University of Ghana http://ugspace.ug.edu.gh SCHOOL OF PUBLIC HEALTH COLLEGE OF HEALTH SCIENCES UNIVERSITY OF GHANA KNOWLEDGE AND PRACTICE OF TUBERCULOSIS INFECTION PREVENTION AND CONTROL MEASURES AMONG NURSES AND DOCTORS IN SELECTED GOVERNMENT HOSPITALS IN ACCRA, GHANA BY ESTHER AMENE OSEI-YEBOAH (I0338961) THIS DISSERTATION IS SUBMITTED TO THE UNIVERSITY OF GHANA, LEGON IN PARTIAL FULFILLMENT OF THE REQUIREMENT FOR THE AWARD OF MASTER OF PUBLIC HEALTH DEGREE JULY, 2019 University of Ghana http://ugspace.ug.edu.gh DECLARATION I, Esther Amene Osei-Yeboah declare that except for other people's investigations which have been duly acknowledged, this dissertation is the result of my own original research, undertaken under supervision and that it has neither in whole nor in part been presented for another degree in this university or elsewhere. ………………………….……… Date……………………… Esther Amene Osei- Yeboah Student Academic Supervisor ……………………………………… Date……………………….. Dr. Paul K. Botwe Department of Biological, Environmental and Occupational Health College of Health Sciences, University of Ghana, Legon ii University of Ghana http://ugspace.ug.edu.gh DEDICATION This dissertation is dedicated to my family iii University of Ghana http://ugspace.ug.edu.gh ACKNOWLEDGEMENT I thank the Lord Almighty for His provision, strength, and grace throughout the duration of this project. I also thank my supervisor, Dr. Paul Kingsley Botwe for his supervision and immense support. I am also grateful to the entire faculty of the School of Public Health for their diverse contribution towards this project. iv University of Ghana http://ugspace.ug.edu.gh ABSTRACT Tuberculosis (TB) is a major occupational hazard in resource limited healthcare settings. Owing to this, the World Health Organization (WHO) has suggested the adoption and implementation of Tuberculosis Infection Prevention and Control (TBIPC) programs in all healthcare facilities. However, studies have reported improper implementation and practice of these TBIPC measures in healthcare facilities in developing countries. Thus, this study examined the knowledge and practice of TBIPC measures among nurses and doctors at Achimota, La General, Greater Accra Regional and Princess Marie Louise Children’s hospitals in the Accra Metropolis. The study was cross-sectional and data was collected by the administration of questionnaire. Using a proportionate stratified sampling, 403 doctors and nurses were selected from these government hospitals. Bivariate analyses and a multiple logistic regression were used to examine the most important predictors of TBIPC. Overall, the results showed that, the proportion of nurses and doctors with effective TBIPC practices was 27.1%. This suggests that nurses and doctors in these selected hospitals may be at increased risk of nosocomial transmission of TB. Additionally, educational level (AOR=2.87; 95% CI=1.182-7.832), number of years worked (AOR= 1.93; 95% CI=1.03-10.107), knowledge about TBIPC (AOR= 2.23; 95% CI=1.671-7.428), and ever attended TBIPC training (AOR= 0.18; 95% CI = 0.011- 0.630) were found to predict TBIPC practices. Therefore, the Ministry of Health should conduct TBIPC training as well as provide resources and logistics in government health facilities to promote effective practice of TBIPC measures. Keywords: tuberculosis infection prevention and control, knowledge, practice, nurses, doctors, healthcare facilities v University of Ghana http://ugspace.ug.edu.gh TABLE OF CONTENTS Content Page DECLARATION ..................................................................................................................... II DEDICATION ........................................................................................................................ III ACKNOWLEDGEMENT ..................................................................................................... IV ABSTRACT ............................................................................................................................. V TABLE OF CONTENTS ....................................................................................................... VI LIST OF TABLES .................................................................................................................. X LIST OF FIGURES ............................................................................................................... XI LIST OF ABBREVIATIONS ............................................................................................. XII CHAPTER ONE ...................................................................................................................... 1 INTRODUCTION .................................................................................................................... 1 1.1 Background .......................................................................................................................... 1 1.2 Problem Statement ............................................................................................................... 2 1.3 Justification .......................................................................................................................... 3 1.4. Research Questions ............................................................................................................. 3 1.5 Study Objectives .................................................................................................................. 4 1.5.1 General Objective.............................................................................................................. 4 1.5.2 Specific Objectives............................................................................................................ 4 1.6 Conceptual framework ......................................................................................................... 4 CHAPTER TWO ..................................................................................................................... 6 LITERATURE REVIEW ........................................................................................................ 6 2.1 Global Epidemiology of TB ................................................................................................. 6 vi University of Ghana http://ugspace.ug.edu.gh 2.2 Global burden of TB ............................................................................................................ 7 2.3 Factors contributing to occupational transmission of TB .................................................... 8 2.4 TBIPC strategies .................................................................................................................. 9 2.5 Knowledge on TBIPC measures ........................................................................................ 10 2.6 Factors influencing TBIPC practices ................................................................................. 11 2.7 Conclusion of Literature Review ....................................................................................... 12 CHAPTER THREE ............................................................................................................... 13 METHODOLOGY ................................................................................................................. 13 3.1 Study Design ...................................................................................................................... 13 3.2 Study Area .......................................................................................................................... 13 3.3 Study Variables .................................................................................................................. 14 3.3.1 Dependent variable........................................................................................................ 14 3.3.2 Independent variables...................................................................................................... 14 3.4 Study Population ................................................................................................................ 15 3.4.1 Inclusion Criteria ............................................................................................................. 15 3.4.2 Exclusion criteria ............................................................................................................ 15 3.5 Sampling ............................................................................................................................ 15 3.5.1 Sample Size ..................................................................................................................... 15 3.5.2 Sampling Technique........................................................................................................ 16 3.5.3 Sample size distribution .................................................................................................. 17 3.6 Questionnaire ..................................................................................................................... 17 3.7 Quality control ................................................................................................................... 17 3.8 Data analysis ...................................................................................................................... 18 vii University of Ghana http://ugspace.ug.edu.gh 3.8.1 Knowledge level of nurses and doctors on TBIPC measures ......................................... 18 3.8.2 Proportion of nurses and doctors with effective TBIPC practices .................................. 19 3.8.3 Administrative Measures ................................................................................................ 19 3.8.4 Factors influencing TBIPC practices among nurses and doctors.................................... 20 3.9 Ethical considerations/issues .............................................................................................. 20 3.9.1 Informed Consent ............................................................................................................ 20 3.9.2 Confidentiality ................................................................................................................ 21 3.9.3 Compensation .................................................................................................................. 21 3.9.4 Risk and Benefits ............................................................................................................ 21 3.9.5 Pretest or pilot study ....................................................................................................... 21 3.9.6 Data storage and usage .................................................................................................... 22 3.9.7 Declaration of conflict of interest ................................................................................... 22 3.9.8 Funding of the study ....................................................................................................... 22 CHAPTER FOUR .................................................................................................................. 23 RESULTS ............................................................................................................................... 23 4.1 Socio-demographic characteristics of respondents ............................................................ 23 4.2 Knowledge on TBIPC Practices ........................................................................................ 24 4.3 TBIPC training ................................................................................................................... 26 4.4 TBIPC Practices ................................................................................................................. 26 4.5 Administrative Controls for Effective Implementation of TBIPC Measures .................... 28 4.6 Bivariate associations among TBIPC practices, socio-demographic characteristics and other factors .............................................................................................................................. 