UNIVERSITY OF GHANA, LEGON 
COLLEGE OF HEALTH SCIENCES 
SCHOOL OF NURSING 
 
 
 
ASSESSMENT OF TUBERCULOSIS INFECTION PREVENTION 
AND CONTROL PRACTICES AMONG HEALTHCARE WORKERS 
IN TEMA GENERAL HOSPITAL 
 
 
 
 
 
BY 
AGNES CODJOE 
STUDENT ID: 10233296 
 
 
 
 
 
 
 
This dissertation is submitted to the University of Ghana, Legon 
 in partial fulfillment of the requirement for the award  
of MSc nursing degree. 
 
 
 
 
 
 
JULY, 2012 
 
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DECLARATION 
 
I,  Agnes  C odjoe , hereby declare that with the exception of references made to other 
people’s work for which I have duly acknowledge and given credence , this dissertation is 
my original work. N o material in this write up has been submitted for any other degree, 
neither has been submitted concurrent ly in candidature for any other degree or certifica te.
 
 
N ame of Student: Agnes C odjoe 
 
 
Signature :................................... 
 
 
Date..........................................: 
 
 
 
 
SUP ERVIS O RS 
 
 
N ame   :   Dr. Prudence Mwini- N ya led zid zor
 
 
Signature.............................. : 
 
 
Date....................................: 
 
 
N ame:   Prof. K wasi Addo 
 
 
Signature :.............................. 
 
 
Date:.....................................  
 
 
 
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DEDICATON 
 
I de di c at e t hi s wo r k t o my hus band, Ant ho ny Ki ngs t o n Co dj o e , my l o ve l y daught e r , 
Br e nda Be nyi wa Co dj o e and Emmanue l l a Ama Co dj o e f o r s uppo r t and 
e nc o ur age me nt . 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
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ACKNOWLEDGEMENT 
 
 
I am most grateful to the almighty God who bestowed upon me the knowledge and 
wisdom, good health and knowledge to finish this script. I express my gratitude to the 
participants of this study without whose co - operation this work would not have been 
completed.  
 
My heartfelt thanks to Dr. Prudence Mwini- N yaledzidzor not only being a wonderful 
academic supervisor during this perio d of study, but also for being a mentor who provided 
exceptional support and encouragement to come up with the work. It is with pleasure that I 
acknowledge my indebtednes s to Dr. K wasi Addo for his relation effort to come up with 
this work. 
 
I thank the acting Dean, Lectures of school of nursing, university of Ghana, Legon for their 
guidance and support. 
 
My family has been a source of persisten t encouragement and without their emotional and 
financ ia l support, this work may not have gotten this far.  
My gratitude also goes to Dr. C harity Sarpong, the Medical Director of Tema, General 
Hospital for granting me the permiss io n to conduct this study in the facilit y.  
 
Finally, immense gratitude and administration goes to all the staff of Tema General 
Hospital who work dilige nt ly and as well gave me the needed assistance as possible.  
For all who contributed in diverse ways, I say thank you.      
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ABSTRACT 
 
This study investigates knowledge and practices of Tuberculosis  infection prevention and 
control among health workers in Tema General Hospital. Two hundred and twenty nine 
(229) randomly selected (stratification) health workers were administered a 54 - item 
questionnaire. The questio nnaire comprised sections designed to provide relevant 
information of concern to the study such as knowledge of Tuberculosis  infection 
prevention and control, practices and challenges. Results showed that health workers had 
fairly good knowledge of Tubercu losis  infection prevention and control. This was 
significantly influenced by participants’ sex, current ward of work and job title but not age 
and number of years of work. Practices used by the health workers were generally good 
and appropriate especially regular hand washing hygiene, education of Tuberculosis  
patients and use of information, education and communication materials. What was lacking 
was wearing of a N 95(N on oil close fitted mask with 95 % filter efficiency that protects 
from inhaling infectiou s droplet nucle i)  and FF P 2 ( an oil and non oil aerosol mask or 
respirator with 94% filter efficiency that protects from inhaling infectious droplet nuclei ) 
when working in high risk Tuberculosis  areas, offering of surgical mask to Tuberculosis  
suspects or cases when they are in the hospital and separation of group suspected or 
confirmed Tuberculosis  patients from other patients. Identified challenges include d  
inadequate education/training programmes for health workers about Tuberculosis  infection, 
preventio n and control, improper ventilation due to overcrowding at the out patients 
department , lack of protective equipment (F F P 2 or N 95 masks, gloves), non availability of 
Tuberculosis  wards for infected patients, stigmatization of staff working on Tuberculosis  
patients and poor resourced laboratory for Tuberculosis  testing. It was concluded that 
health workers need to improve their knowledge on Tuberculosis  infection prevention 
control whilst stakeholders institute measures geared to wards improvement of facilit y and 
logist ic deficit.  
 
 
 
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TABLE OF CONTENTS 
 
DECLARATION…………………………………………………………………………... i 
 
DEDICATION…………………………………………………………………………….. ii 
 
ACKNOWLEDGMENT…………………………………………………………………. iii 
 
ABSTRACT……………………………………………………………………………….. iv 
 
TABLE OF CONTENTS…………………………………………………………………. v 
 
LIST OF TABLES……………….……………………………………………………. .... xi 
 
LIST OF FIGURES............................................................................................................ xii 
 
LIST OF ACRONYMS/ABBREVIATION.................................................................... xiii 
 
 
 
 
CHAPTER ONE INTRODUCTION ……………………………………………………. 1 
1.1 Background to the S tudy… .…………………………………………………………….. 1  
1.2 Problem S tatement.. …………………………………………………………………….. 7  
1.3  Research Q uestions…………………………………….………………………………..  8  
1.4 Purpose of  the S tudy................................. .............. ..........................................................  9  
1.5 O bjectives of the Study............................ .............. ........................................... ................ 9  
1.6 Significa nce of the Study.................................................................... .............. ................ 9  
1.7 O perational Definit io n of Terms......................................................... ............ ... ............. 10  
 
 
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CHAPTER TWOLITERATURE REVIEW................................................................... 12 
2.0 Introductio n....................................................................................... .............................. 12  
2.1 Tuberculos is (TB): Etiology an d Epidemiology………………………………………. 12  
2.2 N osocomial Infectio ns among Health C are Workers and Patients……………………. 16  
2.2.1 Sources of N osocomial Transm ission of TB………………………………………... 19  
 
2.3 ‘Risk of tuberculosis’ among Nurses and O ther Healthcare Workers ……………… 22  
2.4 Tuberculos is P revention, C ontrol Pract ices and Strategies…………………………… 23  
2.5 C onceptual F ramework for Triage P rocedure in Relatio n to Tuberculos is and  
Airborne Infectio n Prevention and Control…………………………………… ..... 25  
2.6 Knowledge of Tuberculosis (TB) Infection and Control………………… …………… 28  
2.7 Practices of TB Infection Prevention and Control…………………………………….. 33  
2.8 C hallenges F aced by Health C are Workers in the Impleme ntat io n of Tuberculos is -  
Infection Prevention Control……………………………………………....………. 40  
2.9 Summary and Conclusion……………………………………………………………... 42  
CHAPTER THREE METHODOLOGY………………………………………………. 4 3 
3.0 Introductio n ……………………………………………………………………………. 43  
3.1. Research design....................................................... ............................................... ....... 43  
3.2. Research Setting......................................................................................... ....... ............  44  
3.3. Target P opulation........................................... .................................. ...... ....................... 46  
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3.4. Sample size............................................................................................. .. ..................... 46  
3. 4.1 Sample S ize determinat io n..................... ................................................ . ................... 47  
3.5 Sampling Techniq ue…………………………………………………………………... 49  
3.6 Data Gathering Tools.................................................................................. .... ................ 49  
3.7. Data Gathering P rocedure.................................................................................. .. .......... 50  
3.8. Validit y and Reliabilit y........................................................................................ ... ....... 5 1  
3.9. Ethical C onsideratio ns........................................................ ..................................... ... ... 52  
3.10 Data Analys is.......................................................................................................... .. .... 53  
3.11. Limitat io ns............................................................................................................ . ..... .  53  
CHAPTER FOUR FINDINGS........................................................................................ 5 4  
4.0 Introductio n............................................................................................................. .... .... 54  
4.1 Demographic Background of Participants.. ………………………………………... 5 4  
4.1.1 Sex of Participan ts…………………………………………………………………... 55  
4.1.2 Age Distribut io n of the P articipants………………………………………………… 56  
4.1.3 Length of Practice in the Hospital………………………………………………… ... 57  
4.1.4 Current Ward/Unit of work ……………………………………………………… ... ..  58  
4.1.5 Job Title of Participants………………………………………………………… ... … 5 9  
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4.2 Level of knowledge of TB infect io n prevention and control M easures… ... ……….. … 60  
4.2.1 K nowledge of the Mode Spread of TB …………………………………………...... 63  
4.2.2 Implementation of Administrative Control Measures by  Participants…………… ... 6 4  
4.2.3 The Require ment of an Examination or Treatment Room for TB Patients…………. 65  
4.2.4 An Easy and Low- Cost Way to Reduce Infections of TB…………………………... 65  
4.2.5 P articipant s K nowledge on Cough Entiquette………… …………………………… 6 6  
4.2.6 Conditions of Particulate Respirators……………………………………………….. 65  
4.2.7 Persons with High Risk of TB Exposure and Infection…………………………… ... 6 8  
4.2.8 The Most Effective Intervention for TB Control……………………………….... ..... 70  
4.2.9 Administrative Control Measures in Ghana………………………………………… 71  
4.2.10 Who Uses Surgi cal Mask in TB Transmission Enviroment……………………….. 72  
4.2.11 The C lass of Respirator Acceptable for the Health C are Worker in Smear – 
Positive Settings…………………………………………………………………... .  7 3  
4.2.12 Intervent io ns Used by Health F acilit y Designs to Prevent TB Infect io n …….. … .. .. 7 4  
4.2.13 Recommended Strategies to Address TB Tansmission…………………………… .  7 5  
4.2.14 Healthcare Workers ’ O pinion on TB as  the Leading C ause O f Death in  
People with HIV/AIDS .....……………………………………………………….. 76  
4.2.15 Health Care Workers’ Opinion on the Fact That the Greatest Risk for TB  
            Spread in a Health C are Setting is By N on Recognit io n and Treatment  
         Of Coughing Patients……………………………………………….……...……… 77  
4.2.16 Participant s ’ K nowledge about Their Control of TB Transmission…… ... ………... 78  
4.2.17 Areas with Minimal Ventilation should be used for Sputum Collection…………... 79  
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4.2.18. The Value of the Infection Control Person………………………………………... 80  
4.2.19 Participants’ Confirmation of Ministry of Health Recommendation of  
           Screening of TB among People Living with HIV .…...……………………………. 81  
4.2.20 Managerial Control Measures for TB Infection……………………………………. 82  
4.3.0  Practices of Preventing Tuberc ulo s is I nfection……………………………………. .. 83  
4.3.1 Attendance at TB Infectio n P revention Training dur ing the Last 3 Years…………. 84  
4.3.2 Usefulness of TB Infection Prevention and Control Training Programme…………. 84  
4.3.3 C omments on Strengths and Weaknesses of TB Infectio n C ontrol Training 
           Programme………………………………………………………………………… . 85 
4.3.4 Practice s of Prevention and C ontrol of TB... ……………………………….... . .. ....... 88  
4.3. 5 Practices of TB Prevention and C ontro l…………………………………………... ... 89  
    4.4 C hallenges to the Impleme ntat io n of TB Infectio n P revention and C ontrol  
Strategies………………………………………………………………………….. .  93  
   4.4.1 Participant s ’ Suggestio ns to Mitigate C hallenges in the Impleme nt at io n  
of Tuberculos is Infectio n Prevention Control in the Hospital………….………… .  94  
CHAPTER FIVE DISCUSSION………………………………………………………. 95  
5.0 Introduction……………………………………………………………………..... ........ 95  
5.1 Demographic Information of Health Workers………………………………………… 96  
5.2 Knowledge about TB Infection and Control Measures……………………………….. 97  
5.3 Practice of Prevention and C ontrol of TB infect io n …………………………….  101 
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5.4 C hallenges faced by Participants in Preventing and C ontrolling TB …………..… 103  
CHAPTER SIX SUMMARY AND CONCLUSION……………………………… 106 
6.1. Summary…………………………………………………………………………….. 106 
6.2 Implications for nursing……………………………………………………….... ........ 107 
6.2.1 Nursing management………………………………………………………………. 107 
6.2.2 Nursing Research…………………………………………………………………... 107 
6.2.3 Nursing Education…………………………………………………………………. 108 
6.2.4 Nursing Practice……………………………………………………………………. 108 
6.3 Suggestio ns and Recommendat io ns ……………………….………………………… 109 
References………………………………………………………………………………... 110  
 
LIST OF TABLES 
Table 3.1: Sample size that was selected from each Job category……………………….. 48  
Table 4.1: Sex Distributions of Participants………………………………………………. 55  
Table 4.2: Age Distribution of Participants……………………………………………….. 56  
Tab le 4.3: Work Experience of Participants……………………………………………… .  57  
 
Table 4.4: Ward/Unit of Practice of Participants………………………………………… 58  
Table 4.5: Job Title of Participants……………………………………………………... .... 59  
Table  4.6: Level of K nowledge of TB Preventio n and C ontrol Measures……………… ... 60   
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Table 4.7: C orrelation between Demographic Variables and K nowledge of TB  
Infection Prevention and Control Measures………………………………………. 61  
Table 4.8: K nowledge on Mode of Spread of TB ………………………………………. 63  
 
Table 4.9: A dminis tra tive TB Inf e c tion P re ve ntion a nd Control Me a s ure s for Imple me nta tion  . ..  6 4  
 
Table 4.10: K nowledge on Requireme nt s of TB Examina t io n or Treatment Room ……… 65  
 
Table 4.11: An Easy and Low- C ost Way to Reduce Infectio ns of TB Droplets  
in the Air…………………………………………………………………………... 66  
 
Table4.12: Cough Entiquette……………………………………………………………… 6 7  
 
Table 4.13 : P a rtic ipa nts K now le dge on the us e of P a rtic ula te Re s pira tors (N -95 or FFP 2) …… 6 8  
 
Table 4.14 Persons with high risk of TB exposure and infection………………………… .  6 9  
 
Table 4.15 : Eff ective Intervention for TB Control……………………………………… .. 70  
 
Table 4.16: Administrative Control Measures in Ghana………………………………... ... 71  
 
Table 4.17: Participants ’ Knowledge on Who uses Surgica l Mask in TB  
                    Transmiss io n Enviro me nt …………………………………………………...  7 2  
Table 4.18: Class Of Respirator for Participants in Smear Positive Setting………………. 7 3  
Table 4.19: Intervent io ns for Health Facilit ies Design to Prevent TB  
                    Infectio n …………………………………………...………………………... 7 4  
 
Table 4.20: Participan ts ’ Recommend Strategies to Address TB Transmiss io n in  
        Heath C are Facilit ies …………………………………………………………. 7 5  
 
Table 4.21 Participants’ Responses about the Greatest Risk for TB Spread in a Health  
                   C are Setting …………………………………………………………………... 77  
Table 4.22: Participants P erception of their Abilit y to Prevent TB ………………………. 7 8  
 
Table 4.23: Participants ’ O pinion on use of Small Area with Minima l Ventila t io n 
                    Sputum C ollectio n ………………………………………………………. . . ... .  7 9  
Table 4.24: Participants ’ view on the value of the infection control person……………… 80  
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Table 4.25: Participant’s confirmation of Ministry of Health Recommendation  
        for TB screenin g……………………………………………………………... 8 1  
Table 4.26: Participants views on Manageria l C ontrol for TB Infection…………………. 8 2  
Table 4.27: Participants’ View on Factors Influencing Practices of TB Infection  
                   Prevention and C ontrol …………….………………………………………... 83  
Table 4.28: Level of TB Infectio n P revention and C ontrol Practices . ……………….…... 86  
Table 4.29: C orrelation between Demographic Variables and Practices on TB  
                   Infectio n P revention and C ontrol …………………..………………………. .. 8 7  
Table 4.30 TB Prevention P ractices ………………………………...……………….. … .… 88  
Ta ble 4.31: Practices of TB Preventio n ……………..……………………………..... ........ 90  
Table 4.32: C orrelation between K nowledge and Practice of TB Infectio n  
      Prevention    and    C ontrol …………………………………………..……….. 92  
    Table 4.33 Challenges Encountered by Participants……………………………………… . 93 
      
 
 
LIST OF FIGURES 
 
Figure 1 : A Proposed C onceptual F rameWork for Triage Procedure in  
Relation to Tuberculos is and Airborne Infectio n Pr evention and Control………... 24  
Figure 4.2: Participants’ Knowledge on TB as the Leading Cause of Death in People  
                  with HIV/AIDS ……………………………..……………………………....... 76  
 
Figure 4.3: Distributions for Training Attendance……………………………………… ... 84  
 
 
 
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LIST OF ACRONYMS/ABBREVIATIONS  
TB    Tuberculos is 
MTB  Mycobacterium Tuberculos is 
PTB  Pulmonar y Tuberculos is 
MDR  TB:- Mult i Drug Resistant TB 
XDR   TB:- Exte ns ive Drug Resistant 
LTB   Latent TB Infectio n
BC G   Bacillus C almette Guèrin 
DO TS  Directly O bserved Treatment S hort C ourse 
IP C   Infectio n and C ontrol Practices 
HIV  Human Immunode f ic ie nc y Virus 
M DG   Mille nnium Development Goals 
SP S S   Statistica l Package for Social Sciences 
WHO   World Health O rganisatio n 
TS T  Tuberculin Skin Test 
IUALTD Internatio na l Union Against Tuberculos is and Lung Disease 
MO H  Ministr y of Health 
MDG  Mille nnium Development Goal 
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IGRA  Interferon- Ga mma Release Assay 
C DC  C entre for Disease C ontrol 
PLHIV  People Living with HIV 
N 95 A non oil close fitted mask with 95% filter efficiency that protects from 
inhaling droplet nuclei 
FF P 2  An oil and non oil aerosol mask or respirator with 94% filter efficiency that 
protects from inhaling infect io us droplet nuclei 
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 CHAPTER ONE 
INTRODUCTION 
 
