It was quite challenging for me to decide to work at the hospital. When I started work, I had to learn [IC] from scratch from our colleagues” [Hospital ICP]" [Ider et al., 2012] (OQ3)36
"“Those doctors and nurses who went for overseas training or those who have good English quite often bring me information about new modern hospital infection prevention methods… and disinfectants. Every time they explain something to me, I felt that was I supposed to be teaching them, not them teaching me.” [Hospital ICP]" [Ider et al., 2012] (OQ4)36
|
Application of IPC precautions
|
"“People know that they should wash their hands, but they don’t. It’s poor accountability…We are planning to install camera systems in hospital delivery rooms to monitor hand washing”[MoH]."
[Ider et al., 2012] (OQ5)36
"“Everybody knows when and how to wash their hands but they don’t ”[Hospital manager]" [Ider et al., 2012] (OQ6)36
"“It [disinfection and sterilization]is the most unattended area of infection control. What we do is just replace a few autoclaves in hospitals and that is it. We need to do a lot in this area”[MoH]" [Ider et al., 2012] (OQ7)36
" “respirators sliding down the nose and requiring constant repositioning,” and respirators “are difficult to wear when the wearer has rhinitis,” “cause the face to perspire,” and “are unattractive.” " [Woith et al., 2012] (OQ8)45
" “The fabric is stiff and because of that there is not a good fit to the bridge of the nose” [Support staff]" [Woith et al., 2012] (OQ9)45
In some institutions, respirators were worn from one to four weeks and changed as needed, described as when they “are dirty or damaged,” “are expired,” or “no longer fit.” [Woith et al., 2012] (OQ10)45
|
Risk perception
|
" “Our hospital has to do the following activities in order to handle work related risk of HIV transmission: giving service to HIV patients in a separate place and taking extra care; training healthcare workers on infection prevention; and organizing a committee that can follow the use of universal precautions in the hospital.” (A 26 year old medical laboratory technologist) " [Alemie et al., 2012] (OQ11)19
|
Exposure and post exposure prophylaxis
|
" “I know three laboratory technicians who sustained needle stick injuries and took post exposure prophylaxis. During the incident, one of them, a friend of mine, shouted and immediately burst into tears and he even tried to cut his finger.” (A 26-year-old medical laboratory technologist) " [Alemie et al., 2012] (OQ12)19
|
Barriers and facilitators to poor practice and adherence
|
"Last year, our [hospital] budget for syringe boxes was cut by the financial people at the Ministry of Health and later in the Ministry of Finance. I was blamed… for not meeting these people and explaining properly for what and why this money was planned [ICP]" [Ider et al., 2012] (OQ13)36
"“Most of my time I spend doing various administrative tasks plus dealing with waste disposal, cleaning, sterilization, sewage problems and even fighting against cockroaches and mice” [Hospital ICP]" [Ider et al., 2012] (OQ14)36
"“Most of our lab equipment is from the 60s and 70s… often we face shortages of reagents and disks… we only do bacteriology tests …it is rare for anaerobic bacteria…we don’t identify bacteria to species level. There are no national standards for laboratory methods… we have a very high workload” [Tertiary hospital lab physician]"
[Ider et al., 2012] (OQ15)36
" “Tuberculosis can be spread through sexual transmission, although this seldom occurs.” [Support staff] " [Woith et al., 2012] (OQ16)45
" “We eat well before going to examine patients because then the infection can’t survive” [Physician] " [Woith et al., 2012] (OQ17)45
" “For the first six months working here, everyone is afraid of getting TB. Then there is a feeling of complacency, we are afraid of nothing.” [Support staff] " [Woith et al., 2012] (OQ18)45
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