32 4.7 Multiple logistic regression showing strength of association ............................................ 34 viii University of Ghana http://ugspace.ug.edu.gh CHAPTER FIVE .................................................................................................................... 37 DISCUSSION ......................................................................................................................... 37 5.1 Knowledge on TBIPC practices ......................................................................................... 37 5.2 Proportion of Doctors and Nurses with effective TBIPC practices. .................................. 38 5.3 Factors influencing TBIPC practices ................................................................................. 39 CHAPTER SIX ...................................................................................................................... 41 CONCLUSION AND RECOMMENATIONS .................................................................... 41 6.0 Conclusion ......................................................................................................................... 41 6.1 Recommendations .............................................................................................................. 41 REFERENCES ....................................................................................................................... 43 APPENDICES ........................................................................................................................ 46 APPENDIX A: PARTICIPANTS INFORMATION SHEET ............................................ 46 Appendix B: Consent Form ..................................................................................................... 49 APPENDIX C: QUESTIONNAIRE ........................................................................................ 50 Appendix D: Ethical Clearance ................................................................................................ 58 ix University of Ghana http://ugspace.ug.edu.gh LIST OF TABLES Table 1: Sample size distribution ..............................................................................................17 Table 2: Socio-demographic characteristics of respondents .....................................................23 Table 3: Knowledge on TBIPC measures .................................................................................25 Table 4: Tuberculosis infection prevention and control training ..............................................26 Table 5: TBIPC Practices ..........................................................................................................27 Table 6: Administrative Controls for Effective Implementation of TBIPC Measures .............30 Table 7: Practice, Knowledge and Administrative Scores of Respondents ..............................32 Table 8: Association between Demographic Characteristics and TBIPC (n=frequency) .........33 Table 9: Association between Other Factors and TBIPC (n=frequency) .................................34 Table 10: Multiple Logistics regression of the factors associated with TBIPC practices ........36 x University of Ghana http://ugspace.ug.edu.gh LIST OF FIGURES Figure 1: Conceptual Framework for Factors Affecting TB Infection Prevention and Control Practices. ......................................................................................................................5 Figure 2: Map showing locations of Achimota, La General, Greater Accra Regional and Princess Marie Louise Children’s Hospitals all in the Accra Metropolis ..................14 xi University of Ghana http://ugspace.ug.edu.gh LIST OF ABBREVIATIONS AIDS Acquired immunodeficiency virus CDC Centre for Disease Control DR-TB Drug-resistant tuberculosis ERC Ethics Review Committee EPTB Extra pulmonary tuberculosis HCWs Health care workers HIV Human immunodeficiency virus IPC Infection prevention and control LTBI Latent TB infection MDR-TB Multi-drug resistant TB PH Public Health PI Principal Investigator PLWHA People living with HIV/AIDS PPE Personal Protective Equipment PTB Pulmonary tuberculosis TB Tuberculosis TBIPC Tuberculosis infection prevention and control WHO World Health Organization XDR-TB Extensively drug resistant tuberculosis xii University of Ghana http://ugspace.ug.edu.gh CHAPTER ONE INTRODUCTION 1.1 Background Tuberculosis (TB) is among the top ten (10) causes of death globally and the leading cause of death from a single contagious organism (Segar & Reuters, 2018), with strains of Mycobacterium tuberculosis spreading through contagious droplets aerosolized by persons with active pulmonary TB (PTB) (von Delft et al., 2015). There has been reported cases of higher rates of nosocomial transmission of TB among healthcare workers (HCWs) in several countries, especially in developing countries such as Ghana (Shrestha et al., 2017), with HCWs being twice at risk of contracting tuberculosis from patients than the general population (Demissie Gizaw et al.,2015). Despite this, the problem of spread of TB infection from patients to HCWs is however overlooked in these developing countries. TBIPC is a combination of interventions targeted at minimizing the risk of nosocomial TB transmission (Lipke et al., 2016). These measures are ; Administrative controls which includes triaging, separation or isolation of people with presumed infectious TB, prompt initiation of TB treatment for confirmed cases , respiratory hygiene (including promotion of cough etiquette) in people with presumed or confirmed TB; Environmental controls which includes use of upper-room germicidal ultraviolet systems and ventilation systems (natural, mixed-mode, mechanical ventilation and recirculated air through high-efficiency particulate air filters); Respiratory protection which is provision of particulate respirators and training of HCWs on components of the respiratory protection program (WHO, 2019). However, given their high cost, these important measures are instituted by health care facilities in high income countries, with only a few facilities in the developing countries (e.g. Ghana) implementing them. Thus, there is the need for studies 1 University of Ghana http://ugspace.ug.edu.gh that will examine our current TBIPC practices in our hospitals. Such studies will inform management decisions aimed at improving TBIPC practices in Health Care Centers in Ghana. The study area in Accra, Ghana comprises of Achimota Hospital, Princess Marie Louise Children’s Hospital, Greater Accra Regional Hospital and La General Hospital. These are the four main government hospitals responsible for provision of health care to majority of the populace in the Accra Metropolis. This study examined the knowledge and practice of TBIPC measures among nurses and doctors in these selected government hospitals in the Accra Metropolis. 1.2 Problem Statement Globally, TB is a major occupational hazard in healthcare settings (von Delft et al., 2015) and has been reported to result in significant morbidity and mortality among HCWs in developing countries (Lipke et al., 2016). It is approximated that over 50% of HCWs worldwide have latent TB infection (Tudor et al., 2014). The estimated incidence of TB in Ghana in 2016 was 156 / 100,000 population with 23% living with HIV as well (Jackson, 2018), however, there is no published data of the incidence among HCWs in Ghana. The risk of TB transmission has significantly increased as a result of the emergence of strains of resistant Mycobacterium tuberculosis and comorbidity with HIV (Ghana Health Service, 2010). This risk is immense when prolonged exposure is associated with inadequate infection prevention and control (IPC) measures (Tamir et al., 2016). Even though HCWs and important stakeholders are knowledgeable about risk of nosocomial TB transmission, there is poor implementation and practice of TBIPC measures in most health facilities (Demissie Gizaw et al., 2015). The principal investigator (PI) with eight (8) years working experience at the Chest Unit of Korle-Bu Teaching Hospital has over the years observed poor implementation and practice of TBIPC measures. Again, the PI has over the years 2 University of Ghana http://ugspace.ug.edu.gh observed that HCWs who reported to the Chest Unit with TB disease were from non-specialized TB wards with none or poor implementation and practice of TBIPC measures. 1.3 Justification The risk of occupational exposure to TB has been reported to be on the increase in a variety of resource limited countries, mostly as a result of improper and inefficient implementation of TBIPC measures (Mirtskhulava et al., 2016). All HCWs including biomedical scientists, health care assistants, community health workers and health science students are at risk but the risk is greater among nurses and doctors (Oxley et al., 2018). Close contact with an infectious case before diagnosis of TB disease is a major factor contributing to occupational transmission of TB (Demissie Gizaw et al., 2015). These undiagnosed TB cases are sometimes admitted and managed together with non-TB cases on non-specialized TB wards repeatedly exposing health workers to TB infection (Tenna et al., 2013). To counter the risk of occupational TB transmission, the World Health Organization (WHO) has suggested the adoption and implementation of TBIPC measures but several studies persistently depict the absence of TBIPC programs as well as improper implementation in health care facilities in developing countries (Oxley et al., 2018). This study therefore sought to provide data on the TBIPC practices among nurses and doctors for assessment, intervention, monitoring, and evaluation purposes which may ultimately curb the problem of occupational TB transmission. 1.4. Research Questions 1. What is the knowledge level of nurses and doctors on TBIPC measures? 2. What is the proportion of nurses and doctors with effective TBIPC practices? 3. What are the factors influencing TBIPC practices among nurses and doctors? 3 University of Ghana http://ugspace.ug.edu.gh 1.5 Study Objectives 1.5.1 General Objective To examine the knowledge and practice of TBIPC measures among nurses and doctors at selected government hospitals in the Accra Metropolis. 1.5.2 Specific Objectives 1. To assess the knowledge level of nurses and doctors on TBIPC measures. 2. To determine the proportion of nurses and doctors with effective TBIPC practices. 3. To determine the factors that influence TBIPC practices among nurses and doctors. 1.6 Conceptual framework Figure 1 is a framework depicting the relationship between associated factors and the practice of TBIPC measure among HCWs. Institutional settings such as healthcare facilities, are noted to significantly contribute to the risk of TB transmission (Shrestha et al., 2017). Thus, the need for the adoption and implementation of TBIPC measures by healthcare facilities to promote the practice of TBIPC measures among HCWs to curtail the risk of nosocomial transmission of TB. Demographic characteristics such as level of education, sex, profession, age, marital status and years of experience affect the individual’s attitude towards TBIPC practice. Adequate knowledge of TBIPC measures by HCWs also influences the practices of TBIPC measures although knowledge in the absence of proper implementation of the TBIPC measures leads to poor practices (Chadha et al., 2012). Again, frequent training on TBIPC measures empowers HCWs to take the necessary precautions to protect themselves from occupational TB transmission (Kumar & Deka, 2010). 4 University of Ghana http://ugspace.ug.edu.gh Demographic Characteristics;  Education  Sex  profession  Age  Number of years of service Implementation of TBIPC measures  Administrative Knowledge on TBIPC control measures Practice of  Environmental TBIPC measures control measures  Personal protective Measures Training on TBIPC Figure 1: Conceptual Framework for Factors Affecting TB Infection Prevention and Control Practices. 