1.1 Background to the study 
Tuberculosis commonly referred to as TB is an ancient infectious disease that has caused 
more suffering and deaths than any other infectious disease and remains a public health 
problem worldwide (WHO , 2005). TB is mainly caused by Mycobact erium t uberculosis  
(MTB) and the main source of infection is untreated smear- positive Pulmonary Tuberculosis 
(P TB) patients discharging the bacilli. It mainly spreads by airborne route when the infectious
patient expels droplets containing the bacilli.  It is also transmitted by consumption of raw 
milk containing Mycobact erium bov is  (Harries & Dye, 2006).  
TB can affect any part of the body such as the spine, skin, brain, bone and often referred to as 
extra pulmonary tuberculosis but TB affecting the lungs is known as pulmonary tuberculosis 
(WHO , 2005). For the purpose of this study, the TB being discussed is pulmonary 
tuberculosis (P TB) due to its contagious nature. Pulmonary tuberculosis, like the common 
cold spreads through the air and when people cough, sneeze, talk or sp it the infected persons 
propel the TB germs known as bacilli into the air. A person needs only to inhale a small 
number of these bacilli to be infected. A person can have active or inactive TB. Active TB 
(Tuberculosis disease) means that the bacteria are a ctive in the body and the immune system 
is unable to stop them from causing illness. P eople with active TB can pass the bacteria on to 
any one they come into contact with through the air and if left untreated, each person with 
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active TB disease will infect an average between 10 to 15 people every year (WHO , 2003).  
TB has been a scourge of humanity throughout recorded history. Even today after the 
availability of effective drugs for more than half a century, it is a major cause of morbidity 
and mortality wo rldwide. O ne- third of the world’s population is estimated to be infected with   
Mycobact erium t uberculosis  infection. There were about 9.27 million new TB cases 
(including 4.1 million new smear - positive cases) and 1.3 million deaths from TB in 2008. 
There were about 11.1 million prevalent TB ca ses and half a million Multidrug- Resistant
Tuberculos is (MDR- TB) cases (resistance at least to Isoniazid and Rifamp ic in) in the world ( 
, 2010).N inety five percent (95 %) of TB cases and ninety eight percent (98%) of TB deaths 
occurred in developing countries (WHO , 2008). 
Similarly, the prevalence of tuberculosis is on the increase globally and in 2009, the 
estimated number of TB cases was 14 million with 1.3 million deaths annually and Sub 
Saharan Africa region record ed the highest deaths.  In South Africa the prevalence of TB 
infection is the highest in the world; 511cases/ 100,000 populations (WHO , 201 0). A study 
conducted by Sandiso (2011) in C ape Town, South Africa among the general population 
revealed that in every third taxi, (a major means of mass transport system in South Africa) 
there is a TB patient.  In sub Saharan Africa, Human Immune - Deficiency Virus (HIV) and 
TB have combined to fuel a sub epidemic Multi- Drug Resistant TB (MDR- TB) and 
Extensive Drug-  Resistant TB (XDR- TB) outbreak and in South Africa this has been 
particularly widely covered (Gandhi, Moll, Sturm, Pawinski, Govender, Lalloo, Zeller, 
Andrews, & Friedland, 2006). 
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According to WHO’s Global TB Report (2009), Ghana is not among the World Health 
O rgani]ation’s (WHO’s) 22 high- burden tuberculosis countries, yet the disease is a major 
health problem in the country as one untreated TB case can infect several people at a time. 
With an estimated 47,632 new TB cases in 2007, Ghana ranks 19th in Africa fo r the highest 
estimated number of new cases per year. N ine percent of the 7,786 TB patients registered in 
2007 died before completing TB treatment. Also, over 46,000 new cases of tuberculosis are 
estimated annually (WHO , 2006). Although data on the disease  is limited, it is also estimated 
that Ghana  has about 123 smear positive cases per 100,000 population per year; thus, with an 
estimated population of 20 million, 25,000 smear positive pulmonary tuberculosis (P TB) 
cases are expected every year (N ational Tuberculosis  C ontrol Programme -  N TP Ghana, 
2006). So far in Ghana, 300 healthcare workers have been infected with TB disease 
(unpublished data N TP , 2011). In a retrospective study carried out from 2004 to 2011 to 
determine TB disease among healthcare worke rs, 62 were found to be infected ( unpublished
data Public Health Unit, K orle - Bu Teaching Hospital, 2012 ) Additionally, four confirmed 
Multi Drug- Resista nt (MDR- TB) cases have been reported in Ghana (WHO , 2010).  
Through activities related to controlling TB, many healthcare workers come into contact with 
the disease. During the pre - antibiotic era (before 1944), TB caused a substantial morbidity 
and mortality among medical and nursing personnel (S epkowitz, 1994). With the advent of 
effective antibiotic therapy and decreasing incidence in High- Income C ountries (HIC ), the 
TB risk declined, leading to complacency about nosocomial transmission of TB. In late 
1980s, nosocomial outbreaks of Multidrug- Resistant (MDR) TB occurred, largely in 
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populations infected w it h the Human Immunodeficiency Virus (HIV) (Menzies, Joshi, & Pai, 
2007). These outbreaks stimulated substantial investment in administrative, personal and 
engineering TB infection control measures in many hospitals in the HIC s, leading to 
successful reductions in transmission (Wenger et al., 1995; Maloney et al., 1995; Fella et al., 
1995 Blumberg et al. 1995). The United States’ Centres for Diseases Control and Prevention 
(1994) for instance reported a 3.2 - fold increase in risk of TB for healthcare workers as 
compared to the general populatio n. 
In the Low and Middle - Income C ountries (LMIC ), the risk of TB among healthcare workers 
(HC W) has received relatively limited scrutiny. Few studies have documented prevalence or 
incidence of nosocomial TB infection and /or disease in different settings since 1990 
(International Union against Tuberculosis and Lung & WHO , 1995 ). Although the 
International Union against Tuberculosis and Lung Disease (IUATLD) and the World Health 
O rganization (WHO ) issued recommendations for infection control within health facilities, 
implementation of many of the recommended practices, such as engineering controls, are 
precluded by resource constraints. There is considerable interest in finding simple yet 
effective measures to prevent nosoco mial transmission of TB in Health care settings. 
Hospitals with inadequate infection prevention and control practices (IP C ) are risky 
environments for emergence and transmission of respiratory infectio us diseases such as TB 
(Lau et al., 20 02 ) and many multiple studies have documented the risk of TB transmission
from patient to Health C are W orkers (HC W) and from patient to patient in low, middle and 
high income resource settings (Joshi, Reingo ld, Menzies & Pai, 200 6 ).  
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Health care workers (HC Ws) in high burde n countries have a higher risk of TB infection and 
disease as compared to the general population because of their exposure to large numbers of 
recognised and unrecognised smear positive pulmonary TB (Joshi et al., 2006). C ases are 
managed at the hospital a nd due to inadequate implementation of TB infection control, the 
estimated prevalence of latent TB infection (LTB) among HC Ws in low and middle income 
countries is 54% with an annual risk of TB infection ranging from 0.5 – 14.3% (Joshi, et al., 
2006). Health care settings also provide an opportune environment for the spread of 
respiratory diseases or infections, where more proximity to coughing or sneezing patients can 
pose a risk of disease transmission. The potential for TB transmission can be more immine nt
in primary and emergency care setting where people first present to seek health care. Patients 
with respiratory illnesses congregate with other patients and companions in the waiting and 
clinical areas which are most often crowded. (Varia, Wilson, Salwa l, Mc Geer, Gournis & 
Galanis, 2005) 
In order to reduce TB infection and disease, many nations have employed various strategies 
or approaches to address the situation. The United N ations Millennium Development Goals 
(MDG) 6, target 8 relating to TB, ³The Stop TB  ´ Global plan, and the United States of 
America’s Presidential Emergency Plan for AIDS Relief (PEPFAR) in partnership, have 
targeted to reduce TB mortality and prevalence by half in 2015. Direct ly  O bserved Treatment 
Short C ourse (DO TS ); an adherence enhancing and fundamental strategy have been 
implemented over the years in all TB centres with much success in TB control worldwide 
(WHO 2010). 
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According to WHO (2010) outbreaks have turned attention to the need to reduce TB 
transmission in health care settings. In 2009, WHO revised policy guidelines for TB infection
control and some countries including Ghana developed country- specific national guidelines 
for implementation. The WHO policy guidelines on TB Infection Prevention and control 
(IP C ) focused on healthcare facilities, congregate settings and households and provided 
guidance in implementing TB control activities. TB infection control is therefore a 
combination of measures aimed at minimizing the risk of TB transmission within 
populations. The founda tions for TB infection control are early and rapid diagnoses and 
proper management of TB patients. Hence, TB infection control activities are divided into 
administrative/managerial, environmental and personal protective equipment (WHO 2009). 
The World Health O rganisation thereby entreated all member countries including Ghana to 
instit ut e these control measures to help reduce the spread of TB in healthcare settings.  
In Ghana, infection prevention and control (IP C ) policy, guidelines and protocols have been 
developed in line with WHO guidelines for TB control and disseminated in all health 
institutions throughout the country, however, their effectiveness were not verified by 
documented research. The ability to control nosocomial infections has further been ne glected 
by non- confor mit y of most health workers to report cases among them.  
 
 
 
 
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1.2 Problem Statement    
The World Health O rganization (WHO ) in 1993 declared TB a global emergency in 
recognition of its growing importance as a public health problem. In 200 9, WHO revised TB 
Infection Prevention C ontrol policy, guidelines and implementation strategies. The WHO 
stipulated guidelines adopted by Ghana were to ensure safe practices among health care 
workers, patients and families. This was disseminated in all the regions in 2010 to ensure that 
TB control strategies are implemented in all health institutions throughout the country 
including the ability to control nosocomial infections as part of quality health care service  to 
the people (WHO , 2006). TB Infection Prevention C ontrol is one of the major strategies to 
prevent and control TB disease in patients and healthcare workers (H C Ws) in the health care 
setting (MO H, 2010). However, tuberculosis transmission among HC Ws, patients and 
families is still a threat espec ially to nurses who have the closest and longest contact with 
patients than other care givers (Lopez, 2008).  
In Ghana, so far, 300 healthcare workers have been infected with TB disease (unpublished
data N TP , 2011). In addition, retrospective study from 20 04 to 2011 to determine TB disease 
among healthcare workers indicates 62 were found to be infected (unpublished data Public 
Health Unit, K orle –Bu Teaching Hospital, 2012). 
In Tema General Hospital where the current study was conducted, there was no availab le 
official data on health workers infected with TB. The TB coordinator of the hospital indicated 
that this was so because the TB reporting format does not include the patients’ occupation 
(personal communication). The total number of TB cases reported in 2011 in the Tema 
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Metropolis, showed that the Tema General Hospital recorded the highest number of 117 
(40%) out of 293cases among eight TB centres (Metro Directorate Annua l Report 2011).  
 Interactions with the TB coordinator of the Tema General Hospital also revealed a number of 
TB cases among some health care workers in spite of the persistent efforts being made to 
prevent and control the infection rate ( personal communication). The researcher, an infection
prevention expert with 10 years experience in working at the facility has observed that some 
practices among health care workers were contrary to the recommended standard guidelines
and strategies on TB infection control despite the adoption and dissemination of TB infection
prevention control in Ghana two years ago.  
However, the question is what has Ministry of Health (MO H), Ghana done to remedy the 
situatio n? 
    
1.3 Research Questions 
The current study therefore sets out to find ans wers to the follow ing research questions :
 What knowledge do health care workers have regarding TB infection prevention and 
control strategies? 
 What are the practices employed by health care workers in the Tema General Hospital 
in imple me nt ing  infect io n preventio n and control of TB? 
 What are the challenges healthcare work ers encounter in the implementation of TB 
infect io n prevention and control strategies? 
 
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1.4  Purpose of the study 
The purpose of the study was to investigate the knowledge and practices of health care 
workers in the implementation of TB infection preventio n and control strategies in the Tema 
General Hospital.  
 
1.5  Objectives of the Study 
The main objective of the study was to assess the knowledge base and practices for TB 
infection prevention and control among health care workers in a hospital setting. In line with 
this objective, the study considered the follow ing specific objectives are to ; 
 Assess the knowledge of health care workers on tuberculosis infection prevention and 
control (IP C ) in Tema General Hospital. 
 Describe  the practices employed by health care workers for the prevention of TB 
infect io n in Tema General Hospital. 
 Identify challenges encountered by health care workers in implementation of the TB -
IP C strategies in Tema General Hospital.  
 
1.6 Significance of the Study 
This study is expected to p ioneer research into the prevention and control of TB and other 
respiratory infections in particular as well as nosocomial infections in general.  It is also 
relevant to the intellectual community; the facts and information that come out of this study 
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provide useful knowledge for learning. It will further improve the steps in the practices that 
will be employed by health care workers to reduce the transmission of TB and other 
respiratory infections among health workers, clients, patients in hospitals and clinics. The 
findings of this research will also be useful to the hospital management in making decisions 
regarding TB and prevention of respiratory diseases in general.  
This study is expected to set a pace to delineate the roles and responsibilities of all 
stakeholders at every level of the provision of health care. It is to provide guidance on which 
activities or measures are to be implemented at health facilities to prevent and control 
nosocomia l TB transmiss io n among health workers, patients and relative s.  
 
 
1.7  Operational Definition of Terms 
Knowledge: Informat io n the health care workers have on TB and its preventio n measures.  
Practices: These are the activities and behaviours of health workers towards prevention of 
TB at Tema General Hospital.  
Health care workers:  Trained N urses, Laboratory Technologist s and technicians, X- ray 
technic ia ns and technologist s, Doctors, Health Assistants/ Hea lt h Aides  
Infection prevention: the necessary actions or any precautionary measure s taken to stop the 
invasion and multiplication of micro - organisms (TB bacilli) and transmission from one 
person to another.  
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Infection control: the necessary actions or any precautionary measure s taken to reduce the 
invasion and multiplication of micro - organism (TB bacilli) and transmission from one person 
to another.  
Assessment: to evaluate health workers on the subject of TB infection prevention and control 
practices.  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
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CHAPTER TWO 
LITERATURE REVIEW 
2.0. Introduction 
This chapter presents relevant empirical data on the topic under investigation. For the purpose 
of clarity, the literature is presented systematically under a number of themes: tuberculosis; 
etiology and epidemiology, nosocomial infections among patients and healthcare workers, 
sources of nosocomial transmission of tuberculosis (TB), TB risk among nurses and other 
health workers, TB prevention, control practices and strategies, knowledge of TB infections
and control, challenges face d by health workers in the implementation of TB infection, 
prevention and control strategy. S ummary, conclusion and research questions of the study are 
also presented. A conceptual framework has also been adopted for the study.  
 
2.1 Tuberculosis (TB): Etiology and Epidemiology 
According to the Ministry of Health of Ethiopia (2002) tuberculosis (TB) is an infectious 
disease that is caused by a bacterium called Mycobact erium t uberculosis . The disease was 
called "consumption" in the past because of the way it would consume from within anyone 
who became infected. According to Med lexicon’s medical dictionary , tuberculosis is a 
specific disease caused by infection with Mycobacterium tuberculosis, the tubercle bacillus, 
which can affect almost any tissue or organ of the body, the most common site of the disease 
being the lungs.  
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Harries, Maher and Graham (2004) contend that, the risk of infection depends on the 
susceptibility of the host, the extent o f the exposure and the degree of infectiousness of the 
index case. When an individual inhales the infectious aerosols, the bacilli lodge into the 
alveoli where they multiply and form a primary lesion. Under normal conditions, in most of 
the cases, the immune system either clears the bacilli or arrests the growth of the bacilli 
within the primary lesion in which case the host is said to harbour latent TB infection (LTBI). 
However, in 5 - 10% of the cases, the bacilli overwhelm the immune system resulting in a 
primary TB within a few months to years. In the rest, post - primary TB occurs when re -
infection occurs or the LTBI is reactivated. N aturally, the immune system forms scar tissue or 
fibrosis around the TB bacteria and this helps fight the infection and prevents the disease 
from spreading throughout the body and to other people. If the body' s immune system is 
unable to fight TB or if the bacteria break through the scar tissue, the disease returns to an 
active state with pneumonia and damage to kidneys, bones, and the meninges that line the 
spinal cord and brain.  
The lifetime risk of developing active TB is 5 - 10 % according to a study by Harries and 
Dye , (2006). O ther studies however revealed that it could be higher because of the underlying 
conditions (like human immunodeficiency virus (HIV) infection, diabetes and other medical 
conditions that suppress immunity) and poor socioeconomic status ( F ederal Ministry of 
Health of Ethiopia, 2006). C onsequently, TB has been classifie d as either being latent or 
active. Latent TB occurs when the bacteria are present in the body, but this state is inactive
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and presents no symptoms. Latent TB is also not contagious. Active TB on the other hand is 
contagious and is the condition that can make you sick with symptoms (WHO , 2008). 
The Morbidity and Mortality Weekly Report (1994) asserts that in general, persons who 
become infected with Mycobact erium t uberculosis  have approximately a 10% risk for 
developing active TB during their lifetimes. This risk is greatest during the first 2 years after 
infection. Immuno compromised persons have a greater risk for the progression of latent TB 
infection to active TB disease; HIV infection is the strongest known risk factor for this 
progression. Persons with latent TB infection who become co - infected with HIV have 
approximate ly an 8% – 10% risk per year for developing active TB. 
 HIV- infected persons who are already severely immunosuppressed and who become newly 
infected with Mycobact erium t uberculosis  have an even greater risk for developing active 
TB.  The probability that a person who is exposed to Mycobact erium t uberculosis  will 
become infected depends primarily on the concentration of infectious droplet nuclei in the air 
and the duration of exposure. C hara cteristics of the TB patient that enhance transmission 
include:  disease in the lungs, airways, or larynx, presence of cough or other forceful 
expiratory measures, presence of acid - fast bacilli (AF B) in the sputum, failure of the patient 
to cover the mouth and nose when coughing or sneezing, presence of cavitations on chest 
radiograph, inappropriate or short duration of chemotherapy and administration of 
Mycobact erium t uberculosis  procedures that can induce coughing or cause aerosolization 
(example, sputum inductio n). 
 
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 Environmental factors that enhance the likelihood of transmission include: Exposure in 
relatively small enclosed spaces, inadequate local or general ventilation that results in 
insufficient dilution and/or removal of infectious droplet nuclei and recircula tion of air 
containing infectious droplet nuclei. C haracteristics of the persons exposed to Mycobact erium 
t uberculosis  that may affect the risk for becoming infected are not as well defined. In general, 
persons who have been infected previously with Mycoba ct erium t uberculosis  may be less 
susceptible to subsequent infection. However, reinfection can occur among previously 
infected persons, especially if they are severely immuno compromised. Vaccination with 
Bacille of C almette and Guérin (BC G) probably does not affect the risk of infection rather; it 
decreases the risk for progressing from latent TB infect io n to active TB.  
 Finally, although it is well established that HIV infection increases the likelihood of 
progressing from latent TB infection to active TB, it is unknown whether HIV infection 
increases the risk for becoming infected if exposed to Mycobact erium t uberculosis .  
 
WHO (2004) notes that, although TB affects many parts of the body, it mainly affects the 
lung. Its clinical presentation, therefore, d epends on the site of infection, the organ affected 
and its severity. Patients with PTB present with pulmonary symptoms (like productive cough, 
haemoptysis, chest pain and shortness of breath), constitutional symptoms (like fever, poor 
appetite, weight loss, night sweats and anorexia) and other symptoms depending on the site of 
the infection. A significant understanding of the symptoms is important to inform the 
community about the symptoms to seek medical advice and to inform health workers in order 
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to increase the index of suspicion to easily pick suspects and detect tuberculosis cases 
presenting to health institutions. As such, early detection of the cases and prompt treatment 
are crucial for TB control.  
The challenge however as identified by Liberato, de Albuquerque, C ampelo and de Melo 
(2004) is that many TB diagnostic tests are available and that no single diagnostic test for TB 
exists that can be performed rapidly, simply, inexpensively, and accurately as a stand - alone-
test. Thus, the diagnosis of active TB is a clinical exercise; and sputum microscopy remains 
the mainstay of diagnosis because of its availability, operational feasibility and ability to 
identify the highly infectious forms of TB, the smear - positive PTB cases (Liberato, de 
Albuquerque, C ampelo & de Melo, 2004; WHO , 2004; C S A, 2005 ).  In effect, the 
significance of TB diagnosis is high if it is complemented by prompt treatment. O therwise, if 
not treated in the earliest five years, 50% of PTB cases die, 25% self- cure and 25% remain 
sick and infectious (Maher, Harries & Getahun, 2005). Maher, Harries and Getahun (2005) 
for instance identified that untreated smear- positive P TB patient can infect 10 - 15 people per 
year on average. The figures were however adjudged to more in Africa (WHO , 2005).  Thus, 
treatment of TB is not only a matter of treating the individual patient, but also is an important 
public health interve nt io n.  
 
2.2 Nosocomial Infections among Health Care Workers and Patients  
According to WHO (2002) nosocomial infection is one of the leading causes of death and 
increased morbidity for hospitalized patients. N osocomial infections have traditionally 
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referred to infections that develop during hospitalization and so have also been known as 
hospital- acquired infections. As health care increasingly expands beyond hospitals into 
outpatient settings, nursing homes, long- term care facilities, and even home care settings, the 
more appropriate term has become healthcare - acq uired infect io n. 
As health care has evolved, lowering the rate of noso comial infections has been a challenge 
for infection control program me s. Advances in medical treatments have led to more patients 
with decreased immune function or chronic disease. The increase in these patients, coupled 
with a shift in health care to the outpatient setting, yields a hospital popula tion that is both 
more susceptible to infection and more vulnerable once infected. The increased use of 
invasive devices and procedures has also contributed to higher rates of infection (WHO 2002, 
Weinstein 2004 , Burke 2003). O f particular danger are the several resistant strains of bacteria 
that have developed through their natural course of adaptation and the overuse of antibiotics.
N early 70% of nosocomial infections are caused by drug- resistant strains of bac teria (Burke 
2003).  
 
Burke (2003) and Boyce et al (2004) added that evidence - based guidelines exist for the 
prevention and control of nosocomial infections, and the guidelines address a wide range of 
issues from architectural design of hospitals to hand hygiene. These guidelines have been 
established primarily by the C entr e for Disease C ontrol and Prevention (C DC ) and the World 
Health O rganization (WHO ), as well as infection- related organizations and other professional 
societies. Proper hand washing is the single most important preventive measure, yet 
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compliance rates among healthcare workers have ranged from 16% to 81% . Heightened 
awareness of this guideline and others, as well as ways to promote adherence, are necessary. 
The Joint C ommission on Accreditation of Health C are O rganisation (2007) further explained 
that reducing the risk of healthcare - associated infec tions is one of the N ational Patient Safety 
Goals developed by the Joint C ommission on Accredita tion of Healthcare O rganizations 
(JC AHO ). Reflecting the expansion of nosocomial infections beyond the hospital, this goal is 
included in the JC AHO safety goals developed for a variety of settings in addition to 
hospitals, including ambula tory care/office - based surgery, long- term care, and assisted living 
settings. 
 
The C entre for Disease C ontrol (1985) on the efficacy of nosocomial infection control 
showed beyond doubt that increase in surveillance activities is able to directly bring down the 
rates of nosocomial infections. It is well known that no socomial infections are most prevalent 
in certain high risk areas such as the intensive care renal dialysis and organ transplant units, 
burns ward, cancer ward, operation theatres, post - operation theatres, postoperative ward 
nursery and the geriatric ward. Therefore, all methods aimed at containing hospital infections
should be primarily focused in these high risk areas.  
 