5 University of Ghana http://ugspace.ug.edu.gh CHAPTER TWO LITERATURE REVIEW 2.1 Global Epidemiology of TB TB is caused by species of Mycobacterium which are rod shaped, non-spore-forming, aerobic bacterium (Knechel, 2009). Two species of Mycobacterium cause TB; Mycobacterium tuberculosis which is transmitted by inhalation of infective droplets coughed or sneezed into the air by the patients with active TB and Mycobacterium bovis which is transmitted by milk from diseased cows (Kumar & Deka, 2010). There are two types of clinical manifestations of TB; pulmonary TB (PTB) involving the lungs and extra pulmonary TB (EPTB) involving other organs such as the pleura, lymph nodes, abdomen, skin, meninges, joins and bones and genitourinary tract. TB is contagious when it occurs in the lungs (Demissie Gizaw et al., 2015). The disease is airborne, with breathing being the main risk activity (Oxley et al., 2018). Chronic cough, sputum production, night sweats, hemoptysis, weight loss, fever and anorexia are distinctive clinical features of PTB (Reyn, 2013). Infection with TB bacteria results in two (2) TB related conditions; active TB disease (symptomatic and infectious) and latent TB infection (LTBI) (asymptomatic and non-infectious) (Respir, 2000). Multidrug-resistant TB (MDR-TB) is a form of Mycobacterium tuberculosis strain resistant to Rifampicin and or Isoniazid which constitute the major drugs of the first line of treatment of TB in combination with Pyrazinamide and Ethambutol (Atipo-tsiba et al., 2017). There is increased risk of transmission of TB as a result of the emergence of resistant strains of Mycobacterium tuberculosis and comorbidity with HIV (Ghana Health Service, 2010). Globally, an estimated 1.7 billion people have LTBI, and may develop active TB disease during their lifetime (Segar & 6 University of Ghana http://ugspace.ug.edu.gh Reuters, 2018). Over 50% of HCWs worldwide are estimated to have LTBI, however, there is not much documentation on the burden of active TB disease among HCWs (Tudor et al., 2014). A meta- analysis estimated that globally, the average annual risk of contracting TB disease for HCWs was three (3) times higher (95% confidence interval 2.43–3.51) compared to the general public (von Delft et al., 2015). Comorbidity of TB and HIV infection in sub-Saharan Africa pose a serious challenge to health delivery (McCarthy et al., 2015). In these settings, HCWs are again affected by drug-resistant TB (DR-TB) at a greater frequency than the communities they serve (Oxley et al., 2018). The first data on the global emergence of extensively drug resistant TB (XDR-TB), which is resistance to second-line drugs was published in March 2006 (Kumar & Deka, 2010). 2.2 Global burden of TB TB remains a major Public Health (PH) issue worldwide (Heuvelings et al., 2017). Currently, TB is the leading cause of death from a contagious disease globally, surpassing HIV and Malaria (Oxley et al., 2018). Approximately ten (10) million people worldwide were diagnosed of TB disease in 2017 (Segar & Reuters, 2018). About four (4) million persons develop active TB and 650,000 people die each year in Africa (Demissie Gizaw et al., 2015). Worldwide, HCWs are at increased risk for TB infection and disease, however, rates of occupationally acquired TB are highest in developing countries (Oxley et al., 2018). A systematic review of TB incidence in developing countries approximated that annually, the risk of TB infection in HCWs ranges from 3.9% to 14.3% (with between 2.6% and 11.3% due to occupational exposure) (von Delft et al., 2015). In China, TB incidence in HCWs is 985 per 100,000 population (Du et al., 2017). In sub- Saharan Africa, about 25% of preventable deaths and transmission of MDR-TB among people living with HIV/AIDS (PLWHA) in hospitals have been recorded with high mortality rates (Demissie Gizaw et al., 2015). In Uganda, scholarly works have reported a high burden of TB with 7 University of Ghana http://ugspace.ug.edu.gh a prevalence of 57 % for LTBI and 1.7 % compared to 0.3 % for active TB among HCWs compared to the general population (Buregyeya, Kasasa, & Mitchell, 2016). Ethiopia has 210 cases per 100,000-population TB prevalence with 44 cases per 100,000-mortality rate making it one of the 22 high TB burden countries. (Demissie Gizaw et al., 2015). Ethiopia is also one of the 27 high MDR-TB burden countries in the world (Shrestha et al., 2017). Surveys among HCWs in South Africa have reported that up to 16% of HCWs in South Africa are living with HIV, greatly predisposing them to occupational TB (Tudor et al., 2014). Compounded with HIV/AIDS, TB has become a formidable threat to South Africa (Tamir et al., 2016). The estimated incidence of TB in Ghana in 2016 was 156 / 100,000 population with 23% living with HIV as well (Jackson, 2018). There is however no published data on nosocomial transmission of TB among HCWs in Ghana. 2.3 Factors contributing to occupational transmission of TB HCWs are susceptible to nosocomial TB as a result of poor implementation and practice of TBIPC measures (Temesgen & Demissie, 2014). Delayed diagnosis and ineffective treatment of TB patients contribute significantly to occupational transmission of TB (Buregyeya et al., 2016). Persistent occupational TB exposure associated with a high prevalence of undiagnosed TB in healthcare facilities also predisposes HCWs to TB (Tamir et al., 2016). Furthermore, HCWs who are practicing without adequate training on TBIPC are at a serious disadvantage since they lack knowledge (Shrestha et al., 2017). Studies have reported lack knowledge of HCWs about TBPIC measures, as a factor which also greatly increases the risk of nosocomial transmission (Buregyeya et al., 2016). Poor ventilation and overcrowding in hospitals with people with infectious but undiagnosed TB cases may also account for a high proportion of TB transmission among HCWs (Oxley et al., 2018). The HIV epidemic as well as the emergence of MDR-TB and XDR-TB have 8 University of Ghana http://ugspace.ug.edu.gh also been reported to be factors that facilitate the transmission of occupational TB in healthcare settings (Engelbrecht et al., 2016). In South Africa, lack of knowledge of TBIPC plans and guidelines and poor administrative participation in implementation of local TBIPC policy are reasons for the high incidence of nosocomial transmission of TB (Oxley et al., 2018). 2.4 TBIPC strategies The goal of TBIPC measures is to reduce the spread of TB infection (Temesgen & Demissie, 2014). According to WHO 2019, the WHO initially proposed recommendations on TBIPC targeted at reducing nosocomial transmission of TB in resource limited settings. The recommendations were then updated in 2009 to provide further guidance on the use of specific measures for health care facilities, congregate settings and households. After the 2009 guidelines had been in effect for a decade, they were perused to provide an amended evidence based assessment, augmenting previous recommendations and linking to core components of effective IPC programs overall. The TBIPC measures are categorized into the following; Administrative control measures, environmental control measures and personal protective measures. Administrative controls is the first and most important component of the TBIPC strategy and it involves leadership’s commitment to establish and implement IPC policies in health facilities (WHO, 2019). These measures include the following; Triage of individuals presenting with signs and symptoms TB, or with TB disease. Respiratory separation or isolation of people with presumed or demonstrated infectious TB. Prompt initiation of effective TB treatment of people with TB disease. Respiratory hygiene (including cough etiquette) in people with presumed or confirmed TB. The Environmental control measures include the following; 9 University of Ghana http://ugspace.ug.edu.gh Upper-room germicidal ultraviolet systems which are recommended to reduce transmission of TB to health workers, persons attending health care facilities or other persons in settings with a high risk of transmission. Ventilation systems including natural, mixed-mode, mechanical ventilation and recirculated air through high-efficiency particulate air filters are recommended to reduce TB transmission to health workers, persons attending health care facilities or other persons in settings with a high risk of transmission. Personal protective measures include the following; Particulate respirators, within the framework of a respiratory protection program, are recommended to reduce transmission of TB to health workers, persons attending health care facilities or other persons in settings with a high risk of transmission. Training of HCWs on components of the respiratory protection program. To safeguard the health of HCWs, these measures should be embraced and vigorously implemented (Oxley et al., 2018). 2.5 Knowledge on TBIPC measures A thorough knowledge of how TB is transmitted is very critical for the implementation and practice of TBIPC measures (Steinberg, 2014). Poor knowledge among HCWs on TBIPC measurees may lead to the increased risk of nosocomial TB transmission (Shrestha et al., 2017). In an assessment of the knowledge and practice of tuberculosis infection control among health professionals in Northwest Ethiopia, Temesgen & Demissie (2014) reported that the overall proportion of health professionals with good knowledge about TBIPC was 63.2%. Mirtskhulava et al., (2016) found a positive correlation between knowledge and practice of TBIPC measures among doctors and nurses, however, significant knowledge difference was discovered when 10 University of Ghana http://ugspace.ug.edu.gh professional category was analyzed. Doctors had higher scores compared to laboratory staff, nurses, and support staff. In another related study on HCWs knowledge, attitudes and practices on tuberculosis infection control, Nepal, the level of knowledge on TBIPC among HCWs was found to be poor (45.8%) (Shrestha et al., 2017). Researchers have indicated that due to the limited knowledge of TBIPC measures, HCWs have expressed serious concerns about the dangers they are exposed to in the various health facilities regarding TB infection. It is therefore important that HCWs have adequate knowledge of TBIPC measures in order to reduce the rate of transmission of TB among them in health care settings. However, knowledge of HCW does not guarantee proper practice of TBIPC measures in the health facilities (Demissie Gizaw et al., 2015). 2.6 Factors influencing TBIPC practices There are several demographic characteristics of HCWs that can influence TBIPC practices. For instance, Demissie Gizaw et al., (2015) found a significant association between effective practice of TBIPC and years of working among HCWs in Addis Ababa. Shrestha et al., (2017) found out that poor TBIPC practices could be attributed to lack of TBIPC policy and/or guideline both at national and institutional levels. Tenna et al., (2013) also identified in their study, Infection control knowledge, attitudes and practices among healthcare workers in Addis Ababa, Ethiopia, that potential barriers to the effective implementation and practice of TBIPC measures included lack of infrastructure, training, and infection control role models. A study on HCWs knowledge, attitudes and practices on tuberculosis infection control, Nepal, clearly indicated a gap in training on TBIPC for HCWs which attributed to poor knowledge and practice of TBIPC measures (Shrestha et al., 2017). In another cross sectional study on TB infection control knowledge and 11 University of Ghana http://ugspace.ug.edu.gh attitudes among health workers in Uganda, Buregyeya et al., (2016) also found out that healthcare workers without adequate training had poor TB knowledge and attitude towards TBIPC practices. 