 
 
 
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2.2.1 Sources of Nosocomial Transmission of TB 
 
According to WHO (2002) in general, the sources of nosocomial infections can be 
categorized as being related to environmental factors (air, water, architecture), patient - related 
factors (age, degree of illness/immune status, length of hospital stay), and iatrogenic factors 
(surgery and invasive procedures, devices and equipment, and antibiotic use). Taken together, 
these sources have a substantial impact on the increasing incidence of nosocomial infections,
as WHO further notes that the rate of nosocomial infections will continue to rise as a result of 
four factors:  
‡ C rowded hospital cond itions 
‡ Increasing number of people with compromised immune systems 
‡ N ew microorga nis ms  
‡ Increasing bacterial resistance 
Sehulster et al (2003) suggest that factors specifically related to the healthcare environment
are not common causes of nosocomial infections. However, consideration should be given to 
the prevention of infection with environmental pathogens, such as fungi (example, 
Aspergillus), bacteria (example, Legionella species), or viruses (example, varicella). In 2003, 
the C entre for Disease C ontrol (C DC ) and the Healthcare Infection C ontrol Practices Advi-
sory C ommittee (HIC P AC ) revised the guideline related to environmental factors for 
infection. The report provides clear recommendations for infection control measures 
according to several environment- related categories, including air (normal ventilation and 
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filtration, as well as handling during construction or repair), water (water supply systems, ice 
machines, hydrotherapy tanks and pools), and environmental services (laundry, 
housekeeping). WHO (2002) share in this opinion but added that several factors may 
facilitate nosocomial infection transmission in hospitals, although their relative importance in 
facilitating transmission is unknown. The overwhelming number of TB patients and repeate d 
exposures to smear- positive TB patients are likely to be critical factors. Arguably, TB 
patients are considered excellent teaching material especially those with pulmonary TB who 
are likely to exhibit signs during a lung exam. As a result they may be use d as test materials
by medical trainees.  Many countries, after an initial classroom based program me  in medical 
sciences, trainees begin their clinical rotations especially at the most part of their final years. 
During this phase of their training, emphasi s is placed on physical examination. Evaluation of 
the respiratory system, for example, is invariably included in licensure examinations. 
However, repeated exposure of trainees is particularly worrisome, given the lack of TB 
infect io n control measures at most healthcare facilit ies in Africa. 
 According to Pai et al. (2006), this fact may explain the high incidence of infection among 
health workers in India. Their trainees spend considerable time eliciting physical signs in 
such patients, which results in re peated exposure to patients with infectious TB during 
trainees’ first clinical rotations.  Delays in diagnosis and initiation of treatment and failure to 
separate or isolate patients with smear - positive TB from other patients also contribute to 
transmissio n risk. Many studies have shown that diagnostic delays are common, and private 
practitioners, in particular, tend to underuse sputum microscopy, thereby increasing the 
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probability of missing infectious TB patients ( P rasad, N autiyal, Mukherji, Jain, Singh & 
Ahuja, 2003 ; Uplekar, Juvekar, Morankar, Rangan & N unn ,  1998 ; Rajeswari, 
C handrasekaran, Suhadev, Sivasubramaniam, Sudha & Renu, 2002 ). Unnecessary or 
prolonged hospitalization of TB patients who could have been treated on an ambulatory basis 
might also contribute to high exposure levels in hospitals.  
 
Several factors might prolong infectiousness of TB patients and thereby facilitate nosocomial 
transmission. Poor adherence to treatment, lack of continuous drug supply, use of suboptimal
treatment regimens, lack of adequate treatment support (e.g., direct observation of therapy-
DO T), and insufficient treatment duration have been reported particularly in the private 
sector (Uplekar, Juvekar, Morankar, Rangan & N unn , 1998; Rangan, 2003 ). Few hospitals in 
low income countries have established infection control procedures. Hospitals, especially 
publicly owned facilities, tend to be crowded, poorly ventilated, and have limited or no 
facilities for respiratory isolation. Most respiratory care procedures (including sputum 
collection) are routinely carried out in a general ward setting, rather than in respiratory 
isolation rooms. Further, few of these hospitals offer routine screening programs to detect and 
treat TB among healthcare workers (P rasad, 2002).  
In some high burdened countries, surveys have identified gaps in knowledge and awareness 
about TB in healthcare workers (Uplekar, 1998 ; S ingla, Sharma & Jain 1998 ). A study by 
Prasad (2002) of 213 nurses showed that only 67% reported Mycobact erium t uberculosis as 
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th e causative organism, and only 22% reported sputum microscopy as the most appropriate 
way to diagnose TB.  
In another survey by Singla, Sharma and Jain (1998), only 12% of 204 private practitioners
reported ordering sputum smears for a patient with suspected TB. For treating TB, 187 
physicians used 102 different regimens. O ther surveys have reported similar findings (P rasad, 
2002, 2003 ; Uplekar, 1991, 1998 ). Finally, according to Sheikh, Rangan, Deshmukh, 
Dholakia and Porter (2005) and Padmapriyadarsini and Swaminathan (2005), healthcare 
workers may believe that they cannot avoid nosocomial infection, which results in resigned 
acceptance on their part. They sugge sted that healthcare workers may not view latent TB 
infection as a problem, hence may rarely be treated, even in high- risk groups such as 
household contacts and HIV infected patients. The health workers ’ resigned acceptance of 
latent TB may even be facilitated in high burdened TB countries or where majority of the 
population are infected.  
 
 
2.3 µRisk of tuberculosis¶ among Nurses and Other Healthcare Workers 
The problem of tuberculosis among nurses has been known to be an important one for several 
years. Bo udreau et al.  (1997) compared health workers who provide direct care (exposed) to 
those who did not provide direct care (unexposed) to TB patients in a 4 - year retrospective 
cohort study at a large metropolitan hospital where multidrug resistant TB had occurred. 
They therefore reported of a 4 - year high risk of Mycobact erium t uberculosis  infection among 
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health workers who provides direct care (exposed) 14.5% for TB patients than those who did 
not provide direct care (unexposed) 1.4%.  
C uhadaroglu et al.  (2002 ) confirmed Boudreau et al (1997) work and proposed post graduate 
education and prevention programs as a means of reducing TB infection. Lopes et al (2008) 
also demonstrated the risk of TB among nursing professionals from a central Brazilian 
hospital. O ne hundred and twenty- eight (128) health professionals from an infectious disease 
referral hospital were interviewed and underwent a 2 - step tuberculin skin test (TS T). The 
results of the study showed that, TS T positivity was detected in 69.5% of nursing 
professionals. They also identified length of professional activity and previous direct contact 
with TB sputum smear- positive patients to be associated with tuberculin Mycobact erium 
t uberculosis  positivity. In view of these findings, they highlighted the importance of infection
in health care workers especially nurses who are in direct contact with TB patients and 
suggested proper infect io n control measures to prevent this infect io n in health care facilit ie s.  
 
2.4 Tuberculosis Prevention, Control Practices and Strategies  
C ontrol measures seek to protect potential sites of infection, interrupt routes of transmission,
boost host defenses and discourage selection of hospital strains of organisms 
(P admapriyadarsini et al, 2005). In the hospital, the first step in setting up a viable infection
control programme is to set up an infection control committee, which is an essential 
administrative requirement for effective control of nosocomial infections. The infection 
control committee should be made up of senior administrative staff, i.e. the C hief Medical 
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Director, the infection control doctor, who is often a clinical microbiologist, an 
epidemiologist or a physician/surgeon with interest in infectious diseases whose opinion is 
respected, an infection control nurse, heads of clinical departments or their representatives 
(surgery, medicine, paediatrics, obstetrics and gynaecology etc), representative of nursin g 
staff, pharmacy, engineering and central sterile services department (C S S D). O ther co - opted 
members include representative s from catering department, operating theatre, medical 
supplies and purchasing (S heikh, Rangan, Deshmukh & Dholakia,, 2005; Padmapriyadarsini
& Swaminathan, 2005). The infection control committee should then give authority to 
infection control policies, and ensure implementation. Beyond the foregoing, many agreed 
that effective TB infection control in healthcare settings depends on early identification,
isolating infected persons, and rapidly and effectively treating persons with TB. In all 
healthcare settings, a basic TB infection control program should be implemented, as 
recommended by WHO and other agencies. WHO also recommends developing an infection
control plan, educ ating healthcare workers and patients, improving sputum collection 
practices, performing triage and evaluation of suspected TB patients in outpatient settings, 
and reducing exposure in the laboratory ( WHO , 1997; Blumber g, 2004 ).  
The Ministry of Health of Ghana (2010) hypothetical Triage procedure in relation to 
tuberculosis and airborne infection prevention and control was adopted for the study to help 
emphasize the importance of cough etiquette, expedited services or separation and sputum 
examina t io n base d on cough. 
 
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N ormal queue  
2.5 Conceptual Framework for Triage Procedure in Relation to Tuberculosis and 
Airborne Infection Prevention and Control 
 
           Do e s  t h e p a t ie n t h a v e a c o u g h ?              N O                   N ormal queue                                                                
                              YES  
            
            Ha s  t h e c o u g h la s t e d fo r t wo  we e ks       N O            Ed u c a t e o n p ro p e r c o u g h e t iq u e t t e                                            
                                                      
                              YES                                 
   
             
 
 
 
                   
 
 
  
Source: adopted from Ministr y of Health of Ghana (2010)  
Figure 1 : showing hypothetical triage procedure in relation to tuberculosis and airborne 
infect io n prevention and control. 
Triage personnel should screen e very patient entering the health facilit y with cough.  
Educate on cough etiquette  
O R
RR  
A: Fa s t Tra c k  B : If pos s ible 
s e pa ra te  
S putum examinat io n  
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O ther tools and examinations may be used ; for example the TB screening questionnaire for 
People Living with HIV (P LHIV). It is widely believed that in most less developed countries, 
of all the recommended interventions, implementing administrative controls is likely to be the 
most feasible and effective strategy. These controls include early detection of patients with 
infectious TB, isolating or at least segregating those with infectious pulmonary TB fr om other 
patients, and rapidly initiating anti- TB treatment, supported by measur es to improve 
adherence e.g., DO TS (WHO , 1999).  
Many researchers also proposed the use of personal respiratory protection measures 
(example, N 95 respirators).  However, Biscotto (2005) opined that they probably also not be 
feasible because of the high cost. He was of the view that respirators may be relatively costly 
to implement and of limited effectiveness in high- incidence, resource - limited settings. The 
use of respirators may have a role in hospitals that manage MDR- TB, but more successful 
and affordable measures include improving natural ventilation through open windows and 
sunlight. The efficacy of UV germicidal lights is being evaluated in other low - income 
countries, and results of such studies are needed to determine their value in reducing 
nosocomial transmission. In developing TB infection control program me , crucial issues are 
educating healthcare workers about nosocomial TB and measures that can help prevent such 
transmission, educating patients on cough procedures, and using simple surgical masks on 
patients with infectious TB (especially if they are not segregated) who are coughing 
(Biscotto, 2005). 
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Periodic testing of healthcare workers for latent TB and treating tho se with latent infections
who are at high risk for progression to active TB might be feasible in selected settings, 
particularly among trainees and junior staff (who seem to be disproportionately affected). 
Screening for latent TB infection with newer, blo od - based Interferon-  Gamma Release 
Assays (IGRAs) may not be feasible in most settings at this time. Although IGRAs have 
some advantages over Tuberculin Skin Test (TS T), including increased specificity and the 
ability to discriminate between infection with Mycobact erium t uberculosis  and 
Mycobact erium bov is, , they have limited applicability in many resource - limited settings 
because of the high costs and the need for laboratory infrastructure ( P ai et al., 2004 ). 
However, new data suggest that IGRAs hold promise for serial testing of healthcare workers 
and can overcome some of the limitations of serial tuberculin testing ( P ai et al., 2006 ). A 
recent study in India showed that in a setting with intensive nosocomial exposure, healthcare 
workers had strong interferon- gamma responses that persistently stayed elevated even after 
treatment for latent infection ( P ai et al., 2006 ). Persistence of infection or re - exposure might 
account for this phenomenon. 
Evaluation of symptomatic healthcare workers for active TB is feasible and should be 
implemented routinely. In addition to the above measures, hospitals should make every effort 
to treat TB patients on an ambulatory basis ( S ingh, 2004 ). If hospitalization is required, every 
effort should be made to segregate potent ially infectious patients from immune compromised 
patients, rapidly diagnose and initiate treatment, and discharge patients promptly with DO T S 
on an outpatient basis.  
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2.6 Knowledge of Tuberculosis (TB) Infection and Control  
Lonnroth and Raviglione (2008 ) and W.H. O . (2008) argued that tuberculosis is a worldwide 
problem because every second a person is infected and every 10 seconds someone dies as a 
consequence of TB. In order to reduce the rate of transmission of TB among healthcare 
workers, it is important that healthcare workers have knowledge of TB infection and control 
practices. However, researchers have indicated that very little in terms of research is known 
about the prevalence of latent tuberculosis infection (LTBI) among healthcare workers 
(S chablon, Beckmann, Harling, Diel & N ienhaus, 2009). Accurate health educational efforts 
about infection and control should not overstate or over dramatize tuberculosis (Auer, Sarol, 
Tanner, & Weiss, 2000).  
Furthermore, a report by Siegel, Rinehart, Jacson, C hiarello and HIS P AC (2007) indicates 
that in American hospitals alone, healthcare - associated infections account for an estimated 
1.7 million infections and 99,000 associated deaths each year. O f these infections, 32% of all 
healthcare - associated infections are urinary tract infections, 22% are surgical site infections, 
and 15% are pneumonia (lung infections) and 14% are bloodstream infections. They signify
infections acquired during or associated with delivery of care in contrast to infections present 
or incubating at the time of the care delivery event. This report is significant as it suggests 
that healthcare workers are in danger of getting infected by diseases in the course of 
providing services to patients. Since TB is very infectious, health workers should endeavo u r 
to use TB preventive measures/strategies and should be encouraged in Ghanaian hospitals in 
order to reduce or eliminate TB infection among healthcare workers. In this direction, 
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education regarding the epidemiology and specific precautions pertaining to the prevention of 
infectious diseases (example TB) are needed. This is to ensure that Health workers are 
educated properly and understood their duties. Thus, written policies for infection co ntrol and 
prevention should be available, updated and enforced (British C olumbia C entre for Disease, 
BC C D, 2004) policies on TB preventio n.  
Most of the studies about tuberculosis practices relating to prevention and control are foreign. 
For instance, a study involving healthcare workers reported a prevalence rate of latent 
tuberculosis infection of 7.2% among health workers in Germany. Specifically, health care 
workers younger than 30 years had the lowest prevalence rate (3.5%) and those in their 50s 
had the highest prevalence rate (22%). This higher prevalence could be due to a low immune
resistance in the middle aged persons. This implies that the age of the worker has a bearing 
on tuberculosis infection such that the older the person the more vulnerable he or she is to 
tuberculosis in the health facility. In addition, physicians and nurses showed a higher 
prevalence rate of 10.8% to 4.5% compared to other professions (S chablan, Beckmann, 
Harling, Diel, & N ienhaus, 2009). This confirms that health workers a re increasingly being 
exposed to and get infected with the tuberculosis bacteria. These studies are revealing the 
vulnerability of the healthcare worker to TB even in a developed country such as Germany. 
C onsidering the poor sanitation of Ghana where every place is dust laden and with polluted 
air even in the hospitals and wards, the healthcare worker in Ghana can be said to be more at 
risk of acquiring TB from their clients. Hence, the essence of the current study to assess the 
TB preventio n control strate gies put in place by health workers.  
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The increasing rate of tuberculosis among healthcare workers in general seems to suggest non 
adherence to control and prevention practices by health workers. In Ghana, there is no data 
on tuberculosis cases among healthcare workers. However, lack of knowledge of tuberculosis
prevention strategies may contribute to a higher risk of nosocomial tube rculosis among 
healthcare workers (HC Ws) in institutional settings in Ghana. Utilizing a community based 
participatory study approach, the views of physicians, nurses, laboratory staff and support 
staff in Russia were solicited regarding tuberculosis and infection control measures (Woith, 
Volchenkov & Larson, 2011). 
In another related study by Dimitrova, Balabano , Atun, Drobniewski, Levicheva and C oker 
(2006), it  was observed that, general knowledge on TB was low. Analysis of variance showed 
a significant k nowledge difference by job category. Physicians scored significantly higher 
than nurses, laboratory staff and support staff. N urses and laboratory staff on the other hand 
scored significantly higher than support staff. Despite these differences, it was obs erved that 
there was still a big knowledge gap or deficit in infectio n control by healthcare workers.  
Researchers have indicated that due to the limited knowledge of TB infection control 
practices, healthcare workers (HC Ws) have expressed serious concerns  about the dangers 
they are exposed to in the various health fa cilit ies regarding TB infect io n.  
In particular, Watkins,  et al (2004) indicated that HC Ws reported feeling inadequately 
prepared for their role in tuberculosis (TB) control strategies and that they had not received 
specific TB training. Similarly, HC Ws in Gambia indicated that they have limited knowledge 
about signs and symptoms of TB (Eastwood, 2002). 
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O ther researchers have also emphasized that, infection control practices of TB in health 
facilities is very low. To determine infection control knowledge, a group of dental workers 
and nurses at a Jordanian University Teaching C entre were sampled and their views solicited. 
The questionnaire was used to gather data in this study. The data showed that, nurses and 
health workers in the Jordanian University Teaching C entre were knowledgeable about TB 
infection control. Specifically, all the nurses and health workers reported higher frequency of 
washing hands after removing gloves than wearing them but only 30% said they routinely use 
the mask (Q udeimat, Farrar & O wais , 2006). The outcome of this study was limited to 
Jordanian University Teaching C entre and therefore cannot be generalized to other settings. 
Also, the sample was not broad as it did not include medical doctors and laboratory staff who 
usually handle sputum of smears of patients. Findings showed that some healthcare workers 
do not use practice control measures of TB infect io ns such as the use of masks.  
O ther studies have explored the connec tion between qualification and experience of health 
workers and knowledge of infection control measures. In a study involving nurses in Super 
Specialty Teaching Institute in India, it was found that, the majority of nurses (73.1%) had 
adequate knowledge of TB infection control measures. However, nurses with higher 
professional qualification were found to have more knowledge of infection control measures 
than those with lower professional qualification. But the number of years one had worked as 
a nurse (that is experience) was not associated significantly with the level of knowledge of 
infection control measures. Specifically, nurses with over 10 year s ’ experience demonstrated 
low knowledge of infection control measures than newly recruited nurses (Aarti, Swa pna & 
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Shakti, 200 1). This study also demonstrated the knowledge gap among nursing staff in 
hospitals despite their increasing exposure to TB patients in hospitals. Though the majority of 
nurses showed increase d knowledge, about 30% d id  not have knowledge o f TB infection 
control measures. Like other studies, this study sampled the views of nurses without 
considering other health professionals such as doctors, laboratory staff amongst others. The 
present study thus will sample doctors, nurses, laboratory technologists, X- ray and health 
aides from the Tema General Hospital as all these health workers interact with patients and 
clients directly and indirect ly.
Empirical studies have also been conducted using students in clinically related disciplines to 
examine TB infection prevention knowledge. A survey design was utilized to study a sample 
of 1480 students studying clinically related courses. The sample selected had cared for TB 
patients before and at least 90% of them had attended at least a lecture on TB infe ction 
prevention. The results showed that, 56.3% knew that TB is transmitted from person to 
person through aerosols but 32.3% also expressed the view that they did not know the correct 
method for administering tuberculin test to clients (Jackson, Harriby, Hoffman & C atanzaro, 
2005).  
In a similar study involving medical students of Birmingham Medical School, researchers 
sought to find out how many medical students knew about TB infection control measures and 
procedures. Data were collected using a semi- structured questionnaire. It was revealed that, 
64% of the sample was aware of hand hygiene while 5% indicated that they had not been 
taught about hand hygiene as a control measure. Twelve percent of the students also stressed 
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that, they got to know of hand hygiene through informal teaching. It was also observed that 
more than half of the students lack ed  knowledge of the use of alcoholic hand gel (58%) as a 
hand sanitizer whilst and 35% also lacked knowledge of the use of gloves (Mann & Wood, 
2006).  
 
2.7 Practices of TB Infection Prevention and Control  
Most researchers have reported that no specific TB infection- control programmes were being 
used in health- care facilities.  Harries at al. (2002) evaluated the impact of multiple 
administrative control measures which were implemented in 40 district and mission hospitals 
in Malawi, following adoption of infection- control guidelines. The data were collected by 
interviewing HC Ws and by screening the TB registers at these facilities. The study revealed 
that the infection- control guidelines were not uniformly implemented, and the median 
complia nce with various measures was 76% (range 3% to 100%).  
The introduction of multiple administrative, personal, and engineering controls in a single 
hospital in Thailand (Roth, Garrett, Laserson et al., 2004) resulted in a significant drop in the 
annual incidence of LTBI in HC Ws from 9.3% to 2.2%. However, the incidence of TB 
disease in HC Ws showed no significant increase (from 179 to 252 per 100,000) 1 –2 year 
after init ia t io n of these control measures.  
In another study in Brazil (Yanai, Limpakarnjanarat, Uthaivoravit, Mastro, Morr et al., 
(2003), in a cross- sectional tuberculin survey determined the baseline LTBI prevalence in 
four hospitals. Hospital A initiated administr ative controls and provided N 95 respirators for 
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all HC Ws required to enter a TB- isolation room. Hospital B had initiated administrative
controls before the baseline TS T testing and, at the onset of the study, had introduced N 95 
respirators and had begun co nstruction of negative - pressure isolation rooms. Hospitals C and 
D had no TB- control measures in place throughout the study. Baseline TS T positivity was 
significantly different in the four hospitals (46.7%, 69.6%, 65.8%, and 62.2% in hospitals A, 
B, C , and D, respectively). After 1 year, the incidence of LTBI (in initially tuberculin-
negative workers) was significantly lower in hospitals A and B, which had implemented 
mult ip le infect io n- co ntro l measures, compared with the other two hospitals.  
In a case - control study by Jelip, Mathew, Yusin et al. (2004), reported that HC Ws with TB 
disease were 5.9 times more likely to have poor knowledge about TB transmission, and 4.3 
times more likely to be unaware of the need for respiratory protection. In a study among 
medical students (Teixeira, Menzies, C omstock et al., 2005), although 90% were aware of the 
risk of TB transmission, only 46% reported the use of personal- protection measures. In a 
study from Thailand (Luksamijarukul, Supapvanit, Loosereewanich, & Aiumlaor,  2004), 
although 97% of HC Ws were aware of TB infection- control policies, only 52% used 
personal- protection measures (e.g., respirators), and only 72% implemented respiratory 
isolation for TB cases. Failure to use personal protection was associated with a 2.6- fold (95% 
C I 1.06 to 6.64) increased risk of TB disease in HC Ws (Harries, N yirenda, Banerjee, Boeree 
& Salaniponi, 1999). This implies that, the use of personal control measures vary from 
country to country. This is shown by the different statistical figures recorded. However, not 
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every health worker use personal control measures indicating that some are still exposed to 
the dangers of getting infected with TB. 
Q ualitative studies have also been carried out to examine TB infection control and 
prevention. Using qualitative and phenomenology approach, researchers used a semi-
structured interview and a quota sample of 20 nurses in a C ape Town Hospital, South Africa. 
C ontent analysis of the qualitative data showed that there were no designated TB wards and 
ventilation was poor. It was also observed that standard operating procedures for TB infection
control were lacking; TB patients and suspected patients were not subjected to IP C measures 
(Dagmar, Frederick & Shadeen, 2010).  
In another major study, Wayne et al, (2005) found that health care worker s adherence to 
C entre for Disease C ontrol (C DC ) recommended respiratory infection C ontrol practices in 
primary C are C linic and emergency departments of five Medical C entres in K ing C ountry,  
findings showed that regardless of occupation,  participants offered masks to coughing 
patients;  however medical practitioners were generally least knowledgeable about separation 
of ILI patients in a private examination room as compared to nurses and nurses a ides. It was 
also revealed that, participants practised  hand hygiene before touching patients (91%), before 
and immediately after removing disposable gloves (81%). About 50% of medical 
practitioners and nurses practis ed hand hygiene after taking pulse or blood pressure. Finally, 
77% of the sample indicated that in their facility there are clear written procedures on what to 
do, and what infection control actions to take when an undiagnosed patient arrives with 
symptoms of respiratory infectio n.  
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Studies in Eritrea suggest that health workers routinely wash their hands after contact with 
blood, body fluids or contaminated items. Thirty percent (30%) were found to wash their 
hands thoroughly by rubbing between fingers and around nails while 70% used gloves in 
between patient contac t ( Rigbe, Almedom, Hagos, Albin & Gutungi, 2005). 
Scholars have acknowledged that TB is a major occupational risk for healthcare workers and 
trainees of healthcare systems. In particular, latent TB infection and TB disease is a major 
source of concern (P a i et al, 2005, Rae et al, 2004, Gopinath et al, 2004, C hadha et al, 2005). 
This observation suggests the need to examine the situat io n of healthcare workers in research.  
In a study, 726 health workers were recruited. They comprised physicians in training,  
attending physicians and nurses. The study was conducted in Sevagram Medical Hospital, 
India using Tuberculin Skin Test (TS T), a whole blood interferon Gamma Release Assay 
(IGRA) to determine infection among health workers. Test result s using TS T found 50 
percent to be positive while IGRA result s recorded nearly 70 percent positives through direct 
contacts with sputum smear- positive TB patients. In terms of the sample used, physicians in 
training were the highly exposed group, followed by attending physicians and then nurses. 
Increasing age and duration of employment were risk factors for latent TB infection (P ai et al, 
2005, Rae et al, 2004, Gopinath et al, 2004, C hadha et al, 2005). The testing instruments used 
in this study suggest ed  that the number of healthcare workers exposed or infected may be 
higher than the recorded number given the different percentages recorded by the test 
instruments. Also, the findings in this study cannot be generalized to other settings because 
infection control practices differ from country to country though there are standard 
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procedures for all health facilities across the globe. Enforcement procedures, challenges faced 
by hospitals in terms of logistics and training given to workers all make this finding limited to 
the Indian setting. The need to explore the situation in Ghana is imperative as it will uncover 
the situatio n among health professiona l s regarding control practices and challenges.
A retrospective review of health care workers, who underwent anti TB treatment in a tertiary 
care hospital in Vellore, identified 125 healthcare workers who had been treated for active 
TB between 1992 and 2001. The annual incidence of pulmonary TB was 0.35 - 1.80 per 1,000 
persons during the period and annual incidence of extra pulmonary TB was 0.34 - 1.57 per 
1,000. However, C hadha et al.  (2005) in their study argued that these rates might have been 
underestimated because only health workers who underwent TB treatment were counted and 
a case control study in the same hospital showed that low body mass index and employment
in medical wards were risk factors for TB disease among health workers. This study relates 
only to the infection rate among workers but did not indicate whether they adhered to 
infection practices and still got infected. Also , the data used for the study was secondary and 
might not give an accurate idea of the current trends regarding infect io n.  
A quantitative study conducted in N igeria show ed  that, there was no full compliance by 
N igerian health workers of infection control practices. Specifically, Sofola and Savage 
(2003), reported that out of the 146 sample recruited, the major ity (70.6%) said they always 
wo re gloves when treating patients while (29.4 %) said they sometimes did so, (45.9 %) said 
they wo re facemasks, while s (52.7%) indicated that they sometimes wor e them and (1.4%) 
said they never wore them. Sterilization was performed using a combination of methods 
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including autoclaving (84.1%), chemicals (29.7%) and others such as boiling (19.3%) and dry 
heat (17.5%). In line with the above data, it is clear that total adherence to infection control is 
still a major problem for health workers.   
Q udeimat et al. (2006) conducted a study concerning the practices of infection prevention, 
100% of dental workers including nurses studied reported routine wearing of gloves. The 
dental nurses assessed also reported higher frequency of washing hands after removing the 
gloves than before wearing them. Routine mask use was also statistically low among nurses 
(30%). However, Ignatavicius, Workman and Mishler (1995) advanced that thorough and 
constant hand washing significantly prevented transmission of pathogens. In addition, the use 
of antimicrobial agents, bathing and grooming for client and nurse, observance of sanitation 
in infect io us disease form the pivot in any infect io n prevention strategy.  
Some researchers noted that, hand washing compliance was significantly low in a medical 
intensive care unit and  a general medical ward with 728 beds in a tertiary care facility in 
Virginia. Hand washing before and after care for TB patients was 9  percent and 22 percent 
respectively (Bischoff, Reynolds, Sessler, Edmond & Wenzel, 2001). The research findings 
show ed  that, hand washing wa s not taken seriously before attending to TB patients but quiet 
high after care. Healthcare workers observe infection control measures immediately after 
contact with patients and less likely before. 
In another study conducted in Heidelbery University Hospital, a 1600 bed teaching hospital, 
Wendt, K nautz and Von Baum (2004) found that, hand hygiene was predominantly achieved 
through the use of the hand rubs. High rates of hand rub use were observed among health care 
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workers [Hand rubs we re used in 1,115, (52.2%) of 2,138 observation]. Sixty- two and half 
percent (62.5%) nurses were reported to significantly use hand rubs more frequently than 
physicians did (51.3%) after contact with patients. However, close of half of health workers 
per the findings did not observe infect io n control practices regarding hand hygiene.   
These results were similar to that observed by Meengs, Giles, C hrisholn, C ordell and N elson 
(1994) when the hand washing frequency was assessed in an emergency department in t he 
Methodist Hospital emergency department of Indiana. In this study, hand washing occurred 
in 50.4% of total contacts. N urses washed after 58.2% of 142 contacts and physicians washed 
35.8% of 263 contacts. This implied that nurses had a higher hand washing frequency than 
the physicians. However the number of years of clinical experience was not significantly 
related to hand washing frequency. Soap and water were used in most instances of hand 
washing while only a few cases were observed when alcohol prepar ation was used.  
A research carried out by Saloojee and Steenhoff (2000) on the health professional’s role in 
preventing nosocomial infections demonstrated that, the infection control compliance among 
health professionals was very poor. The hands were seen by many of the professionals as the 
commonest vehicles by which microorganisms are transmitted between patients. In spite of 
this, the study of the nurses’ practices revealed that, the hands were only cleaned after 30 of 
patient contacts and after 50% of activities that we re likely to result in heavy contamination.
The use of gowns and mask s were also reported to be very low. Among those who wash their 
hands, alcohol hand disinfec t io n and soap hand washing were the methods employed.  
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Preventing nosocomial infection: improving compliance with standard precautions in an 
Indonesian teaching hospital a study by Duerink, Farida, N agelkerke and Van den Braek 
(2005) revealed that compliance with hand hygiene was 46% in an internal medicine wa rd 
and 22% in a paediatric ward studied. Twenty percent (20%) of health professionals recapped 
needles after use while few workers used gown and gloves.  
 
2.8 Challenges Faced by Health Care Workers in the Implementation of  
Tuberculosis -Infection Prevention Control  
 Akyol (2007 ) Sofola and Savage (2003) explained that, health workers are faced with 
various occupational risks as far as TB infection is concern. Though there are standard 
procedures to follow to avoid being infe cted, a number of challenges ranging from lack of 
logistics, human resource and other work related factors have been cited. N on - adherence to 
control practices by health professionals has been attributed to non- availability of required 
resource materials such as masks, gloves, disinfectants amongst others. Thus, the need to 
ensure availabil it y of TB control materials in order to manage TB patients is necessary.  
In addition, increasing workload of healthcare workers ha s been found to lead to non-
compliance of hand hygiene practices. This is probably due to lack of human resource in 
health facilities to handle increasing number of cases. A South African based study revealed 
that adherence to hand washing practices as part of control practices would improve 
compliance by 92% and hence significant reduction in infection rate among health 
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professionals. Poor hand washing practices has also been caused by lack of decontamination 
agents (S aloojee & Steehoff, 2000).  
In Jackson ’s (1999) view, understaffing is a major inhibiting factor. Junior and temporary 
staff work without supervision because of lack of manpower especially experience d  ones to 
ensure as well as enforce infection control practices. This partly contributes to increasing 
rates of infection among health professionals especially junior staff. The literature suggests 
that, junior and temporary workers ’ lack of experience and probably knowledge is a major 
risk factor for all healthcare workers.  
 In a survey conducted in Eritrea to find out about compliance of infection control practices 
among healthcare workers, it was observed that, there was low compliance due to factors 
such as in adequate and in conveniently located sinks, in adequate hand towels, water, quality 
soap and hand lotions or lubricants for use a fter hand washing and lack of time. Also ,  51 
percent of respondents indicated that they prefer red to wear gloves but did not change them 
in between contacts due to scarcity because the gloves protected them and not their patients 
(Rigbe et al., 2005). Furthermore, improper gloving has been cited as a reason for poor hand 
hygiene because contaminated gloves must be removed in accordance with infection control 
measures. N on- adherence will lead to infection spread as there is high risk of microbial 
transmiss io n (Girou, C hai, Brun- Buisso n, 2004).  
 
 
 
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2.9. Summary and Conclusion 
F rom the literature reviewed, many studies both quantitative and qualitative have explored 
how tuberculosis has become a major occupational risk for health workers in contemporary 
times to the extent that more and more health workers are now becoming patients rather than 
specialists to attend to such patients. This situation has prompted research into the area. 
However, a review of literature show that very little research in the area has b een done in 
Africa despite the increasing cases of TB in Africa and Ghana in particular. It is clear from 
the literature reviewed so far that, they majority of the studies have been conducted in the 
Western countries but generalization might not help uncover the situation in Ghana. Also, 
most of the studies were limited to recommended TB infection prevention practices such as 
hand washing before and after contact with patients, wearing of gloves and face masking. 
Also, environmental related control measures , administrative and other measures 
recommended by the World Health O rganization (WHO ) have not been covered in these 
studies.  The present study will bring to light the situation in Ghana to fill the gaps identified
in the literature. 
  
 
 
 
 
 
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CHAPTER THREE 
METHODOLOGY 
3.0 Introduction   
This chapter deals with the research methodology that was adopted for the study. It covers the 
research design, description of the research setting; study population, sampling and sample 
size, sampling technique, data gathering tools, data gathering procedure, validity and 
reliability, ethical considerations, data analysis, strengths and limitations to data collection 
were also presented.  
 
3.1. Research design 
Research design describes how a study is conducted to maximize control over factors that 
could interfere with the desired outcome of a study (Burns & Grove, 2005). A research 
design is therefore the overall plan for obtaining answers to the research questions being 
studied (P olit & Beck, 2008).This research is quantitative in nature and the aim is to make 
correct predictions, as Worrall (2000) contends, one reason that quantitative research enjoys 
widespread heightened respect in the discipline ³lies in the predictive advantages this method 
of inquiry possesses. Indeed, the ability to make correct predictions is one of the more 
outstanding characteristics of quantitative methodology. The majority of studies conducted in 
the area have utilized the quantitative strategy because quantitative data are objective 
(Bowling 2005). An exploratory cross - sectional survey design was used. This method was 
chosen as data was collected on a study population at a particular point in time. It was also a 
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descriptive study because the variables of interest were described, (P olit & Beck 2008).  The 
goal of the research was to assess TB infection prevention and control practices among 
healthcare workers. It seeks to solicit views and opinions from respondents regarding the 
implementation strategies/measures and therefore the appropriateness of such a design.  It 
was therefore appropriate to use the explorat ory research design to achieve the objectives of 
the research.  
 
3.2. Research Setting 
The study was carried out at the Tema General Hospital in the Tema Metropolis. The entire 
metropolis has an estimated population of 379, 175 according to population census (Ghana 
Statistical Service, 2010). However, the current study focused on health work ers in the 
following job categories: N urses, Doctors, X- Ray, Laboratory, Pharmacy, and Health 
Assistants/Health Aides. The total population of these health workers stands at 459 
comprising: N urses (n=347), Doctors (n=51), X- Ray (n=2), Laboratory (n=16), Pharmacy 
(n=10) and Ward Assistants /He a lt h Aides (n=33).  
The metropolis lies at the South Eastern part of the Greater Accra region and it is bordered to 
the East by Dangbe East and West Districts, and to the N orth by Ashaiman Municipality and 
to the West, t he Greater Accra Metropolis and the South, the Atlantic Ocean where Ghana’s 
biggest commercial harbour is located. The metropolis has many heavy industrial activities 
such as Tema O il Refiner y (TO R), Volta Aluminum C ompany (VALC O ).  
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Tema General Hospital is the largest public health institution in the Tema metropolis. The 
hospital was constructed in 1954 by J.W Harrow and Sons Limited and was handed over to 
government of Ghana in 1962. It is the major referral point for all clinics, maternity homes 
and other hospitals both public and private in the metropolis. Due to the surrounding road 
network and commercial nature of the metropolis, the hospital is one of the busiest health 
facilities in the metropolis. The catchment area includes the entire Tema metropolis. It has 
satellite towns and villages such as Lashibi, Sakumono, Afenya, Prampram and Dawenya. It 
also serves as a training facility for students from medical school, nursing and other allied 
health institutions. In addition it provides internship for house officers, physician assistants, 
nursing and other newly qualified staff. 
Tema General Hospital (TGH) has a bed capacity of 282, with a staff strength of 784 made 
up of 51 doctors and dentists, 347 nurses, 16 laboratory technical and technologist, 10 
pharmacists, a number of administrators, biostatisticians and other categories of staff. The 
average out- patient attendance daily is estimated a s 468 with an average daily admission of 
55. It has 14 departments and cent res. These are O bstetrics and Gynaeco logy, Surgery, 
Radiology as well as Paediatrics, and Physiotherapy. The others are laboratory, Eye, Ear, 
N ose and Throat clinics, HIV counselling unit and C hest clinic. The mission of the hospital is 
to provide qualit y primary and secondary healthcare, tea ching and outreach services.  
 
 
 
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3.3. Target Population 
The target population is the complete totality of all subjects (P olit & Hungler, 2003). The 
study population involved health workers such as doctors, nurses, laboratory and X - ray 
technologists, and health aides of the Tema General Hospital who have come into contact 
with TB patients at their various wards and units. This population provided a rich a nd broad 
data for analysis. It also helped the researchers to identify which category of health workers 
lack knowledge of TB infection control practices, do not adhere to such practices and also 
challenges per unit or department as a way of assessing the implementation of the TB 
prevention and control strategies in the Hospital.  
 
3.4. Sample Size  
S ample size is the subset of the population under study . The sample size in this study 
constituted health workers from the following categories such as nurses, doctors, health 
assistants/ health aides, laboratory and Pharmacy staff of the hospital. Sample size calculat ion
was used to determine the participants of the study. In addition, the study participants were 
selected based on the set criteria below;  
 S hould have worked in the hospital for more than 6 months at  the time of the study. 
 S hould demonstrate that they we re willi ng to participate
 S hould be 18 years and above 
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This means that, health workers (doctors, nurses, laboratory and X - ray technologists, health 
assistants/health aides and pharmacists/pharmacy technicians) who did not meet the above 
criteria were not allowed to participate in the study.  
 
3.4.1 Sample Size Determination 
 Yamane’s formula (Israel, 2006) was used to determine the sample si]e in this study. 
Determination of sample size was based on the estimated population size (n=459). The 
formula is stated below. 
n  >N » 1N (e) 2 ] 
n – The sample size 
 N - The population size 
e- The desired level of precision or level of acceptable error = 0.05) 
Total sample size (n) = [459/ (1+459 (0.05) 2 ] = [459/ (1 + 459 x .0025)] 
   = [459/1 + 1.148] 
      = [459/2.148] 
   = 214 
   = 214 
Based on the above, the appropriate sample size for the study is 214. However, to deal with 
uncompleted questionnaires and non- return of questionnaires, additional 10% (n=214) 
sample was added. Thus, the expected total sample size was 235. 
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To determine the required sample size for each job category, a constant proportion was 
obtained and used to determine the percentage that was selected from each category. For 
instance, the constant proportion is [235/459= 0.512]. This constant pro portion (0.512) was 
multiplied by the number of persons in each job category to obtain the expected sample size 
for each category. Finally, the sample size for each category was used to obtain the 
percentage of persons that was selected from each category. The table below presents the 
sample size for each of the job categories in the study.  
Table 3.1: Sample Size that was selected from each Job Category  
Job      Tot al           const ant                Sam ple Size          Percent (%) 
C at egories     N um ber      proport ion           Required          f rom each G roup  
N urses   347          0.512                     178          75.7  
Doctors   51            0.512             26           11.1 
X – Ray  2              0.512       1                       0.4 
Laborato ry   16            0.512       8            3.4 
Pharmacy   10            0.512       5            2.1 
Ward Assistants 33            0.512       17           7.2  
             459        235                 100.00 
 
Source: Field Data, 2012  
 
 
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3.5 Sampling Technique 
S imple random sampling technique was used to select 2 35 eligible health care workers for the 
period of data collection. This was to ensure that each participant had a known, non- zero 
chance of being selected, Blair (2009). In this study the participants were in the job categories 
that were already in the strata which made it more representative. During the process of 
sampling,  the names of the participants in each of the strata were written on a piece of paper 
and were put into a box and were shuffled. The names were then picked randomly from the 
box to form the sample in a series of draws. The aim was to ensure that each respondent had 
an equal chance of being selected.  
 
3.6 Data Gathering Tool 
The instrument for data collection was a questionnaire which was developed to collect data 
from the respondents on specific variables.  
 A questionnaire was used to generate information from the study participants to achieve the 
set objectives for the stud y. The questionnaire was designed to elicit the following 
infor mat io n; 
Section A: Demographic data 
Section B: K nowledge about TB infection and control-  K nowledge questions consisted of 13 
multiple choices and seven ‘true’ or false questions on major domains of TB infection 
prevention and control strategies and general knowledge on TB. In all there were ten (10) 
questions on administrative strategies namely questions; 2, 5, 8, 9, 12, 13,15,18,19 and 20. 
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Three (3) questions were on environmental strategies na mely questions; 3,4,17. Three (3) 
questions 6, 10, 11 were on personal protective equipments and four (4) questions were on 
general knowledge on TB namely questions; 1,7,14 and 16. Any correct answer given score d 
one (1) and a wrong answer scored zero ( 0 ).  An average score of 15 or more answered 
questions were knowledgeable and below less knowledgeab le.    
Section C : Practices for preventing TB infection-  Q uestions on the TB prevention and control 
practices were asked using 4 and 5 point Likert scale range.  
Section D: C hallenges in imple me nt i ng TB prevention strategies .  
The questions were both closed and opened - ended. C losed - ended allows participants options 
to choose from whilst the opened - ended generates a lot of ideas or views from the 
participant s.  A copy of questionna ire specifying the broad areas is presented in (Appendix C ).  
 A self administered questionnaire was used to enable participants to answer the 
questionna ires ; this was because of the perceived high literacy among them.  
 
3.7. Data Gathering Procedure  
P ermission to collect data was obtained from the Medical Director of the Tema General 
Hospital via a permission letter from School of N ursing, University of Ghana, Legon. O n the 
field the researcher introduced herself to the ward/unit in charge s and explained the purpose 
of the study before the recruitment of participants. Participants were given information sheet s 
(Appendix A) to read and those who consented to participate were given consent forms 
(Appendix B) to sign before the administration of the questionnaire. The researcher spent 
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approximately four weeks to complete the data collection and this was from (Monday to 
Friday) each week. A maximum of 12 questionnaires were delivered by hand each day to the 
participants when they were less busy from their routine work schedules. The researcher 
continued administering the questionnaires until all the recruited participants were exhausted. 
All the data was collected by the principal investigator. The data collected each day was 
checked and cleaned manually for completeness, clarity and consistency and was entered into 
the data analysis software S tatistical Package for the Social Sciences (S P S S ) version 16 the 
same day to prevent los s of informa t io n.  
 
3.8. Validity and Reliability 
According to Golafashani (2003) validity determines whether the research truly measures that 
which it was intended to measure or how truthful the research results are. In order to ensure 
validity in this study items on the data gathering sheets w ere taken from a standa rdised 
questionnaire that addressed the research questions of the study. The tool was adopted from 
(N akashima, Likpe, Emerson, Miller 2007) who did an assessment on TB infection 
prevention and control in outpatient settings among health care workers and he alth facilities.
The tool had been used in eight clinics in Zambia and many other countries. Joppe (2000) 
defined reliability as the extent to which results are consistent overtime and an accurate 
representation of the total population under study. Reliability was ensured by documenting all 
procedures that were carried out in the development and conducting of the study so that 
future researchers could replicate it. The data collection instrument was pretested at La 
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General Hospital using 20 health care work ers with similar characteristics who have worked  
for more than six months. Based on the findings of the pilot study, some concepts and 
statements were rephrased. The length of the questionnaire was also reduced from 62 to 55 
questions before finalisation. The pretesting helped the researcher to clarify the tool, and to 
ensure research adequacy and freedom from bias, ambiguity and logical flow of the items on 
the sheet. The aim was to enable participants in the study to understand the questions better.  
 