2.7 Conclusion of Literature Review Front-line HCWs are usually the first to experience the ramifications of a progressively more resistant and fatal TB epidemic (von Delft et al., 2015). The rising incidence of the HIV pandemic and DR-TB have made TB control efforts even more challenging and this has led to a greater concern towards TBIPC (Shrestha et al., 2017). HCWs are in short supply in most resource poor settings and should be considered extremely important national assets but it appears they are dispensable, at least in the minds of policymakers, who persistently fail to apportion adequate resources to ensure their safety in healthcare facilities (von Delft et al., 2015). Efficient implementation of TBIPC measures in healthcare facilities bank on prompt identification and isolation of cases as well as the rapid and efficacious treatment of TB patients (Temesgen & Demissie, 2014). HCWs are undeniably pivotal in the implementation of all facets of TBIPC measures, however, they are unable to comply to these protocols all the time (Brouwer et al., 2014). 12 University of Ghana http://ugspace.ug.edu.gh CHAPTER THREE METHODOLOGY 3.1 Study Design This study was quantitative, descriptive and cross-sectional in nature. 3.2 Study Area The study was conducted at four (4) selected government hospitals in the Accra Metropolis in the Greater Accra region, the capital city of Ghana. The Accra metropolis has four (4) main government hospitals: Princess Marie Louise Children’s Hospital in the Ashiedu Keteke sub- metro, Achimota Hospital in the Ayawaso sub-metro, Greater Accra Regional Hospital in the Osu-Clottey sub-metro and La General Hospital in the Kpeshie sub-metro (Figure 3). Additionally, there are numerous small government clinics, quasi government health facilities, private clinics and hospitals in the Accra Metropolis. 13 University of Ghana http://ugspace.ug.edu.gh Figure 2: Map showing locations of Achimota, La General, Greater Accra Regional and Princess Marie Louise Children’s Hospitals all in the Accra Metropolis 3.3 Study Variables 3.3.1 Dependent variable The dependent variable is TBIPC practices among nurses and doctors. 3.3.2 Independent variables The independent variables are:  Socio-demographic factors: age, sex, educational level, professional category, number of years in service.  Knowledge of TBIPC  TBIPC training  Factors affecting implementation and practice of TBIPC measures 14 University of Ghana http://ugspace.ug.edu.gh 3.4 Study Population The population for this study were nurses and doctors providing care in the clinical setting at the selected government hospitals in the Accra Metropolis. This is because although health workers are generally at risk of contracting occupational TB, the risk is greater in nurses and doctors (Oxley et al., 2018). 3.4.1 Inclusion Criteria The eligible participants were nurses and doctors working at the selected government hospitals in the Accra metropolis; La General Hospital, Achimota Hospital, Princess Marie Louise Children’s Hospital and Greater Accra regional Hospital who agreed and consented to be part of the study. 3.4.2 Exclusion criteria Nurses and doctors who were doing their internship (Rotation Nurses and House Officers) were excluded from the study. Nurses and doctors who had worked for less than six (6) months were excluded because of their short work experience and were also likely not to have undergone any form of TBIPC training. 3.5 Sampling 3.5.1 Sample Size A sample size was derived using the Cochran’s formula. The sample size was determined based on a proportion (51.4%) of HCWs who had good practice on TBIPC in a previous study done in Ethiopia (Demissie Gizaw et al., 2015). The formula is as stated below: 15 University of Ghana http://ugspace.ug.edu.gh 𝑍2 𝛼𝑃(1−𝑃) 1− n = 2 2 *(1+r) 𝑒 n = The sample size z = 95% confidence interval (standard value 1.96). e = The desired level of precision or level of acceptable error = 0.05 r = Non response rate of 10% to deal with uncompleted and unreturned questionnaires 1.962[0.514(1−0.514)] n = 2 *(1+0.1) 0.05 p = Prevalence of 51.4% based on a proportion of HCWs who had good practice on TBIPC in a previous study done in Ethiopia (Demissie Gizaw et al., 2015). Therefore, the sample size for this study was 423 with the assumptions of 95% confidence level and 5% precision. 3.5.2 Sampling Technique Proportionate stratified sampling technique was used in selecting participants for this study. The proportion of nurses and doctors sampled from each hospital were based on total population of nurses and doctors in the facility. The four hospitals have a total of about 1453 nurses and doctors. Study participants were comprised as follows; 20% from Achimota Hospital, 19% from La General Hospital, 12% from Princess Marie Louise Children’s Hospital and 49% from Greater Accra Regional Hospital. In each facility, nurses and doctors who were on duty during the data collection period were approached and consent sought to be included in the study. 16 University of Ghana http://ugspace.ug.edu.gh 3.5.3 Sample size distribution The four institutions were treated as different strata and sampled based on the total population of nurses and doctors in each institution as provided by their directors of human resources. Table 1: Sample size distribution Hospital (strata) Nurses Doctors Total Number Percentage Population sampled sampled Achimota Hospital 261 25 286 83 20% Greater Accra 642 75 717 209 49% Regional Hospital La General Hospital 250 30 280 81 19% Princess Marie 150 20 170 50 12% Louis Children’s Hospital Total 1303 150 1453 423 100% 3.6 Questionnaire A structured questionnaire (Appendix C) with both precoded and open ended formats that showed socio-demographic variables such as sex, age, education, professional category and number of years worked as well as a section for assessment of knowledge and administrative resource availability about TBIPC measures were asked. The questionnaire was self-administered due to the high literacy rate of respondents. 3.7 Quality control A well-structured and pretested questionnaire was administered to respondents and their responses aided collection of the data set. The data collection tool was adopted and modified from a previous 17 University of Ghana http://ugspace.ug.edu.gh study (Lipke et al., 2016). The tool was based on the WHO recommendations in the policy on TBIPC in healthcare facilities, congregate settings and households and the CDC’s guidelines for preventing the transmission of Mycobacterium tuberculosis in healthcare settings. The reliability of the questionnaire was tested and Cronchbac’s alpha of 0.8 was obtained which indicated an excellent reliability coefficient. Four research assistants with Public health (PH) background were recruited. They were trained and supervised to effectively administer the questionnaires. They were monitored adequately during the data collection process up to the end of the study. Data was collected from every respondent and series of checks conducted after daily field work to ensure that questionnaires were well completed and appropriately filled with accurate information before final analysis. 3.8 Data analysis Data from the questionnaire (Appendix C) was coded and entered into Microsoft Excel data sheet. Data analysis was done by vetting the questionnaire and entering into STATA software package version 15 for editing and analysis. 3.8.1 Knowledge level of nurses and doctors on TBIPC measures To assess knowledge level, 11 questions were asked on TBIPC measures. A score of “0” was assigned to an incorrect answer and “1” for a correct answer. Depending on the summative score of the questions designed to assess knowledge, respondents with a mean score above 60%, (that is, a score of ≥ 7 out of 11) and above were classified as having adequate knowledge while those with mean score below 60% (that is, a score of ≤ 7 out of 11) were classified as having inadequate knowledge (Ministry of Health, Ethiopia 2011). 18 University of Ghana http://ugspace.ug.edu.gh 3.8.2 Proportion of nurses and doctors with effective TBIPC practices To determine proportion of HCWs who utilize effective TBIPC practices, 8 questions were asked with regards to practice of TBIPC measures. Respondents were asked to choose from the following answers; “always”, “sometimes”, “rarely”, and “never”. Respondents who chose “always” were given a score of 1 and those that chose “Sometimes”, “Rarely”, and “Never” were given a score of 0. A score of zero was allocated to the responses “sometimes”, “rarely”, and “never” because TBIPC practices are expected to be strictly adhered to always since not doing so increases the risk of nosocomial transmission of TB. The interest was in whether health care providers practiced TBIPC always (score of 1) or not (score of zero). A summative score above 60%, that is, a score of ≥ 5 out of 8 were classified as having effective TBIPC practices while those with scores below 60% (that is, ≤ 5 points out of 8) were classified as having ineffective TBIPC practices (Ministry of Health, Ethiopia 2011). 3.8.3 Administrative Measures Administrative controls were assessed by asking Eight (8) questions related to the availability and use of resources in the health facilities. This was done by using a Likert scale with 5 point ratings: “strongly agree”, “agree”, “neutral”, “disagree” and “strongly disagree”. Each question was labeled with either positive or negative responses with respondents choosing only one response. Strongly agree was given the highest score of 1, agree (2), neutral (3), disagree (4) and strongly disagree (5) when a positive response is needed. When a negative response is however needed, strongly disagree was given the highest score of 1, disagree (2) in that order. Thus the least score would be 8, median score, 24 with and highest score, 40. Any respondent with an administrative score below the median was classified as working in an institution with proper administrative controls while those with average scores above the median were classified as working in an 19 University of Ghana http://ugspace.ug.edu.gh institution with improper administrative controls. An average score equal to the median were however classified as intermediate administrative controls although not acceptable since proper administrative controls in healthcare institutions are required at all times to safeguard the health of HCWs (Ministry of Health, Ethiopia, 2011). 3.8.4 Factors influencing TBIPC practices among nurses and doctors Descriptive analysis using mean, standard deviation, frequencies and percentages were used to describe the different independent variables. Bivariate analysis using chi-square was conducted to determine if there were any significant association between the dependent and independent variables. Using the predictor variables that were found (from the X2 test) to be significantly associated with practice of TBIPC, a multiple logistic regression analysis was then conducted to determine their association with the TBIPC practices. Crude odds ratio (COR) and Adjusted odds ratio (AOR) were determined for each of the independent variables and statistical significance was accepted at (p≤0.05). 3.9 Ethical considerations/issues Approval for the study was sought from the Ethical Review Committee of the Ghana Health Service. Permission was also sought from the Regional Health Directorate, and Heads of the four health facilities used for the study. 3.9.1 Informed Consent Informed consent was obtained from the respondents before they participated in the study. Their participation in this study was absolutely voluntary. Additionally, they were at liberty to withdraw from the study at any given time. 20 University of Ghana http://ugspace.ug.edu.gh 3.9.2 Confidentiality All information collected from participants were kept confidential and would not be traceable to participants. Participants were assured that information collected would solely be used for research purposes and they would not be named in any report dissemination or publication arising from this scholarly work. 3.9.3 Compensation No compensation was given to respondents who participated in this study. This was made known to them before commencement of data collection. 