3.9. Ethical Considerations 
An introductory letter for permission to conduct the study was obtained from School of 
N ursing to the Medical Director in charge of Tema General Hospital as well as heads of 
wards/units. Written informed consent was also sought fro m participants prior to 
administration of the questionnaires. Staff ` were ensured of confidentiality of the nature of 
data that was collected, right to withdraw from the study at any time and the fact that refusal 
to participate and withdrawal would not affect the employment status of the hospital. 
Anonymity was assured by not requesting the names of participants but rather the use of 
numbers (codes). General information on the consent form was included such as the purpose 
of the study, objectives, specific expectation regarding participation and potential cost and 
benefits. The participants were assured of their protection and the information received was 
not exposed to others with the exception of the principal investigator and supervisors of the 
study.     
 
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3.10 Data Analysis 
Data analysis is the process of analyzing all the information and evaluating the relevant 
information that can be helpful in better decision making (S ivia & Skilling, 2006).  The 
answered questionnaires retrieved were edited and checke d for inconsistencies. After that 
they were coded and analysed using the SP S S version 16. The statistical tools used for the 
analysis and presentations of the data were frequency tables , charts and where necessary, one 
variable C hi square test was used to determine differences in the frequencies of various 
responses. The P earsons’ correlation coefficient was used to test the correlation between 
variables whilst t test was used to determine significant differences between groups where the 
data was either interva l or ratio.   
 
3.11 Limitations  
Data for this study was gathered with a self report questionnaire which has its own 
weaknesses such as proneness to social desirability and issues of participant dishonesty. An 
observational study would have offered the researcher the opportunity to see and record 
practices of TB infection prevention and control rather than depending on self report by the 
respondents. Further, the study concentrated on health workers in Tema General Hospital. 
C onsequently findings cannot be generalized to health workers in other health facilities in 
Ghana.   
 
 
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CHAPTER FOUR 
FINDINGS 
4.0 Introduction 
The findings of this study are presented in this chapter in the form of tables and graphs. The 
findings are presented under four main subheadings comprising the demographic background 
of participants (health workers), level of knowledge of TB infection pre vention control 
measures, practices for preventing tuberculosis infection and the challenges faced by the 
health workers in their implementation of TB prevention measures. The chapter ends with the 
statistica l interpretat io n of the hypothesis tested.  
 
4.1  DEMOGRAPHIC BACKGROUND OF PARTICIPANTS  
This section presents the socio - demographic characteristics of the respondents. The variables 
that were considered included sex, length of work at Tema General Hospital, current ward/ 
unit of work and job title of p articipant s.  
 
 
 
 
 
 
 
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4.1.1 Sex of Participants 
Gender equality in any study is very important to give a true representation of both male and 
females, therefore both sexes were allowed to take part in this study to give equal 
representation. The study analysis was based on 229 health workers out of 235 because 6 
respondents did not complete the questionnaires appropriately.  Their distribution is presented 
in Table 4.1.  
 
Table 4.1: Sex Distribution of Participants  
Participants (n=229)  
S ex  Frequency  Percent  
Male  55  24  
Female  174  76  
Total 229 100 
  Source: F ield Data, 2012 
 
Results in Table 4.1 shows that a significant proportion of the sample 76 % (n=174) were 
females, whilst 24% (n=55) were males .   
 
 
 
 
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4.1.2 Age Distribution of the Participants 
Age is considered another important socio - demographic variable. It is believed that age 
influences people’s opinions and attitudes about issues, therefore, the age of participants was 
considered in this study. Table 4.2 presents the age distribut io n of the partic ipant s.  
Table 4.2: Age Distribution of Participants 
Participants (n=229)  
Age  Frequency  Percent  
20 - 25  18  7.9  
12.7  
29.2  
36.7  
5.6  
7.9  
26 - 31  
32 - 37  
38 - 43  
44 - 49  
50+  
29  
67  
84  
13  
18  
Total 229 100 
S ource: Field Data, 2012 
The distribution in Table 4.2 indicates that the majority of respondents 37% (n=84) were 
between the ages of 38 - 43, this was followed by 29 % (n=67) participants who were between 
the ages of 32 - 37 13% (n=29) participants were also between the ages of  26 - 3 1, then, 8% 
(n= 18) participants who were between the 20 - 25 and 50+ age brackets respectively, also  6% 
(n=13) were between 44 - 49 age group.  
  
 
 
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4.1.3 Length of Practice in the Hospital 
Another variable that was taken into consideration was participants ’ lengths of stay at the 
hospital, this was considered because an individual’s length of stay in any particular area be it 
work or residence makes the person acquire some level of knowledge or becomes more 
abreast with the terrain of the area and will be ab le to make a meaningful contribution 
concerning the issue when the need arises. Participants reported on how long they have been 
working in the Hospital. Their responses are presented in Table 4.3.  
 
Table 4.3: Work Experience of Participants 
Participants ( n=229)  
Length of Practice  Frequency  Percent  
6 months - 1 year  26  11.4  
2 - 5 years  
6 - 9 years  
10 - 13 years  
14 years and above  
14  
31  
96  
62  
6.1  
13.5  
41.9  
27.1  
Total 229 100 
S ource: Field Data, 2012 
With reference to Table 4.3 a greater proportion of the participants 42% (n=96) had worked 
at the Hospital for 10 - 13 years, this was followed by 27 % (n=62) who had also worked for 
14 years and above, 14% (n=31) ha d  6- 9 years experience, 6% (n=14) had worked for 2- 5 
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years. The least months/years of work experience in the hospital were those who had spent 
between 6 months to one year working in the hospital and that constituted 11% (n=26).  
4.1.4 Current Ward/Unit of work   
The ward/unit o f practice of the participants is an important variable in the study, the 
outcome of this is presented in Table 4.4.  
Table 4.4: Ward/Unit of Practice of Participants 
Participants (n=229)  
Ward/Unit of Practice  Frequency  Percent  
O utpatient department  62  27.1  
21.0  
15.7  
1.7  
7.9  
9.6  
3.9  
3.5  
0.4  
2.2  
7.0  
Male medical ward   
Female medical ward   
C hest clinic  
Fevers unit  
Children’s ward  
HIV/AIDS counselling  unit  
Laboratory unit  
X - ray unit  
Pharmacy unit  
O ther (eye, EN T, AN C )  
48  
36  
4  
18  
22  
9  
8  
1  
5  
16  
Total 229 100 
S ource: Field Data, 2012 
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As presented in Table 4.4, a significant difference exists between the number of participants 
from the various wards/units. The majority of the participants 27% (n= 62) worked at the 
O P D, male medical ward 48(21%), female medical ward 36(15.7%) and C hildre n’s ward 
22(9.6%). Wards/units where the least number of participants were selected from include d  
the X- ray unit 1(0.4%), chest clinic 4(1.7%), pharmacy unit 5(2.2%), laboratory unit 
8(3.5%), HIV/AIDS counselling unit 9(3.9%), other units ( Eye, Ear, N ose and Throat, 
Antenatal C linic ) 16(7.0%) and fevers unit 18(7.9%).  
 
4.1.5 Job Title of Participants 
The current job title of health workers were reported in this study. Results on this are 
presented in Table 4.5.  
Table 4.5: Job Title of Participants 
Participants (n=229)  
Job Title  Frequency  Percent  
Medical doctor   
Professiona l nurse  
Enrolled nurse  
Laboratory technologist  
X - ray technologis t  
Health assistant/he a lt h aide  
Pharmacy technic ia n  
Pharmacist  
24  
129  
45  
8  
1  
17  
3  
2  
10.5  
56.3  
19.7  
3.5  
0.4  
7.4  
1.3  
0.9  
Total 229 100 
S ource: Field Data, 2012  
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Results in Table 4.5 indicate that a significant proportion of participants 56 % (n=129) were 
professional nurses, 20% (n=45) were enrolled nurses, this was followed by 1 0.5 % (n=24) 
who were medical doctors. 7% (n=17) were also health assistants/health aides, 3.5 % (n=8) 
constituted laboratory technologist, 1 .3% (n=3) were pharmacy technicians. The least 
sampled in this study were pharmacist 0.9% (n=2) and x- ray technologist who constituted 
0.4 % (n= 1 ) respectively. This result is an indication that almost all the health workers were 
allowed the opportunity to take part in this survey and that their views and opinions would be 
considered representative.  
 
4.2 LEVEL OF KNOWLEDGE OF TB INFECTION PREVENTION AND CONTROL 
MEASURES 
Participants’ level of knowledge on TB infection prevention and control measure s was also 
assessed and the results obtained on this are presented in Table 4.6.  
Table 4.6: Level of Knowledge of TB Prevention and Control Measures  
Participants (n=229)  
Variable  Min.  Max.  Mean  Std Dev.  df  t  Sig.  
K nowledge  3  20  13.44  2.95     
Total     228  68.944  .000 
S ource: Field Data, 2012 
 
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Results in Table 4.6, revealed that the minimum score of knowledge of TB recorded by the 
participants was out of a maximum score of 20. Mean knowledge of TB score was 13.44 with 
a standard deviation of 2.95. O ne sample t test analysis (and the skewnes s of the data = - .481) 
indicated that participants expressed significantly fair/moderate knowledge of TB prevention 
and control measures [t ( 2 2 8 ) = 68.944, p = .000].  Thus participants’ knowledge of TB 
prevention and control measures was generally fair/moder ate (neither high nor low).   
Demographic variables that influence participants’ knowledge of TB infection pr evention and 
control measures were also determined by correlating demographic variables and knowledge. 
Relevant informat io n on this is presented in Table 4.7  
Table 4.7: Correlation between Demographic Variables and Knowledge of TB Infection 
Prevention and Control Measures 
Participants (n=229)  
Variable  Sex.  Age  Tenure  C urrent Ward  Job title.  
K nowledge  
Sex  
Age  
Tenure  
C urrent Ward  
Job title  
- .131*  
-  
-  
-  
-  
-  
.021  
.196*  
-  
-  
-  
-  
.016  
.167*  
.638*  
-  
-  
-  
- .138*  
.018  
- .020  
- .040  
-  
-  
- .180*  
- .040  
- .151*  
- .113*  
.119*  
-  
      
*significa nt at .05 
Source: Field Data, 2012  
 
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Results in  Table 4.7 shows that sex of the participant significantly correlates or influences [r 
( 2 2 7 ) = - .131, p = .024] the knowledge of TB infection prevention and control measures. 
Female participants’ demonstrated higher knowledge compared to their male counterparts. 
The correlation between participants’ age and knowledge of TB was not significant though 
positive [r ( 2 2 7 ) = .021, p = .427]. The link between number of years of work (tenure) and 
knowledge of TB was also not significant though this is also positive [r ( 2 2 7 ) = .016, p = .405]. 
C urrent ward where the participant works significantly correlates with knowledge of TB [r 
( 2 2 7 ) = - .138, p = .022]. Participants working in O P D, male and female medical wards, chest 
clinic, fevers unit and children’s ward showed higher knowledge of TB as opposed to their 
counterparts in HIV/AIDS counselling unit, laboratory unit, X- ray unit, pharmacy unit and 
other units. Results in Table 4.7 further revealed that the job title of participants significantly 
correlates/influences their knowledge of TB [r ( 2 2 7 ) = - .180, p = .003]. Medical doctors, 
professional and enrolled nurses and laboratory technolo gists demonstrated higher knowledge 
of TB than X- ray technologis ts, health assistants/a ide, pharmacists and pharmacy technicia ns.  
 
 
 
 
 
 
 
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4.2.1 Knowledge of the Mode of Spread of TB  
On participants’ knowledge of how TB is spread, the following result was obtained.  
Table 4.8: Knowledge on Mode of Spread of TB 
Participants (n=229)  
Means of Spread  Frequency  Percent  df  Ȥ2  Sig  
If u n in fe c t e d p e rs o n c o me s  in t o c o n t a c t  
wit h t h e b lo o d o f a p e rs o n c o n t a in in g t h e TB b a c illi  
 
W h e n TB b a c illi d ro p le t s  b e c o me s u s p e n d e d in t h e 
a ir a n d s o me o n e b re a t h s  in t h e TB b a c illi  
 
A p e rs o n in fe c t e d wit h TB c a n s p re a d t h e b a c t e ria 
t h ro u g h p h y s ic a l c o n t a c t  
 
W h e n a n in fe c t e d p e rs o n p re p a re s  fo o d a n d 
in t ro d u c e s  t h e TB g e rms  in t o t h e fo o d  
10  
 
 
189  
 
17  
 
13  
4.4  
 
 
82.5  
 
7.4  
 
5.7  
   
Total         229          100     3  404.694  .000 
S ource: Field Data, 2012 
 
As regards the mode of spread of TB,  a significant majority of participants 83% ( n=189) had 
the idea about the spread of TB bacilli, whilst a substantial proportion of the sample 18% 
(n=40) had incorrect pieces of information regarding the spread of TB [ Ȥ2 ( 3 ) = 404.694, p = 
.000].   
 
 
 
 
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4.2.2 Implementation of Administrative Control Measures by Participants 
P articipants also enumerated administrative control measures for TB infection prevention and 
control that should be implemented by a hospital staff. Relevant information on this is 
presented in Table 4.9.  
Table 4.9: Administrative TB Infection Prevention and Control Measures for Implementation  
Participants (n=229)  
Means of Spread  Frequency  Percent  df  Ȥ2  
 
Sig  
P rompt ide ntific a tion a nd s e pa ra tion of  
c oughing pa tie nts from othe rs (A )  
 
P romoting c ough e tique tte (B)  
 
‘Fast tracking’ patients suspected of  TB 
 infe c tion for prompt dia gnos is a nd  
 tre a tme nt  
 
All the a bove  
 
A a nd B only  
 
20  
 
 
55  
 
17  
 
 
 
125  
 
12  
8. 7  
 
 
24. 0  
 
7. 4  
 
 
 
54. 6  
 
5. 2  
   
Total 229 100 4  247.447  .000 
S ource: Fieldwork Data, 2012 
As regards administrative control measures which constitute the top most priority among 
other measures for the prevention and control of TB spread, more than half of the sample 
55% (n= 125) knew the correct measures to be undertaken as a preparation for TB prevention
and control. A substantial proportion 45% (n=104 ) had no knowledge about strategic 
administr at ive measures.  
 
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4.2.3 The Requirement of an Examination or Treatment Room for TB Patients  
Participants’ knowledge of requirements of TB examination or treatment room was assessed. 
Results on this are presented in Table 4.10.  
Table 4.10: Knowledge on Requirements of TB Examination or Treatment Room 
Participants (n=229)  
Requireme nts  Frequency  Percent  
Air exhaust directly to the outside  
Ventila t io n solely by air conditio n  
Placement of the patients nearest the window or fan exhausting the air    
Adequate ventilat io n                   
40  
141  
16  
32  
17.5  
61.6  
7.0  
13.9  
Total 229 100 
S ource: Field Data, 2012 
 
C oncerning the requirements of an examination or treatment room for TB patients, 
participants demonstrated a good knowledge of the requirement s of TB treatment room. More 
than half 62% (n=141) had correct responses, 38.4% (n=88) had incorrect responses.  
 
4.2.4 An Easy and Low-Cost Way to Reduce Infections of TB 
P articipants were asked to indicate  the easy and low- cost way to reduce the number of 
infect io ns by TB droplets in the air and their responses are presented in Table 4.11.   
 
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Table 4.11: An Easy and Low-Cost Way to Reduce Infections of TB Droplets in the Air   
Participants (n=229)  
Ways  Frequency  Percent  
Use natural ventilation by opening windows and doors and 
maximi zing cross ventilat io n  
 
Provide respirators or N 95 masks to all staff  
 
Install a mechanic a l ventilat io n system   
 
Wash hands with soap and water before and after every patient contact            
169  
 
 
19  
 
25  
 
16  
73.8  
 
 
8.3  
 
10.9  
 
7.0  
Total 229 100 
S ource: Field Data, 2012 
 
Participants ’ knowledge about the easy and low- cost way to reduce the number of infections
TB droplets in the air was sought. A good sizeable proportion 74% (n=169) responding 
appropriately, whilst, 26% (n=60) responded inappropria te ly.
 
4.2.5 Participants Knowledge on Cough Etiquette 
K nowledge on cough etiquette was also assessed and the relevant information on this is 
presented in Table 4.12.  
 
 
 
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Table 4.12: Cough Etiquette 
Participants (n=229)  
C ough Etiquette    
 
When someone says ³excuse me  ´ after coughing in public  
 
Should be required of all patients, but not necessary for health workers  
 
Include covering your mo u t h  and sneezes with handkerchiefs, tissue, 
or upper arm  
 
All the above  
Frequency  
 
25  
 
18  
 
163  
 
 
23  
Percent  
 
10.9  
 
7.9  
 
71.2  
 
 
10.0  
Total  229 100 
S ource: Field Data, 2012 
 
Participants ’ score on their knowledge on cough etiquettes have also been demonstrated with 
the majority 71% (n=163) responding appropriately and a substantial 29% (n=66) had 
incorrect pieces of infor mat io n about cough etiquettes.  
 
4.2.6 Conditions of Particulate Respirators 
P articipants ’ knowledge on the use of particulate respirators or N - 95 are presented in Table 
4.13.  
 
 
 
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Table 4.13 : Participants Knowledge on the use of Particulate Respirators (N-95 or FFP2) 
Participants (n=229)  
Uses of N - 95/F F P 2    
 
Used for all TB patients or persons suspected of TB in the hospital  
 
Worn by staff when conducting a bronchoscopy Procedure or other 
high risk procedure s for  patients with TB, or XDR TB        
 
Required of  all staff when they are infected with any infectious 
disease to prevent transmiss io ns to patients                      
 
Worn by patient s  when sitting outside to prevent TB droplet s  from 
spreading througho ut the town  
Frequency  
 
48  
 
135  
 
 
28  
 
 
18  
Percent  
 
21.2  
 
61.1  
 
 
11.3  
 
 
6.4  
Total 229 100 
S ource: Field Data, 2012 
As depicted in Table 4.13, participants ’ knowledge with regards to the use of particulate 
respirators showed that more than half of participants in TB control  stands at 61% (n=135) 
kne w the appropriate response s, whils t 35%(n=94) gave inappropriate responses.  
   
 
4.2.7 Persons with High Risk of TB Exposure and Infection 
In the area of the kind of persons with high risk of TB exposure and infection, the following
results were obtained.  
 
 
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Table 4.14: Persons with High Risk of TB Exposure and Infection 
Participants (n=229)  
Groups a t Ris k    
 
 
Thos e tha t live in c row de d, poorly ve ntila te d s e tting s  w he re TB is c ommon  
 
P e rs ons  who a re immune c ompromis e d, s uc h a s HIV /A ID S pa tie nts            
 
Thos e w ith me dic a l c onditions s uc h a s re na l f a ilure , c a nc e r, or dia be te s  
                    
All of the a bove  
Fre que nc y  
 
 
55  
 
82  
 
16  
 
76  
P e rc e nt  
 
 
24. 0  
 
35. 8  
 
7. 0  
 
33. 2  
Total 229 100 
S ource: Field Data, 2012 
As regards to  participants ’ knowledge on persons with high risk of TB exposure and 
infection, a substantial proportion 33% (n=76) had the right information and reported all the 
major people at risk. The majority 67% (n=153) rather indicated specific groups of people at 
risk instead of combining them.  
 
 
 
 
 
 
 
 
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4.2.8 The Most Effective Intervention for TB Control 
P articipants also reported the most effective intervention for TB control and the results on 
this are presented in Table 4.15.  
 
Table 4.15: Effective Intervention for TB Control 
Participants (n=229)  
Effect ive Intervent io n     
 
BC G re - vaccinatio n (A)  
 
C hemoprophyla xis (B)       
 
Early detection of TB patients (C )  
                    
Appropriate treatment of TB patients (D)  
 
Both C and D  
Frequency  
 
30  
 
15  
 
29  
 
17  
 
138  
Percent  
 
13.1  
 
6.5  
 
12.7  
 
7.4  
 
60.3  
Total  229  100  
Source: Field Data, 2012 
In the area of effective intervention for TB control,  more than half 60% ( n=138) had 
appropriate responses. The rest 40% (n=91) however, had incorrect responses.  
 
 
 
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4.2.9 Administrative Control Measures in Ghana  
P articipants were asked to indicate the administrative control measures in Ghana that prevent 
TB transmiss io n. The outcome is presented in Table 4.16.  
Table 4.16: Administrative Control Measures in Ghana 
Participants (n=229)  
Effe c tive Inte rve ntion     
 
P rompt ly  ide ntifying infe c tious c a s e s (A )  
 
Ma nda tory qua ra ntine of sus pe c te d c a s e s  (B)       
 
Se pa ra tion of c oughe rs (C)  
                    
Se tting up quic k turna round time s a t he a lth c a re s e ttings for 
TB c a s e s (D )  
 
Enga ging c ivil s oc ie ty (E)  
 
All of the a bove  
 
A,B,C,E  
 
A,C,D  
Fre que nc y  
 
21  
 
11  
 
13  
 
9  
 
29  
 
80  
 
34  
 
32  
P e rc e nt  
 
9. 2  
 
4. 8  
 
5. 7  
 
3. 9  
 
12. 7  
 
34. 9  
 
14. 8  
 
14. 3  
Total 229 100 
S ource: Field Data, 2012 
 Responses on administrative control measures in Ghana to prevent TB transmission among 
health care workers in Ghana showed that a small proportion 14% (n= 32) had their 
information correct. A high proportion of 86% (n=86) had divergent information which w ere 
incorrect.  
 
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4.2.10 Who Uses Surgical Masks in TB Transmission Environment 
Participants’ knowledge on who uses surgical mask s in an environment where TB 
transmiss io n is a risk is depicted in Table 4.17.  
Table 4.17: Participants ¶ KQRZOHGJH on Who uses Surgical Mas k in TB Transmission 
Environment 
Participants (n=229)  
Who Uses Surgica l Mask  Frequency  Percent  
Doctors   
N urses  
C oughing patient  
Visitors  
Adminis trato rs  
All of the above  
16  
20  
27  
11  
27  
128  
7.0  
8.7  
11.8  
4.8  
11.8  
55.9  
Total  229  100  
Source: Field Data, 2012 
 Participants’ knowledge on personnel who use surgical mask s in TB transmission 
environment revealed that a small proportion 12% (n= 27) reported the right personnel. A 
high proportion 88% (n=202) cited inappropriate personnel. This fact attests that the majority 
of health workers sampled in this survey could not have done the right thing if they were 
asked to advise people on the use of masks.  
 
 
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4.2.11 The Class of Respirator Acceptable for the Health Care Worker in a Smear ± 
Positive Settings 
Participants were also required to indicate the class of respirator s that were acceptable for the 
health care workers working in  settings with smear-  positive patients and the information on 
this is presented in Table 4.18.  
 
Table 4.18: Class of Respirators for Participants in Smear Positive Setting 
Participants (n=229)  
Re s pira tor      
FFP 1  
FFP 2/N - 95  
FFP 3  
FFP 4  
Fre que nc y  
7  
198  
10  
14  
P e rc e nt  
3. 1  
86. 5  
4. 3  
6. 1  
Total 229 100 
S ource: Fieldwork, 2012 
 
A significant proportion of participants,  87% (n=198) demonstrated that they were 
knowledgeable about the class of respirators for health care workers in smear positive 
settings. The rest of the respondents 13 % (n=31) did not know the appropriate respirato r.  
  
 
 
 
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4.2.12 Interventions Used by Health Facility Designs to Prevent TB Infection 
P articipants were required to indicate intervention health facilities design to prevent TB 
infect io n. This is presented in Table 4.19.  
 
Table 4.19: Interventions for Health Facilities Design to Prevent TB Infection 
Participants (n=229)  
Intervent io n      
 
The least costly way to improve ventila t io n  
 
Providing as many rooms as possible to place patients  
 
Improving ventilation, reducing overcrowding and 
providing   pati ents and staff with a safe environme nt  
 
Removing as many windows as to reduce cost  
Frequency  
 
24  
 
24  
 
174  
 
 
7  
Percent  
 
10.5  
 
10.5  
 
75.9  
 
 
3.1  
Total 229 100 
S ource: Fieldwork, 2012 
Approximately 76% (n=174) of participants had correct information about health facility 
designs to prevent TB infection in their hospital, whilst 24% (n= 55) had poor knowledge 
about TB facilit y design. 
 
  
 
 
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4.2.13 Recommended Strategies to Address TB Transmission.  
S ome of the recommended strategies to address TB transmission in health care facilities as 
reported by participants are presented in Table 4.20.  
 
Table 4.20: Participants Recommend ed Strategies to Address TB Transmission in Health Care 
Facilities 
Participants (n=229)  
Recommended Str ategies       
 
Improving natural ventilat io n (A)  
 
Preventing overcrowding in waiting areas and 
hallwa ys (B)  
Having patients show proof of BC G vaccinatio n (C )  
 
All of the above  
 
A and B only  
Frequency  
 
12  
 
25  
 
17  
 
47  
 
128  
Percent  
 
5.2  
 
10.9  
 
7.5  
 
20.5  
 
55.9  
Total  229  100  
Source: Fieldwork, 2012 
In search of the recommended strategies to address TB transmission in health care facilities,
about half of the participants 56 %( n=128) recommended improving natural ventilation and 
preventing overcrowding in waiting areas and hall ways. The rest 44% (n=101) indicated 
other strategies which we re not appropriate.  
 
 
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Participant s ’ Responses to ‘True or False ’ Sentences 
The survey further sought participants’ knowledge about TB infection prevention and control 
measures, using ‘true or false ’ responses to questions.   
 
4.2.14 Healthcare Workers ¶ Opinion on TB as the Leading Cause of Death in People 
with HIV/AIDS 
P articipants were asked to indicate whether TB is the leading cause of death in people with 
HIV/AIDS and the results on this are depicted in Figure 4.2. 
 
Figure 4.2: Participants ¶ Knowledge on TB as the Leading Cause of Death in People 
with HIV/AIDS 
 
Source: Field Data, 2012 
 
Figure 4.2 shows that 88 % of participants reported appropriately that TB is the lea ding cause 
of death in peo ple with HIV/AIDS . However, 12 % had their responses incorrect.  
 
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4.2.15 Health Care Workers ¶ Opinion on the fact that the Greatest Risk for TB Spread 
in a Health Care Setting is by Non Recognition and Treatment of Coughing Patients  
P articipants were o indicate whether if it was true or false that the greatest risk for TB spread 
in health care setting is by coughing patients who have not been recognized as having TB and  
hence are not receiving treatment. The ir  responses are presented in Table 4. 2 1.  
Table 4.21: Participants ¶ RHVSRQVHV Dbout the Greatest Risk for TB Spread in a Health 
Care Setting 
Participants (n=229)  
Response     
 
True  
 
False  
Frequency  
 
202  
 
27  
Percent  
 
88.2  
 
11.8  
Total 229 100 
S ource: Field Data 2012 
 A significant proportion of 88% (n=202) had correct knowledge compared to those with 
incorrect knowledge who constituted 12% (n=27) of participants.  
 
  
 
 
 
 
 
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4.2.16 Participants ¶ Opinion about Their Control of TB Transmission 
Participant’s perception their ability to prevent TB transmission in clinics and hospitals was 
assessed and their responses are presented in Table 4.22.  
Table 4.22: Participants Perception of their Ability to Prevent TB 
Participants (n=229)  
Response     
 
True  
 
False  
Frequency  
 
50  
 
179  
Percent  
 
21.8  
 
78.2  
Total 229 100 
S ource Field Data 2012 
Most participants disagree d  with the assertion that health workers can do little to prevent TB 
transmission in hospitals and clinics. Those who disagree d  constituted 78% (n= 179), whilst 
only 22% (n=50) agreed .  
 
 
 
 
 
 
 
 
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4.2.17 Areas with Minimal Ventilation should be used for Sputum Collection 
P articipants were also assessed on their opinion on the claim that areas with minimal 
ventilation should be used for sputum collection because they safely contain the TB droplets. 
Relevant informat io n on this is presented in Table 4.23.  
Table: 4.23 Participants ¶ Opinion on Use of Small Areas with Minimal Ventilation for 
Sputum Collection 
Participants (n=229)  
Response     
 
True  
 
False  
Frequency  
 
75  
 
154  
Percent  
 
32.8  
 
67.2  
Total 229 100 
S ource field work 2012 
 
About 67% (n=154) correctly reject ed  the idea that small area s with minimal ventilation 
should be used for sputum collection because they safely contain TB droplets. O nly 33% 
(n=75) accepted the idea as correct.   
 
 
 
 
 
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4.2.18. The Value of the Infection Control Person 
P articipants were asked about the valuable contributions that the infection control person 
provides to his /her facility and patients . Q uestions concerning leadership, adherence to 
transmission pre vention efforts and develop ment of policies and procedures that result in 
minimizing or eliminating transmission of pathogens to patients and staff were highlighted .
Their responses are shown in Table 4.24.  
Table 4.24. Participants ¶ View on the Value of the Infection Control Person  
Participants (n=229)  
Response     
 
True  
 
False  
Frequency  
 
214  
 
15  
Percent  
 
93.4  
 
6.6  
Total 229 100 
       Source: F ield Data, 2012 
A significant proportion of participants ,  93% (214) noted that the infection control person can 
provide leadership and other policies that minimize TB transmission. However, 7% (n=15) 
thought otherwise.  
 
 
 
 
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4.2.19 Participants ¶ Confirmation of Ministry of Health Recommendation of Screening 
of TB among People Living with HIV 
Participants’ awareness about the Ministry of Health’s recommendation on screening of TB 
among people living with HIV at the time of enrolment and at each encounter thereafter was 
also measured and their responses are indicated in Table 4.25.  
 
TDEOH . 3DUWLFLSDQW¶V CRQILUPDWLRQ RI MLQLVWU\ RI HHDOWK RHFRPPHQGDWLRQ IRU TB  
Screening 
P articipant s (n=229)  
Response     
 
True  
 
False  
Frequency  
 
198  
 
31  
Percent  
 
86.5  
 
13.5  
Total 229 100 
      Source field Data, 2012 
Regard ing the Ministry of Health ’s recommendation of TB screening, 87% of the sample (n= 
198) admitted , whilst 14% (n= 31) did not.   
 
 
 
 
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4.2.20 Managerial Control Measures for TB Infection 
P articipants ’ views on the assertion that managerial control measures for TB infection control 
included instituting screening of health care workers on TB was also assessed. Relevant 
infor mat io n on this is indicated in Table 4.26.   
Table 4.26: Participants ¶ Views on Managerial Control for TB Infection 
Participants (n=229)  
Response     
 
True  
 
False  
Frequency  
 
176  
 
53  
Percent  
 
76.9  
 
23.1  
Total 229 100 
      Source Field Data, 2012 
 Most participants admitted that one of the managerial control measures for TB control is by 
screening health care worker s. Those who admitted this constituted 77% (n=176) of the 
sample. The rest,  23% (n=53) however, disagree d with this statement.  
 
 
 
 
 
 
 
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4.3 .0 PRACTICES OF PREVENTING TUBERCULOSIS INFECTION 
This section looks at participants view on TB infection prevention and control through 
experience, professional education, in service training/short course s and mentor/preceptor 
relationships. The study sought to find out the extent to which participants value these types 
of preparation. Their responses are presented in Table 4:27.  
Table 4.27: Participants ¶ View on Factors Influencing Practices of TB Infection 
Prevention and Control 
Participants (n=229)  
F actor  Extremely 
Valuable  
Very 
Valuable  
Moderately 
Valuable  
Somewhat 
Valuable  
N ot 
Valuable  
N ot 
Applicable  
Experience  
 
Professional 
Education  
 
In - service 
training/short 
course  
M entorship  
87  
 
111  
 
 
100  
 
 
88  
79  
 
64  
 
 
39  
 
 
45  
41  
 
33  
 
 
34  
 
 
35  
16  
 
11  
 
 
21  
 
 
23  
6  
 
8  
 
 
33  
 
 
37  
0  
 
2  
 
 
2  
 
 
1  
Total       
S ource: Field Data, 2012 
With reference to Table 4.27, a significant proportion of participants reported that 
professional education (111 ) and experiences (87) were extremely valuable followed by in-
service training (1 00 ) and mentorship (88 ) respectively.  
 
 
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4.3.1 Attendance at TB Infection Prevention Training during the Last 3 Years  
P articipants were asked to state whether they had attended any TB infection prevention and 
control training programmes in the past three years.  
Figure 4.3: Distribution for Training Attendance 
84%
16%
Yes
No
 
Source: Field Data, 2012 
Participants ’ attendance at any TB infection prevention training programme in the past three 
years showed a significant proportion,  84% had attended such programmes; only 16% had 
not attend ed  such programmes in the past three years.   
 
4.3.2 Usefulness of TB Infection Prevention and Control Training Programme 
A sizeable number (211) of participants attended training program me s on TB infection 
prevention and control. They were require d to indicate the usefulness of such programmes 
and findings showed that 62% (n=131) reported the programme they attended was extremely
useful. Approximately less than half 38% (n=82) had divergent views that the programme 
was very, moderately, somewhat and not useful. It must, however, be noted that the above 
distribut io n is for only those who attended the training programme.  
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4.3.3 Comments on Strengths and Weaknesses of TB Infection Control Training 
Programmes 
The strengths and weaknesses of the TB infection control training programme s were also 
assessed; participants were therefore asked to mention the strengths and weaknesses of the 
programmes they had  attended . The follow ing are their views and opinions.
(a)  S trengths of the training programme s attended: 
 The training helped the health workers to know the need to encourage patients to 
complete their TB treatments.
 It has helped the health worker s to be more informed as to how best they can protect 
themselves from being infected with TB.  
 Health workers were able to learn new things e.g. giving treatments to clients at no 
cost, overlooking of defaulter s .  
 The programme has helped the health worker in managing TB patients, their families,
as  well as the environme nt.
(b)  Weaknesses of the training programme s attended: 
 The programme did not deal effective l y with the issue of stigmat isat io n of TB.  
 Lack of financ ia l resources to organise a well public ised and resourced training
programme, apparent lack of interest by hospital directors/super inte nde nt s and 
administr ator s in issues related to TB. 
 The programme was time constrained 
 
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Participants’ practice of TB infection prevention and control and factors that influence this 
was also assessed. Results on practices are presented in Table 4.30.  
Table 4.28 : Level of TB Infection Prevention and Control Practices 
Participants (n=229)  
Variable  Min.  Max.  Mean  Std Dev.  df  T  Sig.  
Practice    20  95  59.58  10.13     
Total     228  88.958  .000 
S ource: Field Data, 2012 
Results in Table 4. 28 , revealed that participants’ TB infection prevention and control 
practices were significantly good [t ( 2 2 8 ) = 88.958, p = .000]. This is because they recorded 
mean score of practice of 59.58 out a total maximum score of 95 on the various practices. 
Findings further showed that some demographic factors influence the practices. Relevant 
infor mat io n on this is presented in Table 4. 29 .   
 
 
 
 
 
 
 
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Table 4.29 . Correlation between Demographic Variables and Practices on TB Infection 
Prevention and Control 
Participants (n=229)  
Variable  Sex.  Age  Tenure  C urrent Ward  Job title.  
Practice  
Sex  
Age  
Tenure  
C urrent Ward  
Job title  
- .007  
-  
-  
-  
-  
-  
.109*  
.191*  
-  
-  
-  
-  
.029  
.163*  
.548*  
-  
-  
-  
- .118*  
.016  
- .026  
- .040  
-  
-  
- .203*  
- .048  
- .157*  
- .123*  
.125*  
-  
      
*Significa nt at 0.05 
Source: Field Data, 2012  
 
Results in Table 4.29, revealed that sex had no significant influence on TB infection 
prevention and control practices [r ( 2 2 7 ) = - .007, p = .456]. Thus male and female health 
workers exhibited similar practices regarding TB infection prevention and control. Age 
however, had a significant positive correlation with practice [r ( 2 2 7 ) = .109, p = .050]. Thus 
older health workers were engaged in better practices towards TB infection prevention and 
control. N umber of years of work did not correlate significantly with practice however, 
current ward of work and job title correlate significa nt ly and negative l y with practice.  
 
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4.3.4 Practices of Prevention and Control of TB  
P articipants were asked to indicate how often the following statements applied to them and 
the outcome is presented in Table 4. 30 .  
Table 4.30  TB Prevention Practices 
Participants (n=229)  
Sta te me nt  N  Me a n  Std Error  Std D e via tion  
I e d u c a t e s u s p e c t e d TB p a t ie n t s  t o wa s h t h e ir 
h a n d s  
229  4.45  .04564  .69069  
I p ra c t ic e h a n d h y g ie n e a n y t ime I c o me in t o 
c o n t a c t wit h p a t ie n t s  re s p ira t o ry s e c re t io n s  
229  
 
4.43  .04251  .64322  
I u s e in fo rma t io n , e d u c a t io n a n d 
c o mmu n ic a t io n ma t e ria ls  s u c h a s  p o s t e rs  t o 
e d u c a t e a n d p a t ie n t s  a wa re n e s s  o n TB  
229  4.43  .04295  .65001  
I s e p a ra t e o r fa s t t ra c k p a t ie n t s  wh o a re 
id e n t ifie d a s  TB s u s p e c t s  fro m o t h e r p a t ie n t s  
229  4.42  .03912  .59203  
I e d u c a t e c o u g h in g p a t ie n t s  t o a p p ly c o u g h 
e t iq u e t t e (c o v e r mo u t h , n o s e wit h ma s k)  
229  4.35  .05078  .76845  
I we a r N95/ FFP2 ma s k wh e n wo rkin g in 
h ig h ris k TB a re a s  
229  1.82  .03740  .56589  
I o ffe re d s u rg ic a l ma s k t o TB s u s p e c t s  o r 
c a s e s  wh e n t h e y we re in t h e h o s p it a l  
229  1.74  .05015  .75889  
In t h e wa rd s  I s e p a ra t e o r g ro u p s u s p e c t e d o r 
c o n firme d TB p a t ie n t s  fro m o t h e r p a t ie n t s  
229  1.55  .06644  1.00537  
In my wo rkp la c e I h a v e a c c e s s  t o re s o u rc e s  
t o p re v e n t TB in fe c t io n s u c h a s  h a n d h y g ie n e 
it e ms , s u rg ic a l ma s k a n d N95  
229  1.49  .03589  .54306  
Total       
S ource: Field Data, 2012  
 
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Though practices of TB infection prevention and control were good, a few specific practices 
were not regularly used. Results in Table 4. 30  revealed that wearing of N - 95/F F P 2 when 
working in high risk TB areas, offering surgical ma sk to TB patients, separating suspected or 
confirmed TB patients from other patients, and having access to resources to prevent TB 
infection were not part of the practices of the health workers on regular basis.  However, the 
participants reported that they often undertook the following practices; educate d suspected 
TB patients, practised  hand hygiene, use d  information materials, separate d  TB patients from 
other patients and educate d coughing patients. These assertions were reported with mean 
scores of 4.45, 4.43, 4.3, 4.42 and 4.35 respectively.  
 
 
4.3.5 Practices of TB Prevention and Control 
P articipants were also required to indicate their agreement or disagreement with certain 
assertions regarding practices of TB infection prevention and control. Results on this are 
presented in Table 4. 31 .  
 
 
 
 
 
 
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Table 4.31 : Practices of TB Prevention 
Participants (n=229)  
S tatement  n  Mean  Std Error  Std Deviatio n  
     
Pa t ie n t s  v is u a l a le rt s  s u c h a s  p o s t e rs  a d v is in g 
p a t ie n t t o in fo rm s t a ff if t h e y  h a v e re s p ira t o ry 
s y s t e ms  
229  4.476  .04655  .70437  
M y kn o wle d g e o f TB a n d h o w t o p re v e n t it s  
t ra n s mis s io n t o s t a ff a n d p a t ie n t s  is  a d e q u a t e fo r 
my c u rre n t le v e l o f p ra c t ic e  
229  4.427  .04289  .64909  
It is  imp o rt a n t t o min imize t h e t ime TB s u s p e c t s  
s p e n d a ro u n d o t h e r p a t ie n t s  in t h e o u t p a t ie n t 
d e p a rt me n t  
229  4.37  .04783  
 
 
.72381  
 
 
Th e win d o ws  in my fa c ilit y a re o p e n e d fo r 
ma ximu m  c ro s s  v e n t ila t io n  
229  4.21  .04879  .7321  
Pro p e llin g fa n s  e xa mp le (c e ilin g fa n s ) a n d a ir -  
c o n d it io n e rs  a re mo s t o ft e n u s e d in my fa c ilit y 
t h a n n a t u ra l c ro s s  v e n t ila t io n  
229  3.00  .00875  .13245  
Sp u t u m mic ro s c o p y is  d o n e in d e s ig n a t e d a re a 
ra t h e r t h a n in t h e ma in la b o ra t o ry  
229  3.00  .01751  .26491  
Ce ilin g fa n s  a re fu n c t io n in g c le a n e d a n d  in g o o d 
c o n d it io n a ll t h e t ime  
229  1.73  .03884  .58771  
Th e re fe re n c e ma t e ria ls  s u p p lie d in my fa c ilit y is  
a d e q u a t e t o ma in t a in my c o mp e t e n c e wit h 
re g a rd s  t o t h e a p p lic a t io n s  o f TB in fe c t io n c o n t ro l  
229  1.62  .04542  .68730  
In my wo rkp la c e , t h e d o o rs  a re o p e n e d d a ily fo r 
ma ximu m c ro s s  v e n t ila t io n  
229  1.46  .04692  .71000  
Pa t ie n t s  wit h a c t iv e TB a re mo s t o ft e n n o t 
a d mit t e d t o t h e s a me wa rd wit h o t h e r p a t ie n t s  
229  1.27  .03336  .50486  
       
S ource: Field Data, 2012 
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 Mean score of 3 and above implied that participants agree it is a good practice and vice 
versa.  The results in Table 4. 29 indicate that, the following are the good practices adopted in 
the health facility; the use of patient visual alerts like posters, ensured that the health workers 
ha d  adequate knowledge in TB prevention to staff and patient, minimizing the time that TB 
suspects spent with patients in the outpatient department and opening windows for maximum
cross ventilation. This was reported with mean scores of 4.47, 4.42, 4.37 and 4.21 
re spectively. The respondents were neutral to the following practices; the use of fans and air 
conditioners instead of natural ventilation and doing sputum microscopy in a designated area 
rather than in the main laboratory. These were reported with a mean sc ore of 3 for both of the 
practices. Also the following bad practices were reported; ceiling fans not being cleaned, the 
inadequate supply of reference material in the facilities with regards to the applications of TB 
infection control, doors not being regularly opened for maximum cross ventilation and lastly 
patients with active TB most often admitted to the same ward with other patients. These bad 
practices were reported with mean scores of 1.73, 1.62, 1.46 and 1.27.  
 