3.9.4 Risk and Benefits Apart from the time that was lost by participants in answering the questionnaires, there were no risks or cost associated in choosing to participate in the study. However, findings from this study are expected to inform management decisions and policies aimed at improving TBIPC measures in healthcare facilities in Ghana to help prevent nosocomial transmission of TB and eventually help reduce the national and global burden of TB. 3.9.5 Pretest or pilot study Pretesting of questionnaire was done at the Korle-bu Teaching Hospital, Accra among 45 nurses and doctors who had worked for more than six (6) months. This helped in identifying questions which were incomprehensible to respondents as well questions that might lead to biased answers. The pretest gave an insight into the duration required to administer the questionnaire. After the pre-test, the questionnaire was revised accordingly and finalized for the actual field work. 21 University of Ghana http://ugspace.ug.edu.gh 3.9.6 Data storage and usage Data collected in this study was strictly for research purposes. The data was stored with passwords on electronic media and in safely locked boxes. Anonymity was ensured in dissemination of findings from this study since participants were not be identified by their names. 3.9.7 Declaration of conflict of interest The researcher as the principal investigator does hereby declare no conflict of interest in this study. 3.9.8 Funding of the study The study was self-sponsored. 22 University of Ghana http://ugspace.ug.edu.gh CHAPTER FOUR RESULTS 4.1 Socio-demographic characteristics of respondents A total of 423 participants were recruited in the study. However, only 403 consisting of 26.8% (108/403) doctors and 73.2% (295/403) nurses responded to the questionnaire giving a response rate of 95.3%. Most respondents (45.2 %) were between the ages of 26-31 years with mean age 31.1 ± 0.25 SD years. About 63.3% were females and 36.7% were males. Majority, (49.9%) had a first degree and above as their qualification. About 47.4% had worked for a period between 2-5 years (Table 2). Table 2: Socio-demographic characteristics of respondents Variable Frequency Percentage (%) Age of respondents (Yrs.) 20-25 53 13.2 26-31 182 45.2 32-37 133 33.0 38-43 30 7.4 44-49 2 0.5 ≥50 3 0.7 Sex (N=403) Male 148 36.7 Female 255 63.3 Educational level of respondents (N= 403) Certificate 40 9.9 Diploma 162 40.2 Degree and Above 201 49.9 Professional category (N=403) Doctors 108 26.8 Nurses 295 73.2 Number of years worked (N=403) ≤1 98 24.3 2-5 191 47.4 6-9 69 17.1 10-13 35 8.7 ≥14 10 2.5 23 University of Ghana http://ugspace.ug.edu.gh 4.2 Knowledge on TBIPC Practices The results showed that 241 (59.8%) had adequate knowledge while 162 (40.2%) had inadequate knowledge on TBIPC practices (Table 7). Ninety-three percent were able to give the correct description of how TB is spread. Respondents knowledge on requirements of TB examination or treatment room was assessed and 224 (55.6%) gave a correct response that examination of a suspected TB patient should not be in a room with ventilation solely by air condition. With regards to knowledge on an easy and low- cost way to reduce the number of infectious TB droplets in the air, most respondents 220 (54.6%) gave a correct response that one must use natural ventilation by opening windows and doors and maximizing cross -ventilation. Participants’ score on their knowledge of cough etiquettes showed that majority, 326 (80.9%) answered correctly that cough etiquettes includes covering your coughs and sneezes with handkerchief, tissue, or upper arm. Concerning the most effective intervention for TB control, 245 (60.8%) answered correctly that there should be the need for early detection of TB patients and when detected, there should be appropriate treatment given. Participants’ knowledge of who uses surgical masks in an environment where TB transmission was a risk was sought and 370 (91.8%) gave a correct response that surgical masks should be used by coughing patients. Participants were asked to indicate whether managerial control measures for TB infection control included instituting screening of health care workers on TB and 339 (84.3%) answered in the affirmative (Table 3). 24 University of Ghana http://ugspace.ug.edu.gh Table 3: Knowledge on TBIPC measures Variable Frequency Percentage (%) Description of how TB is spread (N=403) Correct response 376 93.3 Incorrect response 27 6.7 Hospital staff should implement effective administrative control measures Correct response 291 72.2 Wrong response 112 27.8 Examinations of treatment room for TB patients Correct response 224 55.6 Incorrect response 179 44.4 How to reduce the number of infectious TB droplets in the air Correct response 220 54.6 Incorrect response 183 45.4 Cough etiquette Correct response 326 80.9 Wrong response 77 19.1 Use of particulate respirators Correct response 128 31.8 Wrong response 275 68.2 Most effective intervention for TB control Correct response 245 60.8 Wrong response 158 39.2 Use of surgical mask where TB transmission is a risk Correct response 370 91.8 Wrong response 33 8.2 Small areas with minimal ventilation should be used for sputum collection Correct response 242 60.1 Wrong response 161 39.9 Managerial control measures for TB infection control include instituting screening of health care workers on TB Correct response 339 84.3 Wrong response 63 15.7 25 University of Ghana http://ugspace.ug.edu.gh 4.3 TBIPC training Table 4 summarizes the results of TBIPC training among the respondents. The results revealed that only 28.8% of respondents had ever attended TBIPC training within the past three years. Out of the respondents who had ever attended a training on TBIPC, about 57.8% had attended training twice and about 56.9% perceived the training as extremely useful. Table 4: Tuberculosis infection prevention and control training Variable Frequency Percentage (%) Ever attended TBIPC training (N=403) Yes 116 28.8 No 287 71.2 If yes indicate how many times (N=116) Once 43 37.0 Twice 67 57.8 Thrice 6 5.2 Usefulness of training (N=116) Extremely useful 66 56.9 Very Useful 32 27.6 Moderately Useful 18 15.5 4.4 TBIPC Practices Table 5 describes TBIPC measures practiced by respondents. About 54.8% of respondents sometimes adopted the use of posters to educate and increase patient’s awareness on TB and 21.8% always used it. It was also found out that 46.7% of respondents sometimes educated coughing patients to apply cough etiquette while forty percent educated coughing patients always. The results also showed that 46.2% of respondents sometimes separated or fast tracked patients who were identified as TB suspects from other patients in waiting areas and 33.5% always did it as a control measure. About 54.1% asserted that they sometimes separated or grouped suspected or confirmed TB patients from other patients on the ward while 29.3% always did it. With regards to 26 University of Ghana http://ugspace.ug.edu.gh the use of Personal Protective Equipment (PPE), 37.5% asserted that they sometimes wore N95/FFP2 mask when working in high risk TB areas, 36.9% always wore masks and 20.8% rarely wore it. Concerning the offering of surgical mask to TB suspects or cases when they are in the hospital, 11.9% reported they always did it, 40% sometimes did it, 24.6% rarely did it and 23.5% never did it. With respect to hand hygiene, majority (92.3%) asserted they always practiced hand hygiene anytime they came into contact with patients’ respiratory secretions or carry out other procedures (Table 5). Table 5: TBIPC Practices Variable Frequency Percentage (%) Use of posters to educate and increase patients awareness on TB Always 88 21.8 Sometimes 221 54.8 Rarely 70 17.4 Never 24 6.0 Educate coughing patients to apply cough etiquette Always 157 40.0 Sometimes 188 46.7 Rarely 46 11.4 Never 12 2.9 I separate or fast track patients who are identified as TB suspects from other patients in waiting areas Always 135 33.5 Sometimes 186 46.2 Rarely 66 16.4 Never 16 3.9 In the wards, I separate or group suspected or confirmed TB patients from other patients Always 118 29.3 27 University of Ghana http://ugspace.ug.edu.gh Sometimes 218 54.1 Rarely 58 14.4 Never 9 2.2 I educate suspected TB patients to wash their hands anytime they produce respiratory secretions Always 128 31.8 Sometimes 181 44.9 Rarely 79 19.6 Never 15 3.7 I wear N95/FFP2 mask when working in high risk TB areas. Always 149 36.9 Sometimes 151 37.5 Rarely 84 20.8 Never 19 4.8 I offer surgical mask to TB suspects or cases when they are in the hospital Always 48 11.9 Sometimes 161 40.0 Rarely 99 24.6 Never 95 23.5 I practice hand hygiene anytime I come into contact with patients with respiratory secretions or carry out other procedures. Always 372 92.3 Sometimes 24 6.0 Rarely 4 0.9 Never 3 0.8 4.5 Administrative Controls for Effective Implementation of TBIPC Measures Table 6 sums up the results of administrative controls at the various hospitals as reported by respondents. About 47.5% of respondents disagreed when they were asked whether they had access to resources to prevent TB infection such as hand hygiene items, surgical mask and N95 in their workplaces. Nearly half, 49.4% of respondents disagreed with the assertion that patient’s visual alerts, example posters advising patient to inform staff if they have respiratory symptoms, 28 University of Ghana http://ugspace.ug.edu.gh were available at all vantage points in their facility. Sixty five percent of the respondents agreed that the windows and doors in their facility were opened daily for maximum cross ventilation. 46.2% were undecided when they were asked whether sputum microscopy was done in a designated area rather than in the main laboratory in their facility. When respondents were asked whether patients with active TB were most often admitted to the same ward with other patients, 44.2% strongly disagreed to this assertion. Approximately 38.7% of respondents agreed to the fact that propelling fans example (ceiling fans) and air conditioners were most often used in their facility than natural cross ventilation while 32% disagreed. However, 44.2% of respondents disagreed that ceiling fans in their facility were functioning, cleaned and in good condition all the time (Table 6) 29 University of Ghana http://ugspace.ug.edu.gh Table 6: Administrative Controls for Effective Implementation of TBIPC Measures Variable Frequency Percentage (%) In my workplace I have access to resources to prevent TB infection such as hand hygiene items, surgical mask andN95 Strongly Agree 31 7.7 Agree 151 37.6 Neutral 27 6.7 Disagree 191 47.5 Strongly disagree 2 0.5 Patient’s visual alerts example Posters advising patient to inform staff if they have respiratory symptoms are available at all vantage points in my facility. Strongly Agree 32 7.9 Agree 113 28.0 Neutral 33 8.2 Disagree 199 49.4 Strongly disagree 26 6.5 My facility has set up quick turnaround times for TB cases. Strongly Agree 18 4.5 Agree 248 61.5 Neutral 59 14.6 Disagree 75 18.6 Strongly disagree 3 0.7 The windows and doors in my facility are opened daily for maximum cross ventilation. Strongly Agree 41 10.2 Agree 262 65.0 Neutral 47 11.7 Disagree 51 12.7 Strongly disagree 2 0.6 Sputum microscopy is done in a designated area rather than in the main laboratory. Agree 70 17.4 Neutral 186 46.2 Disagree 48 11.9 30 University of Ghana http://ugspace.ug.edu.gh Strongly disagree 70 17.4 Agree 7.1 29 Patients with active TB are most often admitted to the same ward with other patients Strongly Agree 12 2.9 Agree 36 8.9 Neutral 18 4.5 Disagree 159 39.5 Strongly disagree 178 44.2 Propelling fans example (ceiling fans) and air conditioners are most often used in my facility than natural cross ventilation. Strongly Agree 17 4.2 Agree 156 38.7 Neutral 41 10.2 Disagree 129 32.0 Strongly disagree 60 14.9 Ceiling fans are functioning, cleaned and in good condition all the time. Strongly Agree 21 5.2 Agree 109 27.1 Neutral 62 15.4 Disagree 178 44.2 Strongly disagree 33 8.1 31 University of Ghana http://ugspace.ug.edu.gh Table 7: Practice, Knowledge and Administrative Scores of Respondents Variable Frequency Percentage (%) Practice (N=403) Effective 109 27.1 Ineffective 294 72.9 Knowledge (N=403) Adequate 241 59.8 Inadequate 162 40.2 Administrative Controls (N = 403) Improper controls 178 44.2 Intermediate 59 14.6 Proper control 166 41.2 TBIPC implementation challenges (N=403) Lack of resources 190 47.2 Lack of PPEs 170 42.2 Inadequate training 43 10.6 4.6 Bivariate associations among TBIPC practices, socio-demographic characteristics and other factors A bivariate analysis was performed to examine the relationship between socio-demographic and other variables and TBIPC practices at 5% level of significance. The results showed that there were statistically significant associations between age (p < 0.001), sex (p < 0.001), educational level (p 0 < 0.001), profession (p = 0.001), number of years worked (p = 0.007) and TBIPC practices (Table 8). Other variables that were also significantly associated with TBIPC were knowledge on TB (p = 0.013), ever attended TBIPC training (p < 0.001) and frequency of training on TBIPC (p = 0.007). Administrative control measures were also found to be significantly associated with TBIPC practices (p = 0.001) (Table 9). 32 University of Ghana http://ugspace.ug.edu.gh Table 8: Association between Demographic Characteristics and TBIPC (n=frequency) TBIPC practice n (%) Chi-square Effective Ineffective Total p- value Age <0.001* 20-25 8 (15.1) 45(84.9) 53 (100.0) 26-31 33 (18.1) 149 (81.9) 182 (100.0) 32-37 65 (48.8) 68 (51.2) 133 (100.0) 38-43 2 (6.7) 28 (93.3) 30 (100.0) 44-49 1 (50.0) 1(50.0) 2 (100.0) ≥50 0 (0.0) 3(100.0) 3 (100.0) Sex <0.001* Male 68(45.9) 80(54.1) 148 (100.0) Female 41(16.1) 80(83.9) 255 (100.0) Educational level <0.001* Certificate 6 (15.0) 34 (85.0) 40 (100.0) Diploma 24(14.8) 138(85.2) 162 (100.0) Degree and Above 79 (39.3) 122 (60.7) 201(100.0) Profession 0.001* Doctor 42 (38.9) 66 (61.1) 108 (100.0) Nurse 67(22.7) 228 (77.3) 295 (100.0) Experience (Years) 0.007* ≤1 19(19.4) 79 (80.6) 98 (00.0) 2-5 68 (35.6) 123 (64.4) 191 (100.0) 6-9 15 (21.7) 54 (78.3) 69 (100.0) 10-13 6 (17.1) 29 (82.9) 35(100.0) ≥14 1(10.0) 9 (90.0) 10 (100.0) *Significant at p≤0.05 33 University of Ghana http://ugspace.ug.edu.gh Table 9: Association between Other Factors and TBIPC (n=frequency) TBIPC practice n (%) Chi-square Effective Ineffective Total p- value Knowledge of TB 0.013* Inadequate 33 (20.4) 129 (79.6) 162 (100.0) Adequate 76 (31.5) 165 (68.5) 241 (100.0) Ever attended TB <0.001* training Yes 87 (75.0) 29 (25.0) 116 (100.0) No 22 (7.7) 265 (92.3) 287 (100.0) Frequency of training 0.007* Once 26 (60.0) 17(40.0) 43 (100.0) Twice 58 (86.6) 9 (13.4) 67 (100.0) Thrice 4 (66.7) 2(33.3) 6 (100.0) Administrative 0.001* controls Improper 57 (32.0) 121(68.0) 178 (100.0) Intermediate 4 (6.8) 55 (93.2) 59 (100.0) Proper 48 (28.9) 118 (71.1) 166 (100.0) *Significant at p≤0.05 4.7 Multiple logistic regression showing strength of association Multiple logistic regression analysis was conducted on all factors that were statistically significant at the bivariate level. These factors were educational level, number of years worked, knowledge on TB and ever had training on TBIPC (see Table 10). The results showed that nurses and doctors with educational level of degree and above were 2.87 times more likely to have effective TBIPC practices compared to those with certificates (AOR=2.87; 95% CI=1.182-7.832). Nurses and doctors who had worked for a period between 2-5 years were 1.93 times more likely to have effective TB practices compared to those who had worked for less than one year (AOR= 1.93; 95% CI=1.03-10.107). 34 University of Ghana http://ugspace.ug.edu.gh Nurses and doctors with adequate knowledge on TB were 2.23 times more likely to practice effective TBIPC measures compared to those with inadequate knowledge (AOR= 2.23 ; 95% CI=1.671-7.428). Nurses and doctors who had never had any training TBIPC had 82% reduced odds of practicing effective TBIPC measures compared to those who had training (AOR= 0.18 ; 95% CI = 0.011- 0.630) (Table 10) 35 University of Ghana http://ugspace.ug.edu.gh Table 10: Multiple Logistics regression of the factors associated with TBIPC practices Variable Effective n (%) Ineffective n (%) COR (95%Cl) AOR(95%CI) Age 20-25 8 (15.1) 45(84.9) 1.0 1.0 26-31 33 (18.1) 149 (81.9) 1.25 (0.537-2.889) 0.42 (0.061-2.914) 32-37 65 (48.8) 68 (51.2) 5.38 (2.756-12.27) 3.27 (0.782-10.284) 38-43 2 (6.7) 28 (93.3) 0.40 (0.079-2.029) 0.82 (0.340-2.42) 44-49 1 (50.0) 1(50.0) 5.63 (0.318-9.408) 2.76 (0.182-8.432) ≥50 0 (0.0) 3(100.0) 0.0 0.0 Sex Male 68 (45.9) 80 (54.1) 1.0 1.0 Female 41 (16.1) 80 (83.9) 0.23 (0.142-0.359) 0.49 (0.136-1.753) Educational level Certificate 6 (15.0) 34 (85.0) 1.0 1.0 Diploma 24(14.8) 138(85.2) 0.98 (0.374-2.600) 0.97 (0.251-3.786) Degree and Above 79 (39.3) 122 (60.7) 3.67 (1.473-9.142) 2.87(1.182-7.832) Profession Doctor 42 (38.9) 66 (61.1) 1.0 1.0 Nurse 67(22.7) 228 (77.3) 0.462 (0.288-0.741) 1.43 (0.307-6.653) Experience ≤1 19 (19.4) 79 (80.6) 1.0 1.0 2-5 68 (35.6) 123 (64.4) 2.29 (1.284-4.113) 1.93 (1.03-10.107) 6-9 15 (21.7) 54 (78.3) 1.15 (0.539-2.470) 1.32 (0.171-10.274) 10-13 6 (17.1) 29 (82.9) 0.86 (0.313-2.366) 0.45 (0.219-5.432) ≥14 1(10.0) 9 (90.0) 0.46 (0.551-3.871) 0.38 (0.173-6.371) Knowledge Inadequate 33 (20.4) 129 (79.6) 1.0 Adequate 76 (31.5) 165 (68.5) 1.80 (1.126 - 2.878) 2.23(1.671-7.428) Ever attended TB training Yes 87 (75.0) 29 (25.0) 1.0 1.0 No 22 (7.7) 265 (92.3) 0.03 (0.015-0.512) 0.18 (0.011-0.630) Frequency of training Once 26 (60.0) 17(40.0) 1.0 Twice 58 (86.6) 9 (13.4) 4.21(1.661 - 10.690) 2.82 (0.022-8.876) Thrice 4 (66.7) 2(33.3) 1.30 (0.215 - 7.944) 1.27(0.325-6.542) n (%) represents frequency (percentage), COR represents Crude Odds Ration, AOR represents Adjusted Odds Ratio and CI represents confidence interval 36 University of Ghana http://ugspace.ug.edu.gh CHAPTER FIVE DISCUSSION 5.1 Knowledge on TBIPC practices In order to reduce the rate of transmission of TB among nurses and doctors, it is important they have adequate knowledge on TBIPC measures. This is because a thorough knowledge of how TB is transmitted is very critical for the implementation and practice of TBIPC measures (Steinberg, 2014). Overall, the proportion of nurses and doctors with adequate knowledge on TBIPC measures in this study was 59.8% and thus had 2.23 increased odds of having effective TBIPC practices compared to those with inadequate knowledge. The knowledge score of 59% in this study, was higher compared to a study in Nepal where 54% of HCWs scored “good” level of knowledge on TBIPC measures (Shrestha et al., 2017). The dissimilarity in the scores may be due to the differences in the study population where all HCWs (including non-clinical staff such as administrators) were sampled in the Nepal study while this study only considered doctors and nurses. These nurses and doctors may have had TBIPC as part of their syllabi content during their professional education and are also likely to have undergone some form of training on TBIPC In contrast, the knowledge score of 59% was lower compared to a similar study in South Africa where the mean knowledge score of HCWs was 61.5% (Steinberg, 2014). The variation in the scores can be attributed to the smaller sample size of 129 in the South African study compared to the 403 in this current study. Regardless, the knowledge score of 59% revealed in this study is moderate at best and should be improved upon since knowledge deficit is a major barrier to implementation and practice of TBIPC in healthcare facilities (Shrestha et al., 2017). 37 University of Ghana http://ugspace.ug.edu.gh 5.2 Proportion of Doctors and Nurses with effective TBIPC practices. The proportion of nurses and doctors with effective TBIPC practices was as low as 27.1%. This proportion were those who practiced TBIPC measures always. This suggests HCWs in the studied healthcare facilities are at risk of nosocomial transmission of TB due to ineffective practice of TBIPC measures. This may be due to lack of training on TBIPC since only 28.8% of participants had ever had any form of training on TBIPC which is woefully inadequate. This can also be attributable to lack of resources such as posters for patient education; overcrowding and lack of adequate space for isolation of TB patients at health facilities; irregular supply of PPEs such as nose mask and N95 mask as reported by respondents. Approximately 47.2% and 42.2% of participants cited lack of resources and lack of PPEs respectively as challenges that they face in the implementation and practice of TBIPC strategies and measures in their facilities. This assertion is supported by a similar study by Storla et al., (2008), which also mentioned lack logistics, irregular supply of PPEs such as nose mask and N95 mask, and lack of training as major challenges that impeded the implementation and practice of TBIPC measures. Congruently, Temesgen and Demissie (2014) also reported that inadequate logistics and lack of training led to poor implementation and practice of TBIPC measures in a similar study. The findings from this study are consistent with a similar study in Maluti Adventist Hospital where HCWs scored low TBIPC practices of 36.4 % and cited poor administrative controls, lack of respirators as some contributing factors (Steinberg, 2014). However, the low TBIPC practices of 27.1% revealed in this study are inconsistent with the findings in another study done in South Africa where 72.9% of respondents reported good practices (Engelbrecht et al.,2016). Engelbrecht et al., (2016), however asserts that observations of practices at the facilities revealed this high 38 University of Ghana http://ugspace.ug.edu.gh proportion of 72.9% to not necessarily be the case. He purported that respondents may have reported high scores to look good in the eyes of the researchers. 5.3 Factors influencing TBIPC practices Educational level, professional category, number of years worked were the determinants of effective TBIPC practices. The study revealed that nurses and doctors with educational level of degree and above were more likely to practice effective TBIPC compared to those with diploma and certificates. This could be attributed to the fact that at the degree or masters level, most HCWs are more likely to have much knowledge because of syllabi content and this might in turn influence their practice. It was observed that nurses and doctors who had worked for a period between 2-5 years were more likely to have effective TBIPC practices compared to those who had worked for less than one year. This is in agreement with a study in Addis Ababa, Ethiopia where HCWs with more than six years working experience were 2.51 times more likely to have effective TBIPC practices compared to those who had worked for less than 3 years (Demissie Gizaw et al., 2015). These findings might stem from the fact the more the number of years worked, the greater the experience acquired and thus the more likely it is for HCWs to learn some TBIPC measures on the job compared to those with little experience. This current study did not consider age, sex, profession as predictors or determinants of TBIPC practices and it is consistent with the work of Temesgen & Demissie (2014) who also found no significant difference between practice and demographic charactersitics such as sex. Contrastingly, a similar study done in India revealed socio-demographic characteristics as a predictor of effective TBIPC practices (Sreeramareddy et al., 2014). 39 University of Ghana http://ugspace.ug.edu.gh Training was also found to be positively associated with effective practice of TBIPC measures in this study. Nurses and doctors who had never attended training on TBIPC had an 82% reduced odds of practicing effective TBIPC measures compared to those who had training. Similarly, training was found to be a predictor of TBIPC practice in a study among health professionals in Ethiopia which revealed that those who had TB related training had an increased odd of 2.51 of having effective practice compared to those without any training (Demissie Gizaw et al., 2015). In contrast, a study in South Africa among HCWs did not find TB related training to be a predictor of good practices (Engelbrecht et al., 2016). In congruence, another study in Northwest Ethiopia found training on TBIPC to be a predictor of good knowledge but not of good practice (Temesgen & Demissie, 2014). This they reported could be attributed to the fact that training was more theoretical than skill based and questioned the quality of those trainings. 