 
 
 
 
 
 
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The correlation between knowledge and practice of TB infection prevention and control was 
also assessed. The results on this are presented in Table 4.32  
Table 4.32: Correlation between Knowledge and Practice of TB Infection Prevention 
and    Control  
Participants (n=229)  
Variabl es  M  
 
SD  d f  r  Sig  
K nowledge  13.44  2.95     
Practice  59.58  10.13     
Total    227  .147  .013 
S ource: Field Data, 2012  
 
 Results in Table 4.32, revealed that a significant positive correlation exist s between 
knowledge of TB infection prevention and control and practice of TB infection prevention 
and control [r  ( 2 2 7 ) = .147, p = .013]. This implies that participants with higher knowledge on 
TB infection prevention and control engaged in better practice s of TB infection prevention 
and control. 
 
 
  
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4.4 Challenges to the Implementation of TB Infection Prevention and Control 
Strategies .  
This section looks at some of the challenges participants encounter in their implementation of            
TB infect io n pre ventio n and control. These challe nges are listed as follows :  
 Table 4.33 Challenges Encountered by Participants 
Participants (n=229)  
Ch a lle n g e s        
In a d e q u a t e e d u c a t io n / t ra in in g p ro g ra mme s  fo r h e a lt h wo rke rs  
a b o u t TB in fe c t io n , p re v e n t io n a n d c o n t ro l.  
Ov e rc ro wd in g a t t h e OPD le a d in g t o imp ro p e r v e n t ila t io n  
La c k o f p ro t e c t iv e e q u ip me n t . e .g ., FFP2 o r N - 95 ma s ks , g lo v e s  
No TB wa rd s  fo r in fe c t e d p a t ie n t s , h e n c e t h e y mix u p wit h o t h e r 
p a t ie n t s . Th is  in c re a s e s  t h e ra t e o f in fe c t io n  
La c k o f s u p e rv is io n fro m t h e s u p e rio rs  t o e n a b le s mo o t h ru n n in g o f 
t h e fa c ilit y c o u p le d  wit h t o o mu c h wo rklo a d o n s t a ff  
La c k o f me a n s  o f t ra n s p o rt fo r fo llo w u p o n TB p a t ie n t s  re c e iv in g 
t re a t me n t s  
St ig ma t is a t io n fro m s t a ff me mb e rs  o f s t a ff wo rkin g o n TB p a t ie n t s  
Po o r re s o u rc e d la b fo r TB t e s t in g , a p p a re n t o v e r c e n t ra lis a t io n o f 
TB c o n t ro l p ro g ra mme s , h u ma n a n d ma t e ria l re s o u rc e d is t rib u t io n , 
a c t iv e s t a ff n o t re s o u rc e d t o wo rk   
 
Fre q u e n c y  
45  
 
25  
55  
35  
 
24  
 
10  
 
11  
 
24  
Pe rc e n t  
19.5  
 
10.9  
24.0  
15.3  
 
10.4  
 
4.4  
 
4.8  
 
10.5  
Total 229 100 
S ource: Field Data, 2012 
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The challenges encountered by participants in their practice of TB infection prevention and 
control in Table 4.33 shows that approximately 24 % (n=50) reported about the inability of 
the hospital to provide protective equipment e.g. FF P 2 or N - 95 masks and gloves for heath 
workers. More than half 78% (n=174) mentioned other challenges that confront them in the 
hospital.  
 
4.4.1 Participants ¶ Suggestions to Mitigate Challenges in the Implementation of 
Tuberculosis Infection Prevention Control in the Hospital 
In the light of the prevailing challenges being faced by participants in the various areas at the 
Hospital, the follow ing suggest io ns we re made to address the problems :  
 S eparate wards to be provide d for TB infected patients from other patients. 
 In - service training for both old and new staff should be organized frequently to enable 
health workers to become more abreast with preventive strategies.  
 Improve ventilation and reduce overcrowding and provid e patients and staff with a 
safe environme nt.
 More protective equipment must be provided to health care workers  
 
 
 
 
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CHAPTER FIVE 
DISCUSSION 
5.0 Introduction 
This study was conducted to investigate the knowledge and practices of health care workers 
in the implementation of TB infection prevention and control in the Tema General Hospital. 
The study collected information on four main sections comprising the demographic 
characteristics of health care workers, knowledge of health workers concerning TB infection
prevention control measures, practices for preventing tuberculosis infection and the 
challenges faced by these workers in their implementation of the prevent ion and control 
programme.  
The chapter ends with the implication of the findings of the study to the N ursing profession 
and recommendations of the study. Data was obtained from two hundred and twenty nine 
(229) health workers who met the inclus io n criteria and consented to participate in this study.   
The findings are discussed in relation to previous literature using the three specific  objectives 
of the study which we re to: 
 Assess the knowledge of participants on tuberculosis infection prevention and cont rol 
(IP C ) in Tema General Hospital. 
 Describe the practices employed by participants for the prevention of TB infection in 
Tema General Hospital. 
 Identify challenges encountered by participants in implementation of the TB - IP C 
strategies in Tema General Hospital.  
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5.1 Demographic Information of Health Workers 
The study sampled more females 76.0% compared to males. This is to be expected and 
characteristics of nurses. N urses form close to 65% of the overall population of most 
hospitals and about 90% of all nurses are females. This may have accounted for the higher 
proportion of nurses in this study. The highest age group sampled was those in the 38 - 43 age 
brack ets accounting for 36.7%. This shows that participants in this study we re relatively 
young.  
O n number of years of work, almost half 41.9% have worked for 10 - 13 years. The 
distribution of the various wards/and units of participants were reported in this st udy. They 
were distributed across various wards and units. However, the majority 27.1% had worked in 
the outpatient s’ department (O .P .D).  
The current job titles of health care workers were also investigated in this study. The 
distributions indicated that an average proportion of professional nurses 56% were the highest 
sampled in the study. There were quite a few doctors 10% who could help in the 
implementation of the prevention and control of TB in this study. In spite of the fact that 
doctors do not have ample time to educate patients on certain aspects of prevention and 
control, they do so anytime the y had the opportunit y. 
Synthesizing the demographic background of the participants, the researcher is of the view 
that the sample consisted of relatively yo ung health workers who ha d  worked for an 
appreciable number of years with the required experience to share regarding TB infection 
prevention and control. Further more, most of them were professionals and enrolled female 
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nurses working at the O P D which also showed that they had  had the opportunity to have 
contact with most patients thereby enabling them to contribute immensely to the current 
study. The rich demographic background was also correlated with the major issues of the 
study (knowledge and practice) in order to determine whether they play a role or ha ve  an 
influe nc e.     
 
5.2 Knowledge about TB Infection and Control Measures 
This study investigated the knowledge level of respondents in relation to the prevention and 
control of TB. The knowledge of an individual has direct impact on his ability to practice 
what he knows. The domains used to investigate the knowledge of participants were 
administrative strategies, environmental strategies, use of personal protective equipment and 
general knowledge on TB. Findings revealed that general knowledge was fairly/moderately 
good since participants scored a mean score of 13.44 out of a maximum knowledge score of 
20. The majority of the respondents in this study,  72% were somehow knowledgeable in TB 
infect io n control measures.  
The moderate knowledge of TB infection prevention and control as a finding of the current 
study supports the findings of Q udeimat, Farrar and O wais (2006) at the Jordanian University
Teaching C entre whose data revealed that nurses and health workers were knowledgeable 
about TB infection control. It also supports the findings of Aarti, et. al (2001) who in a study 
involving nurses in Super Specialty Teaching Institute in India, found that, the majority of 
nurses (73.1%) ha d  adequate knowledge o f TB infect io n control measures. 
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The consistency between the findings of the current study and that of Q udeimat, et.al (2006) 
and Aarti, et. al (2001) could be accounted for by a number of reasons. For instance, TB is 
one of the leading causes of death amo ng HIV/AIDS patients and AIDS is a major problem 
for the world irrespective of country and continent. It is therefore logical that there is a 
similarity in the knowledge level of health workers in Jordan and Ghana on TB infection 
prevention and control. 
Th e findings were however, divergent from the findings of Eastwood (2002) who observed 
that healthcare workers in Gambia have limited knowledge about signs and symptoms of TB. 
It also differs from the findings of Dimitrova, et. al (2006) who reported that ge neral 
knowledge of TB infection prevention and control was low. The divergent findings 
demonstrate the need for additional investigation into healthcare workers ’ knowledge of not 
only signs and symptoms of TB but general knowledge of TB and its infection p revention 
and control. This is because though findings of the current study revealed that general 
knowledge was fairly good, 45% of the participants were not knowledgeable in the action 
used in adminis tra t ive control measures in Ghana.  
 
Some demographic variables of participants had significant influence on knowledge of TB 
infection prevention and control. Sex of the participants significantly influence d  the 
knowledge of the health worker resulting in female workers demonstrating higher knowledge 
of TB infection prevention and control compared to their male counterparts. This observation 
is as a result of the fact that nurses are mostly responsible for health talks at the O .P .D and 
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are often seen giving health talks on prevention and control of most conditions. Therefore the 
high proportion of female nurses in this study may have contributed to the higher level of 
knowledge on TB prevention and control by the female nurses than their male counterparts.  
C urrent ward/unit of work also correlated significantly with knowledge of TB infection 
prevention and control. Health workers working in O P D, Male and Female medical wards, 
Chest clinic, Fevers unit and Children’s ward showed higher knowledge of TB as opposed to 
their counterparts in HIV/AIDS counseling unit, laboratory unit, X- ray unit, pharmacy unit 
and other units. Demonstration of more knowledge by nurses at the O P D than any other 
ward/unit may be due to the fact that often, the first point of contact of patients to health 
workers where most of the education programmes are held is at the O P D. N urses at the O .P .D 
are required to impact knowledge on prevention and control measures each day before clinic 
starts. N urses in the O .P D are therefore knowledgeable in most areas of prevention and 
control programmes. This is evident in the findings of the current study.  
 
It was also observed that job title/category significantly influence d  the knowledge on TB 
infection prevention and control. Medical doctors, professional and enrolled nurses and 
laboratory technologists demonstrated higher knowledge of TB than X- ray technologists, 
health assistants/aide, pharmacists and pharmacy technicians. This observation is in line with 
the findings of Dimitrova, et. al (2006) who found a significant knowledge difference by job 
category. Physicians scored significantly higher than nurses, laboratory staff and support 
staff. N urses and laboratory staff on the other hand scored significantly higher than support 
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staff. This also supports the findings of Aarti, Swapna and Shakti (2001) that nurses with 
higher professional qualification were found to have more knowledge of infection control 
measures than those with lesse r professiona l qualifica t io n. 
 
N u mber of years of work correlated positively with knowledge of TB infection prevention 
and control however, this was not significant. This observation supports the findings of Aarti, 
et. al (2001) who found that the number of years as a nurse (i.e. experience) was not 
associated significa ntly with level of knowledge of infection control measures. Specifically, 
nurses with over 10 years ’ experience demonstrated low knowledge of infection control 
measures than newly recruited nurses.  
 
The age of the health worker had no significant influence on knowledge though the 
correlation was positive (older workers demonstrating higher knowledge). Unlike the 
situation where one would have thought that the relatively young participants may have 
positively impacted on the general knowledge of par ticipants since they are believed to have 
the passion to learn new ways of improving nursing practice compared to the older 
generation, the opposite was the case. O lder participants demonstrated higher k nowledge 
though the difference wa s not significant.  This demonstrates the knowledge gap among 
younger healthcare workers despite their increasing exposure to TB patients in hospitals.  
Finally, the findings also revealed that a significant positive correlation exist ed  between 
knowledge of TB infection preve ntion and control and practice. The positive link between 
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knowledge and practice may be due to TB infection prevention and control policy which 
requires that every health facility nationwide adhere to certain practices. Health workers 
adopted the following as good practices in their health facility; the use of patient visual alerts 
like posters, ensuring that the health workers had adequate knowledge on TB prevention. 
Thus this signals that knowledge and practice are interrelated where those who know put in to 
practice what they know.   
 
5.3 Practice of Prevention and Control of TB infection 
F indings revealed that participants usually prepare d  themselves for TB infection prevention 
and control through experience, professional education, in service training/sh ort course and 
mentor/preceptor relationships. The participants reported that professional education and 
experience were more valuable respectively. In- service training and mentor/ preceptor were 
rated as less valuable. In service training has been a sourc e of rich knowledge in the past 
when it was done quite often; presently it is done once a year or once in two years. This 
might have impacted on its value as a source of preparation. Mentor/P receptor was also 
considered the least valuable source of informa tion. Mentorship is not well understood in 
most parts of the nation and as such most people do not mentor others. It is therefore not 
surprising most participants did not view it as a valuable source of preparation. O n the other 
hand, experience could be a rich source of preparation and it wa s unusual for participants to 
have chosen professional education over it. This study ’s findings are in line with those of 
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Aarti, et. al (2001) who revealed the connection between qualification and experience of 
health workers and knowledge of infect io n control measures.  
The findings showed that generally, participants engaged in appropriate practices geared 
towards TB infection prevention and control (mean practice score of 59.58 out of a maximum 
of 95). This was also e vident in the participants’ report on the frequency of certain preventive 
strategies in practice. They often undert ook  the following practices; educate d suspected TB 
patients, practice d  hand hygiene, use d  information materials, separate d TB patients from 
o ther patients and educate coughing patients. The use of these practices ,  especially hand 
hygiene is in support with the recommendation by C ent res for Disease C ontrol and 
Prevention (C DC ) and the World Health O rganization (WHO ), N GO s and other professional
societies that proper hand washing is the single most important preventive measure. it also 
supports the findings of Q udeimat, Ferra and O wais (2006) that all the nurses and health 
workers reported higher frequency of washing hands after removing gloves than wearing 
them. 
  
Use of hand hygiene practices observed by this study contradicts findings of other 
researchers. For instance, it was argued that increasing workload of healthcare workers have 
been found to lead to non- compliance of hand hygiene practice s. A South African study 
revealed that adherence to hand washing practices as part of control practices would improve 
compliance by 92% and hence significant reduction in infection rate among health 
professionals. Poor hand washing practices ha ve  also been caused by lack of decontamination 
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agents (S aloojee & Steehoff, 2000). In addition, in a study in Eritrea to find out compliance
of infection control practices among healthcare workers, it was observed that, there was low 
compliance due to factors such as lack of adequate and conveniently located sinks, adequate 
hand towels, water, quality soap and hand lotions or lubricants for use after hand washing and 
lack of time.  
 
Inspite of the generally good TB infection prevention and control practices b y participants, 
some equally good practices were not adhered to. Findings showed that wearing of N 95/F F P 2 
mask by health workers, offering of surgical mask to TB suspects, separating TB suspects 
from other patients and access to TB prevention resources wer e rarely done which supports 
the observation by Q udeimat, et. al (2006) that only 30% of nurses said they routinely use d  
the mask. Availability of logistics and facilities is one critical factor that can greatly influence
the strict adherence to TB infection prevention and control by health workers. There is the 
need to investigate availability and adherence to TB infection prevention and control 
practices. 
 
5.4 Challenges faced by Participants in Preventing and Controlling TB 
In spite of the existence of fairly good knowledge of TB infection prevention and control of 
the majority of participants as well as good practices geared towards TB infection prevention 
control, there existed some challenges as the majority of participants approximately 22% 
(n=50) rep orted about the inability of the hospital to provide protective equipment such as 
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FFP 2 or N - 95 masks and gloves for health workers as a major challenge. The observation of 
these challenges supports the observation of Akyol (2007), Sofola and Savage (2003) who 
explained that, health workers are faced with various occupational risk as far as TB infection
is concern ed . Though there are standard procedures to follow to avoid being infected, a 
number of challenges ranging from lack of logistics, human resource a nd other work related 
factors have been cited. N on- adherence to control practices by health professionals has been 
attributed to non- availability of required resource materials such as masks, gloves, 
disinfectants amongst others. Thus, the need to ensure a vailability of TB control materials in 
order to manage TB patients is necessary. 
Findings further revealed that more than half 78% (n=174) mentioned other challenges that 
confront ed  them in the hospital as they tried  to adhere to TB infection prevention and control 
measures. These challenges include d  the lack of TB wards for infected patients; hence they 
mix ed  up with other patients. This increases the rate of infection, inadequate education / 
training programmes for health workers about TB infe ction, prevention and control, 
o vercrowding at the O P D which makes for improper ventilation, lack of supervision from the 
superiors to enable smooth running of the facility couple with too much workload on staff, 
p oor ly  resourced laboratory for TB testing, apparent over centralization of TB control 
programmes, human and material resource distribution, active staff not resourced to work, 
lack of means of transport for follow up on TB patients receiving treatments and  
stigmatization by staff members of staff working on TB patients. These challenges negatively
affect the practices of TB infection prevention and control and consequently results in non -
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adherence and compliance with TB infection prevention and control practices. This poses 
danger for both patients and health workers as argued by Girou, C hai and Brun- Buisson 
(2004),  that non- adherence will lead to infection spread as there is high risk of microbial 
transmiss io n.  
In order to avert any danger of infection spread as a result of the above challenges ,  
participants made various suggestions. These include d the need for the provision of separate 
wards for TB infected patients from other patients, organization of in- service training for both 
old and new staff frequently to enable health workers to become more abreast w ith preventive
strategies, improvement of ventilation and reduction of overcrowding and providing patients 
and staff with a safe environment and provision of more protective equipment for health care 
workers.  
 
 
 
 
 
 
 
 
 
 
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CHAPTER SIX 
SUMMARY AND CONCLUSION 
6.1. Summary 
This chapter outlines the summary and conclusion, implications of findings and suggestions 
and recommendations of the research. The study was on the assessment of tuberculosis 
infection prevention and control practices among health care worker s in Tema General 
Hospital.  
 
Findings of this study pointed out that knowledge about TB infection prevention and control 
is fairly/moderately good. Demographic variables such as sex, current ward of work and job 
title had a significant influence on participants’ knowledge of TB infection prevention and 
control. Age of participants and number of years of work did not have any significant
influence on participants’ knowledge.  Findings further showed that participants engaged in 
appropriate practices o f TB infection prevention and control. Practices were significantly
influenced by participants’ age, current ward of work and job title but not sex and number of 
years of work. Professional education, experience, in- service training/short course and 
mentorship played valuable roles in the preparedness for TB infection prevention and control. 
Though knowledge and practices of TB infection prevention and control were fairly good, 
they were not without challenges such as overcrowding at the O P D leading to improper 
ventilation, no TB wards for infected patients, lack of protective equipment (F F P 2 or N - 95 
masks, gloves) among others. Suggestions were made by participants geared towards 
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addressing some of these challenges. These findings have certain implications which are 
considered below.  
 
6.2 Implications for nursing 
Implications of the findings for nursing derived from this study are reported in four main 
areas of nursing: manageme nt, research, education and practice.  
 
6.2.1 Nursing management 
C hallenges enume rated by participants in this study such as overcrowding at the O P D which 
leads to improper ventilation, no TB wards for infected patients, lack of protective equipment 
(F F P 2 or N - 95 masks, gloves) imply that much cannot be achieved in the implementation o f 
TB infection prevention and control unless N ursing administrators and managers de velop and 
implement policies directed towards addressing these challenges. Further, participants 
considered in- service training as valuable in the preparation towards TB infection prevention 
and control. Short courses relevant to the subject area must be organized regularly to ensure 
that best practice is ensured. Supervision of nurses in this area must be done to ensure strict 
adherence to policies.  
 
6.2.2 Nursing Research 
The current research points out that though knowledge was fairly good, more needs to be 
done in unearthing health workers knowledge of TB infection prevention and control. The 
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use of observational method which would ensure researchers observing practices ra ther than 
the use of questionnaire is paramount. N urses must be encouraged to pursue research areas 
pertaining to TB prevention and control to enhance and enrich the existing literature based 
upon which policies would be formulated and implemented in order to improve TB infection
prevention and control.  There is the need for more research in this area to throw more light 
on health workers knowledge of TB infect io n prevention and control in the whole country.  
 
6.2.3 Nursing Education  
 Professional education was considered the most valuable factor in the preparation for TB 
infection prevention and control. This is an indirect call for the inclusion of this in the 
curriculum of nursing training especially professional nursing training. This will ensure that 
professional nurses are well equipped in this area. Further, knowledge of TB infection 
prevention and control was fairly good which also imply that more education and training is 
needed.  
 
6.2.4 Nursing Practice  
Literature reveals that the rate of nosocomial infections has been a challenge for infection 
control program me s in many countries. C hallenges encountered and mentioned by 
participants especially regarding lack of protective equipment (F F P 2 or N - 95 masks, gloves) 
is a pointer to the possibility of high rate of nosocomial infections. Health workers must be 
monitored, supervised and encouraged to work professiona lly so as to prevent this.  
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6.3 Suggestions and Recommendations 
 Regular and frequent in- service training and short courses must be organized to equip 
and improve the knowledge of health workers on TB infect io n prevention and control.  
 P rovision of adequate logistics to ensure smooth working environment for the health 
workers is recommended.
 Health workers directly linked to TB prevention and contro l must be trained in 
educating and helping patients to adhere to the protocols.  
 There is the need for the expansion of health facilities in order to ensure separation of 
suspected and infected TB patients from other patients to reduce the rate of inactio n.  
 Research needs to be conducted on adherence and compliance to TB infection 
prevention and control in all health facilit ie s in the country.  
 