40 University of Ghana http://ugspace.ug.edu.gh CHAPTER SIX CONCLUSION AND RECOMMENATIONS 6.0 Conclusion This study sought to examine the knowledge and practice of TBIPC measures among nurses and doctors at four (4) selected government hospitals in the Accra Metropolis. The proportion of nurses and doctors with effective TBIPC practices were low (27.1%). However, the overall knowledge score of nurses and doctors on TBIPC was moderate (59.8%). Level of education, number of years worked, knowledge about TBIPC measures and training on TBIPC were the factors associated with TBIPC practices. It can be inferred from this outcome that knowledge does not always translate into practice. 6.1 Recommendations The knowledge score of nurses and doctors on TBIPC measures was moderate (59.8%) and thus needs to be improved upon. Training or refresher courses on TBIPC measures should therefore be organized by the management of the various healthcare facilities for health care professionals to equip them with the needed knowledge to enhance the practice of TBIPC measures. Overall, an alarmingly low proportion of nurses and doctors (27.1%), effectively practiced TBIPC measures in their healthcare facilities. This could be attributable to lack of resources such as posters for patient education; overcrowding and lack of adequate space for isolation of TB patients at health facilities; irregular supply of PPEs such as nose mask and N95 mask as reported by respondents. The onus therefore falls on the Ministry of Health to provide the needed logistics and resources including PPEs to health care facilities to help 41 University of Ghana http://ugspace.ug.edu.gh improve TBIPC practices in healthcare facilities in Ghana. The ministry should also invest in the expansion and or provision of isolation wards in the various health facilities for isolation of suspected TB cases before diagnosis. The National TB Control Program should ensure the adoption and implementation of effective TBIPC program by all healthcare facilities as well as carry out periodic monitoring and evaluation of the effectiveness of the TBIPC programs in minimizing the risk of nosocomial transmission of TB in healthcare facilities. There should be frequent screening of health care workers for TB to promptly detect and treat infected individuals. Healthcare workers should also seek and attend training programs on TBIPC to improve upon their infection prevention and control practices. Research should be carried out to determine the prevalence of both latent and active TB among healthcare workers in Ghana. 42 University of Ghana http://ugspace.ug.edu.gh REFERENCES Atipo-tsiba, P. W., Eballe, O., Messe, R., Koulimaya, A., Bel, S., Diomandé, A., & Abayi, A. M. (2017). Multidrug-Resistant Tuberculosis : Review of the Literature from A Case of Choroidal Granuloma Associated with a Pott ’ s Disease Secondary to a Pulmonary Localization, 4(3), 7–9. https://doi.org/10.19080/JOJO.2017.04.555636 Brouwer, M., Coelho, E., Das Dores Mosse, C., Brondi, L., Winterton, L., & Van Leth, F. (2014). Healthcare workers’ challenges in the implementation of tuberculosis infection prevention and control measures in Mozambique. PLoS ONE, 9(12), 1–12. https://doi.org/10.1371/journal.pone.0114364 Buregyeya, E., Kasasa, S., & Mitchell, E. M. H. (2016). Tuberculosis infection control knowledge and attitudes among health workers in Uganda: a cross-sectional study. BMC Infectious Diseases, 16(1), 416. https://doi.org/10.1186/s12879-016-1740-7 Center of Disease Control (CDC). (2013). Facts about TB, XDR TB Elimination, Center of Disease Control (CDC). Retrieved from J. Respir. (2000). TB Elimination. Centers for Disea Demissie Gizaw, G., Aderaw Alemu, Z., & Kibret, K. T. (2015). Assessment of knowledge and practice of health workers towards tuberculosis infection control and associated factors in public health facilities of Addis Ababa, Ethiopia: A cross-sectional study. Archives of Public Health, 73(1), 15. https://doi.org/10.1186/s13690-015-0062-3 Du, J., Pang, Y., Ma, Y., Mi, F., Liu, Y., & Li, L. (2017). Prevalence of tuberculosis among health care workers in tuberculosis specialized hospitals in China. Journal of Occupational Health, 59(3), 292–295. https://doi.org/10.1539/joh.16-0251-BR Engelbrecht, M., Rensburg, A. J. Van, Kigozi, G., & Rensburg, H. C. J. D. Van. (2016). Factors associated with good TB infection control practices among primary healthcare workers in the Free State Province , South Africa. BMC Infectious Diseases, 1–10. https://doi.org/10.1186/s12879-016-1984-2 Ghana Health Service. (2010). Ghana TB guidelines, (May 2010), 1–33. Heuvelings, C. C., Vries, S. G. De, & Grobusch, M. P. (2017). International Journal of Infectious Diseases Tackling TB in low-incidence countries : improving diagnosis and management in vulnerable populations. International Journal of Infectious Diseases, 56, 77–80. https://doi.org/10.1016/j.ijid.2016.12.025 43 University of Ghana http://ugspace.ug.edu.gh Jackson, R. P. (2018). S t r a t e g i c f o c u s, (June), 2018. Kumar, V., & Deka, M. K. (2010). A systematic review of different type of tuberculosis, (October). Lipke, V., Kapata, N., Mwinga, A., Gare, M., Emerson, C., Lipke, V., … Lanje, S. (2016). Evaluation of a TB infection control implementation initiative in out-patient Evaluation of a TB infection control implementation initiative in out-patient HIV clinics in Zambia and Botswana, (June). McCarthy, K. M., Scott, L. E., Gous, N., Tellie, M., Venter, W. D. F., Stevens, W. S., & Van Rie, A. (2015). High incidence of latent tuberculous infection among South frican health workers: An urgent call for action. International Journal of Tuberculosis and Lung Disease, 19(6), 647–653. https://doi.org/10.5588/ijtld.14.0759 Ministry of Health. Ethiopia. (2011). National Guideline for Family Planning Services in Ethiopia, 1–65. Nancy A. Knechel. (2009). Tuberculosis: Pathophysiology, Clinical Features, and Diagnosis, 29(2). https://doi.org/10.4037/ccn2009968 Oxley, I., Peters, J. A., & Rossouw, C. (2018). HHS Public Access, 46, 1–17. https://doi.org/10.1016/j.lpm.2017.01.014.Agents Reyn, C. F. Von. (2013). review article. https://doi.org/10.1056/NEJMra1200894 Segar, M., & Reuters, /. (2018). WHO Global Tuberculosis Report Executive Summary 2018. Retrieved from http://www.who.int/tb/publications/global_report/tb18_ExecSum_web_4Oct18.pdf Shrestha, A., Bhattarai, D., Thapa, B., Basel, P., & Wagle, R. R. (2017). Health care workers’ knowledge, attitudes and practices on tuberculosis infection control, Nepal. BMC Infectious Diseases, 17(1), 1–7. https://doi.org/10.1186/s12879-017-2828-4 Sreeramareddy, C. T., Qin, Z. Z., Satyanarayana, S., Subbaraman, R., & Pai, M. (2014). Delays in diagnosis and treatment of pulmonary tuberculosis in India : a systematic review SUMMARY, (October 2013). Steinberg, W. J. (2014). Attitudes , knowledge and practices of healthcare workers regarding occupational exposure of pulmonary tuberculosis, 6–11. https://doi.org/10.4102/phcfm.v6i1.597 Storla, D. G., Yimer, S., & Bjune, G. A. (2008). tuberculosis, 9, 1–9. 44 University of Ghana http://ugspace.ug.edu.gh https://doi.org/10.1186/1471-2458-8-15 Tamir, K., Wasie, B., & Azage, M. (2016). Tuberculosis infection control practices and associated factors among health care workers in health centers of West Gojjam zone, Northwest Ethiopia: A cross-sectional study. BMC Health Services Research, 16(1), 1–11. https://doi.org/10.1186/s12913-016-1608-y Temesgen, C., & Demissie, M. (2014). Knowledge and practice of tuberculosis infection control among health professionals in Northwest Ethiopia; 2011. BMC Health Serv Res, 14(1), 593. https://doi.org/10.1186/s12913-014-0593-2 Tenna, A., Stenehjem, E. A., Margoles, L., Kacha, E., Blumberg, H. M., & Kempker, R. R. (2013). Infection control knowledge, attitudes and practices among healthcare workers in Addis Ababa, Ethiopia. Infect Control Hosp Epidemiol, 34(12), 1289–1296. https://doi.org/10.1086/673979.Infection Tudor, C., Van der Walt, M., Margot, B., Dorman, S. E., Pan, W. K., Yenokyan, G., & Farley, J. E. (2014). Tuberculosis among health care workers in KwaZulu-Natal, South Africa: a retrospective cohort analysis. BMC Public Health, 14(1), 891. https://doi.org/10.1186/1471- 2458-14-891 von Delft, A., Dramowski, A., Khosa, C., Kotze, K., Lederer, P., Mosidi, T., … Zumla, A. (2015). Why healthcare workers are sick of TB. International Journal of Infectious Diseases, 32, 147–151. https://doi.org/10.1016/j.ijid.2014.12.003 WHO. (2019). WHO guidelines on tuberculosis infection prevention and control 2019. 45 University of Ghana http://ugspace.ug.edu.gh APPENDICES Appendix A: Participants Information Sheet STUDY TITLE: KNOWLEDGE AND PRACTICE OF TUBERCULOSIS INFECTION PREVENTION AND CONTROL MEASURES AMONG NURSES AND DOCTORS AT SELECTED GOVERNMENT HOSPITALS IN ACCRA, GHANA. INTRODUCTION: I am Esther Amene Osei-Yeboah, an MPH student at the School of Public Health University of Ghana Legon. I am conducting a research on the topic Knowledge and Practice of Tuberculosis Infection Prevention and Control Measures among Nurses and Doctors at Selected Government Hospitals in Accra, Ghana in partial fulfillment of the award of a Master’s Degree. BACKGROUND AND PURPOSE OF RESEARCH: Tuberculosis (TB) is currently the leading cause of death worldwide from a single infectious organism. There is increased risk of occupational transmission of TB to health care workers (HCWs) but the risk is greater in nurses and doctors. This is as a result of improper implementation of the tuberculosis infection prevention and control (TBIPC) measures recommended by the World Health Organization (WHO) and lack of knowledge about these measures stemming from no or inadequate training of health workers. The aim of this study is to examine the knowledge and practice of TBIPC measures among nurses and doctors at selected government hospitals in the Accra Metropolis. This will shed light on improper implementation and practices of TBIPC measures in health care facilities that predispose nurses and doctors to nosocomial transmission of tuberculosis. NATURE OF RESEARCH: This is a cross sectional and quantitative study involving a total of 423 Nurses and Doctors working at Greater Accra Regional Hospital, Achimota Hospital, La General Hospital, and Princess Marie Louise Hospital. 46 University of Ghana http://ugspace.ug.edu.gh PARTICIPANTS INVOLVEMENT: If you agree to participate in this study, you may be required to answer some questions on tuberculosis, practices or measures that you employ to prevent tuberculosis transmission to yourself, colleagues and patients, training you have received on TBIPC as well factors that affect the practice and implementation of TBIPC measures at your facility. The questions will require approximately 30- 40 minutes for completion. POTENTIAL RISK: There is minimal risk involved in this study as you may be uncomfortable with answering some of the questions. If such a situation happens, you can skip those questions or withdraw from the study without penalty and without having to give any reasons. BENEFITS AND COMPENSATION: There is no compensation or direct benefit from your participation in this study. However, the information obtained from this study will inform management decisions aimed at improving TB control practices in Health Care Centers in Ghana to help decrease the nosocomial transmission of TB and eventually help reduce the national and global burden of tuberculosis. COSTS: Participation in this study will be at no cost to you since questionnaires will administered on days that they are on duty. CONFIDENTIALITY: All the information collected from the study participants will be kept confidential and will not be traceable to the participants. Data will be under lock and key and electronic versions will be password protected with only the P1 having access to them. You will not be identified by name in any dissemination reports or publications resulting from this study. VOLUNTARY PARTICIPATION OR WITHDRAWAL: Participation in this study is voluntary and decision to participate, stay or withdraw from study is at the discretion of the participant and will be of no consequence. 47 University of Ghana http://ugspace.ug.edu.gh OUTCOME AND FEEDBACK: Findings from this research will be published in a peer reviewed journal. A report will also be sent to the Ethics Review Committee. FUNDING: This study is self-sponsored. SHARING OF PARTICIPANTS INFORMATION/DATA: The data will be used only by the Principal Investigator (PI), solely for research and academic purposes. Data will not be shared with any individual or organisation and will be destroyed by burning questionnaires after five (5) years. Ethical clearance will be sought again should the need arise for reuse of the data by the PI. PROVISION OF INFORMATION AND CONSENT FORM: You will be given a copy of the information sheet and Consent form after it has been signed to keep. Any questions or additional information should be directed to the Principal Investigator (PI) Esther Amene Osei-Yeboah, Department of Biological, Environmental and Occupational Health, School of Public Health, University of Ghana, Phone contact: 0246693167, Email: meaka2015@gmail.com Or Dr. Paul Kingsely Botwe, Department of Biological, Environmental and Occupational Health, School of Public Health, University of Ghana, Phone contact: 0205944689, Email: pual.botwe@utas.edu.au Or Miss Hannah Frimpong, of the Ethics Review Committee (ERC) of the Ghana Health Service (GHS), Phone Contact: 0507041223, Email: hannah.frimpong@ghsmail.org or ghserc@gmail.com 48 University of Ghana http://ugspace.ug.edu.gh Appendix B: Consent Form PARTICIPANTS’ STATEMENT I acknowledge that I have read or have had the purpose and contents of the Participants’ Information Sheet read and satisfactorily explained to me in English. I fully understand the contents and any potential implications as well as my right to change my mind (i.e. withdraw from the research) even after I have signed this form. I voluntarily agree to be part of this research. Name or Initials of Participant………………………….. ID Code ……………………… Participants’ Signature …………………………………. Date………………………… INVESTIGATOR STATEMENT AND SIGNATURE I have adequately informed the participant and I certify that the purpose, procedures, potential risks and benefits associated with this study have been explained to the above individual to the best of my ability. Researcher’s name………………………………………. Signature …………………………………………………. Date…………………………………………………………. 49 University of Ghana http://ugspace.ug.edu.gh Appendix C: Questionnaire Dear participant, The aim of this study is to examine the knowledge and practice of tuberculosis infection prevention and control measures among nurses and doctors at selected government hospitals in the Accra Metropolis. The questions will require approximately 30-40 minutes for completion. The findings of this research will contribute to improving the measures that nurses and doctors will employ to prevent the spread of TB in health care settings. Thank you. SECTION A: DEMOGRAPHIC INFORMATION Please kindly provide answers to the under listed questions. Respond to the items by ticking (√) or writing in the spaces provided. 1. Age……………………………………………………………………………………… Please tick age bracket: a. 20 – 25 years ( ) b.26 – 31 years ( ) c. 32 – 37 years ( ) d. 38 – 43 years ( ) e. 44 – 49 years ( ) f. 50 years and above ( ) 2. Sex: a. male ( ) b. Female ( ) 3. Educational Level: a. certificate ( ) b. Diploma ( ) c. Degree ( ) d. Masters d. PhD ( ) 4. Profession: a. Medical doctor ( ) b. Nurse ( ) 5. How long have you been practicing as a nurse or doctor? 50 University of Ghana http://ugspace.ug.edu.gh a. 6 months – 1 year ( ) b. 2 years – 5 years ( ) c. 6 years – 9 years ( ) d. 10 years – 13 years ( ) e.14 years and above ( ) 6. Place of work: a. Achimota Hospital ( ) b. La General Hospital ( ) c. Princess Marie Louise Children’s Hospital ( ) d. Ridge Hospital ( ) 7. Current department/ward/unit of work: please indicate the department/ward/unit you work…………………………………………………………………………………………… SECTION B: KNOWLEDGE ABOUT TB INFECTION PREVENTION AND CONTROL MEASURES Please specify your knowledge about tuberculosis infection prevention and control. Each question requires one answer. Please answer by ticking (√) appropriate response. 1. Which of the following best describes how TB is spread? a. If uninfected person comes into contact with the blood of a person containing the TB bacilli ( ) b. When TB bacilli droplets become suspended in the air and someone breaths in the TB bacilli ( ) c. A person infected with TB can spread the bacteria through physical contact. ( ) d. When an infected person prepares food and introduces the TB germs into the food. ( ) 2. Hospital staff should implement which of the following administrative control measures for TB infection prevention and control? Tick as many as applicable. a. Prompt identification and separation of coughing patients from others. ( ) 51 University of Ghana http://ugspace.ug.edu.gh b. Promoting cough etiquette ( ) c. “Fast tracking” patients suspected of TB infection for prompt diagnosis and treatment ( ) d. All the above ( ) e. A and B only ( ) 3. The examination or treatment room for patients whom you suspect may have TB should have all of the following except: a. Air exhaust directly to the outside ( ) b. Ventilation solely by air condition ( ) c. The placement of the patients nearest the window or fan exhausting the air. ( ) d. Adequate ventilation ( ) 4. An easy and low-cost way to reduce the number of infectious TB droplets in the air is to: a. Use natural ventilation by opening windows and doors and maximizing cross –ventilation ( ) b. Provide respirators or N95 masks to all staff ( ) c. Install a mechanical ventilation system ( ) d. Wash hands with soap and water before and after every patient contact ( ) 5. Cough etiquette: a. Is when someone says “excuse me” after coughing in public ( ) b. Should be required of all patients, but not necessary for healthcare workers ( ) c. Include covering your coughs and sneezes with handkerchief, tissue, or upper arm ( ) d. All of the above ( ) 52 University of Ghana http://ugspace.ug.edu.gh 6. If particulate respirators (also known as N-95 or FFP2 masks) are available in your hospital, they should be: a. Used for all TB patients or persons suspected of TB in the hospital ( ) b. Worn by staff when conducting a bronchoscopy procedure or other high risk procedure for a patient with TB, MDR TB, or XDR TB ( ) c. Required for all staff when they are infected with any infectious disease to prevent transmission to patients ( ) d. Worn by patient when sitting outside to prevent TB droplet from spreading throughout the town ( ) 7. What is the most effective intervention for TB control? a. BCG re-vaccination ( ) b. Chemoprophylaxis ( ) c. Early detection of TB patients ( ) d. Appropriate treatment of TB patients ( ) e. Both C and D ( ) 8. In an environment where TB transmission is a risk, surgical mask should be used by: a. Doctors ( ) b. Nurses ( ) c. Coughing patients ( ) d. Visitors ( ) e. Administrators ( ) f. All the above ( ) Please indicate by ticking whether the following sentences are true/ false. 9. In healthcare setting, the greatest risk for TB spread is by coughing patients who have not been recognized as having TB and are not receiving treatment. a. True ( ) b. False ( ) 53 University of Ghana http://ugspace.ug.edu.gh 10. Small areas with minimal ventilation should be used for sputum collection because they safely contain the TB droplets. a. True ( ) b. False ( ) 11. Managerial control measures for TB infection control include instituting screening of health care workers on TB. a. True ( ) b. False ( ) SECTION C: TB INFECTION PREVENTION AND CONTROL TRAINING This section gathers information with regards to training you have received on tuberculosis infection prevention and control. C.2.a Have you ever attended a tuberculosis infection prevention training program for the past 3 years please? Please tick (√): Yes ( ) No ( ) C.2.b If yes, please indicate by ticking how many times in the last 3 years a. once ( ) b. twice ( ) c. thrice ( ) d. several times ( ), please indicate number of times……………. C.2.c Please indicate the usefulness of the training by ticking ( ) from options below Extremely useful (√) Very useful ( ) Moderately useful ( ) Not useful ( ) 54 University of Ghana http://ugspace.ug.edu.gh SECTION D: PRACTICES FOR PREVENTING TUBERCULOSIS INFECTION This section gathers information relating specifically to your practice with regards to Tuberculosis infection prevention and control (including training you have received, administrative and environmental controls as well as personal protective equipment) D.1 Please indicate how often the following statements apply to you. Please tick (√) one response in the table provided below. Statement Always Sometimes Rarely Never (a) I use information, education and communication (IEC)materials such as posters to educate and increase patients awareness on TB (b) I educate coughing patients to apply cough etiquette (cover mouth, nose with mask, tissue, handkerchief or coughing into arms) (c) I separate or “fast track” patients who are identified as TB suspects from other patients in waiting areas. (d) In the wards I separate or group suspected or confirmed TB patients from other patients (e) I educate suspected TB patients to wash their hands anytime they produce respiratory secretions. (f) I wear N95/FFP2 mask when working in high risk TB areas example (direct observed therapy short course (DOTS) room, TB microscopy room, TB wards) (g) I offer surgical mask to TB suspects or cases when they are in the hospital. (h) I practice hand hygiene anytime I come into contact with patients with respiratory secretions or carry out other procedures. 55 University of Ghana http://ugspace.ug.edu.gh D.2 Please indicate the extent to which you agree or disagree with the following statements below. Tick (√) your responses in the table below. One response for each item is appropriate. Statement Strongl Agre Neutr Disagr Strongl y e al ee y Agree Disagr ee a. In my workplace I have access to resources to prevent TB infection such as hand hygiene items, surgical mask andN95 b. Patients visual alerts example Posters advising patient to inform staff if they have respiratory symptoms are available at all vantage points in my facility. c. My facility has set up quick turnaround times for TB cases d. The windows and doors in my facility are opened daily for maximum cross ventilation. e. Sputum microscopy is done in a designated area rather than in the main laboratory. f. Patients with active TB are most often admitted to the same ward with other patients. g. Propelling fans example (ceiling fans) and air conditioners are most often used in my facility than natural cross ventilation. h. Ceiling fans are functioning, cleaned and in good condition all the time. 56 University of Ghana http://ugspace.ug.edu.gh SECTION E – CHALLENGES a) What are some of the challenges you encounter in the implementation of TB infection prevention and control strategies or measures in your facility? ………………………………………………………………………………………………… ………………………………………………………………………………………………… ………………………………………………………………………………………………… ………………………………………………………………………………………………… ………………………………………………………………………………………………… ………………………………………………………………………………………………… ………………………………………………………………………………………………… ………………………………………………………………………………………………… ……………………………………………………………………………………………… ………………………………………………………………………………………………… ………………………………………………….……………………………………………… ……………………………………………………………………………………………… Thank you for your participation 57 University of Ghana http://ugspace.ug.edu.gh Appendix D: Ethical Clearance 58