 
 
 
 
 
 
 
 
 
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APPENDIX C 
QUESTIONNAIRE 
Dea r pa rti c i pa nt,  
T his study a i ms a t assessing pul mona ry tuberc ulosis (T B ) i nfection prevention a nd control 
meas ures tha t hea l th c a re workers employ to reduce TB tra ns mission a mong themselves, cl ients 
a nd   the communi ty as a whole. The questions wi l l requi re a pproxi ma tel y 30 -40 mi nutes 
completi ng . T he fi ndi ngs of this researc h wi l l contri bute to improvi ng the meas ures tha t 
hea l thc a re workers wi l l employ to mi ni mi ze the sprea d of TB i n hea l th c a re setti ngs .  
T ha nk you.  
 
SECTION A:DEMOGRAPHIC INFORMATION 
Please ki ndl y provi de a ns wers to the under l is ted questions . Respond to the items by ticking ( ) 
or writing i n the spa ces provi ded.  
1.  Sex ( a ) ma le (   ) (b) Fema le (  )  
 
2.  Age bracket: 
 (a ) 20 – 25 yea rs (   ) (b) 26 – 31 years (   ) (c ) 32 – 37 yea rs (   ) (d) 38 – 43 years (   )
 (e) 44 – 49 years (   ) (f) 50 yea rs a nd a bove (    )  
3.  How long have you been working in the Tema General Hospital  
 (a ) 6 months – 1 year (   ) (b) 2 yea rs – 5 yea rs (     ) (c ) 6 years – 9 yea rs (    )  
 (d) 10 years – 13 years (    ) (e) 14 years a nd a bove (    )  
4.  Current ward/unit of work: please indicate the ward/unit you work  
 
( a ) O utpa tient Depa rtment (   )   (b) Ma le Medi c a l Wa rd (    )    (c ) Fema le Medi c a l Wa rd (    ) 
(d) C hest C l i ni c (    )   (e) Fevers Unit (  ) (f) Children’s Ward (    )   (g) HIV/AIDS counseling 
uni t (    )    (h) L a bora tory uni t (    )     (i ) X - ra y uni t (     )    (j ) Pha rma c y uni t (     )                     
(k) Others (please specify)………………………………………………………………. 
 
 
 
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 5.  Job Title 
 (a ) Medi c a l doctor (    ) (b) Professiona l nurse (    ) (c ) E nrolled nurse (    )  
 (d) L a bora tory Technolog is t (    ) (e) X-ra y technolog is t (    )  
 (f) Heal th assis ta nt / Heal th Ai de (   ) (g ) Pha rma c y techni c i a n (    ) (h) Pha rma c is t (   )  
 
SECTION B: KNOWLEDGE ABOUT TB INFECTION PREVENTION AND CONTROL MEASURES  
Please speci fy your knowledge a bout tuberc ulosis i nfection control. Ea c h question requi res one 
ans wer. Please ans wer by ticking ( )a ppropri a te response.  
1.  Whi c h of the followi ng best descri bes how TB is sprea d?  
( a)  If uni nfected person comes into conta c t wi th the blood of a personconta i ni ng the TB 
ba c i l l i .  
( b)  When TB ba c i l l i droplets become sus pended i n the a i ra nd someone brea ths i n the TB 
ba c i l l i .  
( c)   A person i nfected wi th T B c a n s prea d the ba c teri a throug h phys i c a l  conta c t.  
( d)  When a n i nfected person prepa res food a nd i ntroduces the TB germs i nto the food.  
 
2.  Hospi ta l s ta f f s houl d i mplement whi c h of the followi ng a dmi nis tra ti ve control meas ures 
for TB i nfection prevention a nd control? T i c k as ma ny as a ppl i c a ble.  
( a)  Prompt i denti f i c a tion a nd sepa ra tion of coug hi ng pa tients from others .  
( b)  Promoti ng coug h eti quette  
( c)  “fast tracking” patients suspected of TB infection for prompt diagnosis and treatment  
( d)  Al l the a bove  
(e)  A a nd B onl y  
 
3.  T he exa mi na tion or trea tment room for pa tients whom you s us pect ma y ha ve TB s houl d 
ha ve a l l of the followi ng excepts :  
( a)  Ai r exha us t di rectl y to the outs i de  
( b)  Venti l a tion solely by a i r condi tion  
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( c)  T he pl a cement of the pa tients nearest the wi ndow or fa n exha us ti ng the a i r.  
( d)  Adequa te venti l a tion  
 
 
4.  An eas y a nd low- co st wa y to reduce the number of i nfectious TB droplets i n the a i r is to:  
( a)  Use na tura l venti l a tion by openi ng wi ndows a nd doors a nd ma x i mi zi ng c ross -
venti l a tion  
( b)  Provi de respi ra tors or N95 mas ks to al l s ta f f  
( c)  Ins ta l l a mecha ni c a l venti l a tion s ys tem  
( d)  Was h ha nds wi th soap a nd wa ter before and a f ter every pa tient conta c t  
 
 
 
5.  Coug h eti quette:  
( a)  Is when someone says “excuse me” after coughing in public  
( b)  Shoul d be requi red of a l l pa tients , but not necessary for heal thc a re workers  
( c)  Inc l ude coveri ng your coug hs a nd s neezes wi th ha ndkerc hief, tissue, or upper a rm  
( d)  Al l of the a bove  
 
6.  If pa rti c ul a te respi ra tors (a lso known as N-95 or FFP2 mas ks ) a re a va i l a ble i n your hospi ta l , 
they s houl d be:  
( a)  Used for a l l T B pa tients or persons sus pected of TB i n the hospi ta l  
( b)  Worn by s ta f f when conduc ti ng a bronc hoscopy procedure or other hi g h ris k 
procedure for a pa tient wi th T B , MD R T B , or XD R T B .  
( c)  Requi red for a l l s ta f f when they a re i nfected wi th a ny i nfectious disease to prevent 
tra ns mission to pa tients .  
( d)  Worn by pa tient when s itti ng outs i de to prevent T B droplet from s prea di ng 
throug hout the town.  
 
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7.  Persons who ha ve a hi g h ris k of TB exposure a nd i nfection i nc l ude: Ti c k as ma ny as 
a ppl i c a ble.  
( a)  T hose tha t l i ve i n c rowded, poorl y venti l a ted setti ng where TB is common  
( b)  Persons who a re immunocompromised, s uc h as HIV/AID S pa tients  
( c)  T hose wi th medi c a l condi tions suc h as rena l fa i l ure, ca ncer, or di a betes  
( d)  Al l of the a bove  
 
8.  Wha t is the most effecti ve i ntervention for TB control?  
( a)  B C G re-va c c i na tion  
( b)  C hemoprophyl a x is  
( c)  E a rl y detection of TB pa tients  
( d)  Appropri a te trea tment of TB pa tients  
(e)  Both C a nd D  
 
9.  Admi nis tra ti ve control meas ures in Gha na prevents TB tra ns mission by the followi ng 
a c tions :  
( a)  Promptl y i denti f yi ng i nfectious cases  
( b)  Ma nda tory qua ra nti ne of s us pected cases  
( c)  Sepa ra tion of coug hers  
( d)  Setti ng up qui c k turna round ti mes at hea l th c a re setti ngs for TB c ases  
(e)  E ng a g i ng c i vi l society  
( f)  Al l of the a bove  
( g)  A, B , C , E  
( h)  A, C , D  
 
 
10.  In a n envi ronment where TB tra ns mission is a ris k, s urg i c a l mas k s houl d be used by:  
( a)  Doctors  
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( b )  Nurses  
( c)  Coug hi ng pa tients  
( d)  Vis i tors  
(e)  Admi nis tra tors  
( f)  Al l the a bove  
 
11.  Wha t c l ass of respi ra tor is a c cepta ble for the Heal th C a re Workers (HC W) worki ng i n a 
setti ng wi th s mear- positi ve pa tients ?  
( a)  FFP1  
( b)  FFP2 or N- 95  
( c)  FFP3  
( d)  FFP4  
 
12.  Wha t a re some of the recommended s tra teg ies to address TB tra ns mission i n hea l thc a re 
fa c i l i ties?  
( a)  Improvi ng na tura l venti l a tion  
( b)  Preventi ng overc rowdi ng i n wa i ti ng a reas a nd ha l l wa ys  
( c)  Ha vi ng pa tients show proof of B C G va c c i na tion  
( d)  Al l of the a bove  
(e)  A a nd B onl y  
 
13.  Good heal th fa c i l i ty desig ns to prevent T B i nfection uses intervention tha t a re di rected 
towa rd:  
( a)  T he leas t costl y wa y to improve venti l a tion  
( b)  Provi di ng as ma ny rooms as possible to pl a ce pa tients  
( c)  Improvi ng venti l a tion, reduc i ng overc rowdi ng a nd provi di ng pa tients a nd s ta f f wi th a 
s a fe envi ronment  
( d)  Removi ng as ma ny wi ndows as possible to reduce cost  
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 Please indicate by ticking (  whether the following sentences are true/ false. 
14.  T B is the leadi ng c a use of death i n people wi th HIV/AID S.  
( a)  T rue  
( b)  Fa lse  
 
15.  In hea l thc a re setti ng , the g rea test ris k for TB s prea d is by coug hi ng pa tients who ha ve not 
been recog ni zed as ha vi ng T B a nd a re not receivi ng trea tment.  
( a)  T rue  
( b)  f a lse  
16.  T B is suc h a n i nfectious disease tha t hea l th workers ca n do li ttle to prevent tra ns mission 
of TB i n c l i ni cs a nd hospi ta ls  
( a)  T rue  
( b)  Fa lse  
17.  Sma l l  a rea  wi th mi ni ma l venti l a tion s houl d be used for s putum collection beca use they 
s afely conta i n the TB droplets  
( a)  T rue  
( b)  Fa lse  
18.  T he va l ue tha t the i nfection control person provi des to his /her fa c i l i ty a nd pa tients a re to 
provi de leaders hi p, a dherence to tra ns mission prevention efforts a nd to develop poli c ies 
and procedures tha t resul t i n mi ni mi zi ng or eli mi na ti ng tra ns mission of pa thogens to 
pa tients a nd s ta f f .  
( a)  T rue  
( b)  Fa lse  
 
19.  Mi nis try of Heal th recommends screeni ng of TB a mong people li vi ng wi th HIV a t the ti me 
of enroll ment a nd a t eac h encounter thereaft er  
( a)  T rue  
( b)  Fa lse  
 
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20.  Ma na geri a l control meas ures for TB i nfection control i nc l ude i ns ti tuti ng s creeni ng of 
heal th c a re workers on TB .    
( a ) T rue      (b) Fa lse  
 
 
 
 
 
 
 
 
 
 
 
 
SECTION C: PRACTICES FOR PREVENTING TUBERCULOSIS INFECTION  
 
T his section g a thers i nfor ma tion rela ti ng s peci f i c al l y to you r p ra c ti ce wi th reg a rds to 
tube rc ulosis i nfection prevention a nd control (i nc l udi ng tra i ni ng you ha ve received, 
a dmi nis tra ti ve a nd envi ronmenta l controls as well as persona l protecti ve equi pment)  
C.1 Please indi c a te by ticking (√) from options below how va l ua ble the followi ng ha ve been to  
your prepa ra tion for TB i nfection prevention a nd control.  
 
ITEM EXTREMEL
Y 
VALUABLE 
VERY 
VALUABL
E 
MODERATE
LY 
VALUABLE 
SOMEWHA
T 
VALUABLE 
NOT 
VALUABL
E 
N/A
. 
( a)  E x perience        
( b)  professiona l 
E duc a tion  
      
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( c)  In - servi ce tra i ni ng 
or s hort course  
      
( d)  Mentor/preceptor        
 
C.2a Ha ve you a ttended tuberc ulosis i nfection prevention tra i ni ng prog ra mme for the pas t 3 
yea rs .  
 
  Yes                           No   
 
C2.b If yes, please indi c a te i ts usefulness 
………………………………………………………………………………………………………………………………………. 
 
Extremely 
useful 
Very useful Moderately 
useful 
Somewhat 
useful 
Not useful 
     
     
     
 
C.3If you ha ve ever been g i ven tra i ni ng on TB i nfection control please comment on the streng th 
a nd wea knesses of the tuberc ulosis i nfection prevention a nd control tra i ni ng prog ra mme.   
………………………………………………………………………………………………………………………………………………………
………………………………………………………………………………………………………………………………………………………
………………………………………………………………………………………………………………………………………………………. 
 
 
C.4   Please indi c a te how often the followi ng s ta tements a ppl y to you. Please tick (√) one 
response in the ta ble provi ded below.  
Statement Always Sometimes Rarely Never 
( a)  I use informa tion, educ a tion a nd 
communi c a tion  (IE C ) ma teri a ls suc h as 
posters to educ a te a nd i nc rease pa tients 
 
 
 
 
 
 
 
 
 
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a wa reness on TB  
( b)  I educ a te coug hi ng pa tients to appl y 
coug h eti quette (cover mouth, nose wi th 
mas k, tissue, ha ndkerc hief or coug hi ng i nto 
a rms )  
 
 
 
 
 
 
 
( c)  I separate or “fast track” pa tients who 
a re identi f ied as TB s us pects from other 
pa tients i n wa i ti ng a reas .  
 
 
 
 
 
 
 
 
( d)  In the wa rds I sepa ra te or g roup 
s us pected or confi rmed TB pa tients from 
other pa tients  
 
 
 
 
  
 
(e)  I educ a te sus pected TB pa tients to was h 
thei r ha nds a nyti me they produ ce 
respi ra tory secretions .  
 
 
 
 
 
 
 
 
( f)  I wea r N95/FFP2 mas k when worki ng i n 
hi g h ris k TB a reas exa mple(di rect observed 
thera py s hort course (DO T S) room,T B 
mi c roscopy room, TB wa rds )  
 
 
 
 
 
 
 
 
 
( g)  I offered s urg i c a l mas k to TB s us pects or 
cases when they a re i n the hospi ta l .  
 
 
 
 
 
 
 
 
( h)  I pra c ti ce ha nd hyg iene anyti me I come 
into conta c t wi th pa tients wi th respi ra tory 
secretions or ca rry out other procedures.  
 
 
 
 
 
 
 
 
( i)  In my workpl a ce I ha ve a c cess to 
resources to prevent T B i nfection s uc h as 
ha nd hyg iene items , s urg i c a l mas k a ndN95.  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
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C.5Please indi c a te the extent to whi c h you agree or disagree wi th the followi ng s ta tements 
below. Tick (√) your responses in the ta ble below. O ne response for each i tem is a ppropri a te.  
Statement Strongly 
Agree 
Agree Neutral Disagree Strongly 
Disagree 
a.  ( a ) My knowledge of TB a nd 
how to prevent i ts tra ns mission to 
sta ff a nd pa tients is a dequa te for 
my c urrent level of pra c ti ce.  
 
 
 
 
 
 
 
 
 
 
 
 
b.  ( b) Pa tients vis ua l a lerts 
exa mple Posters a dvis i ng pa tient to 
inform s ta f f i f they ha ve respi ra tory 
s ymptoms a re a va i l a ble a t a l l 
va nta ge points i n my fa c i l i ty  
     
c.  ( c ) It is i mporta nt to 
mi ni mi ze the ti me TB s us pects 
spend a round other pa tients i n the 
outpa tient depa rtment or a nti -
retrovi ra l ( AR T ) thera py c l i ni c 
wa i ti ng a reas  
 
 
 
 
 
 
 
 
 
 
d.  ( d) T he reference ma teri a ls 
suppl ied i n my fa c i l i ty is a dequa te 
to ma i nta i n my competence wi th 
reg a rds to the a ppl i c a tions of TB 
i nfection control.  
 
 
 
 
 
 
 
 
 
 
e.  (e) The wi ndows i n my 
fa c i l i ty a re opened da i l y for 
ma x i mum c ross venti l a tion.  
 
 
 
 
 
 
 
 
 
 
f .  ( f ) In my workpl a ce, the 
doors a re opened for ma x i mum 
c ross venti l a tion  
 
 
 
 
 
 
 
 
 
 
g.  ( g ) Sputum mi c roscopy is 
done indesig na ted a rea ra ther tha n 
i n the ma i n l a bora tory.  
 
 
 
 
 
 
 
 
 
 
h.  ( h) Pa tients wi th a c ti ve TB 
a re most often a dmi tted to the 
 
 
 
 
 
 
 
 
 
 
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same wa rd wi th other pa tients .  
i .  ( i ) Propell i ng fa ns 
exa mple(Ceil i ng fa ns ) a nd a i r -
condi tioners a re most often used i n 
my fa c i l i ty tha n na tura l c ross 
venti l a tion  
 
 
 
 
 
 
 
 
 
 
j .  ( j ) Cei l i ng fa ns a re 
func tioni ng , c lea ned a nd i n good 
condi tion a l l the ti me.  
 
 
 
 
 
 
 
 
 
 
 
 
 
SECTION D – CHALLENGES 
a )  Wha t a re some of the cha l lenges you encounter i n the i mplementa tion of TB i nfection 
prevention a nd control s tra teg ies or meas ures in your fa c i l i ty i n the followi ng ?  
 
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b) Please dis cuss further a ny issues, concerns or s ug gestions you ma y ha ve reg a rdi n g the 
i mpleme nta tion of tube rc ulosis i nfection preven tion con trol i n Tema Genera l 
Hospital………………………………………………………………………………………………………………………………………....
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Thank you for your participation  
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 APPENDIX A  
PARTICIPANT INFORMATION SHEET  
STUDY TITLE: ASS ES S MEN T O F TUBERC ULO S IS IN F EC TIO N PREVEN TIO N AN D 
C O N TRO L PRAC TIC ES AMO N G HEALTHC AR E WO RK ERS IN TEMA GEN ERAL 
HO S P ITAL  
Dear par t ic ipa nt, my na me is A gnes C odjoe a nd I a m a n MS C st ude nt a t t he Sc hoo l o f N urs ing,  
U niver s it y o f G ha na Le go n. T his s t ud y is to he lp hea lt hcar e pro fe ss io na ls o n wa ys o f min im izing  
TB infect io n t ra ns miss io n a mo ng t he mse lves a nd  ot her s. T he s t ud y a ims a t de ter min ing t he  
kno w led ge  a nd pr act ices o f hea lt hca re worke rs in t he Te ma  G e nera l Ho sp ita l o n t ub erc ulo s is  
infect io n co nt ro l s tra te gies. T he d ura t io n o f t he s t ud y is fro m 4 t h  May to 4 t h  June 2012. C ross  
sect io n o f st a ff w ho wo rk in va r io us wa rds / unit s of t he hosp ita l w here pat ie nts inte ract w il l be  
se lect ed to  par t ic ipate  in t he st ud y.  T he  infor ma t io n obta ined fro m t his st ud y w ill be used  to  
impro ve t uberc ulos is infec t io n co ntro l p ract ices a nd t hus red uce t he poss ib le tra ns mis s io n o f 
tuberculos is infect io n to staff, clients and visitors in the facilit y.  
I f yo u a gree  to  part ic ip a te  in t his s t ud y, yo u ma y be r eq uired  to  a ns wer  so me  q ues t io nna ires  
about w hat yo u k now abo ut t uberc ulos is, pra ct ices or mea s ures  t ha t yo u e mp lo y to p re ve nt 
tub erc ulo s is tra ns mis s io n to sta ff a nd c lie nts a nd c ha lle nge s yo u might e nco unter d ur ing t he  
imp le me nt at io n o f t he se me as ures. Yo u ma y spe nd abo ut 30 - 40 minut es to a nswe r t he  
ques t io nna ires. Par t ic ipat ing in t his st ud y is ent ire ly vo luntar y. Yo u ha ve t he r ight to r e fuse to  
part ic ipat e a nd t his w il l not a ffec t yo u. Yo u a lso ha ve t he r ight to stop t he int er view a t a nyt ime  
and I will only require that you let me know anytime you feel like going out of the study.   
T here a re no d irec t bene fits or r isks in pa rt ic ipa t ing. Yo u w ill not be pa id o r co mpe nsa ted for  
yo ur  par t ic ipat io n. Howe ve r, t he infor mat io n t hat  w il l be ob ta ined w ill he lp us/ yo u re - or ga nize  
ser vice s to impro ve t he qua lit y o f ca re w it h re ga rds to T B infect io n co ntro l prac t ice s in t he  
facilit y and beyond, and thus, help to reduce the spread of TB infect io n to staff and patients.  
A ll t he  infor ma t io n co llect ed fro m yo u w il l be  t reated  in st r ic t co nfide nce  a nd w ill be  used  for  
acade mic p urpo ses o nly. Yo u w il l no t be ide nt ified b y na me in a ny d isse mina t io n repo rts or 
publicat io ns resulting from this study.  
P er mis s io n has be e n obta ined fro m t he M ed ica l D irec tor o f t he T e ma Ge nera l Hosp ita l to  
conduct this study.  
Do you have any questions for me regarding this study?  
I f yo u ha ve a ny furt her quest io ns re gard ing t his st ud y yo u ma y contact me o n te lep ho ne number  
0243161974 and my supervisors;  
N AME: DR PRUDEN C E MWIN I- N YALEDZIGBO R – Telephone number 0274131004  
N AME: DR K WAS I ADDO – Telephone number 0243334869  
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 APPENDIX B  
INFORMED CONSENT FORM FOR THE RESEARCH PARTICIPANTS 
 
I ha ve b ee n infor med abo ut t he p urpose, p roced ure,  pote nt ia l r isks  a nd b e ne fits  o f t his  s t ud y. I 
ha ve had t he oppor t unit y to ask q uest io ns a nd a ny quest io n asked has bee n a nsw ered to my 
sat is fact io n.  I k now t ha t I ca n re fuse to pa rt ic ipa te in t his  st ud y w it ho ut a ny los s o f be ne fit to  
w hic h I wo uld ha ve ot he rw ise bee n e nt it led. I unders ta nd t ha t if I a gr ee to par t ic ipate I ca n 
w it hd raw my co nse nt a t a nyt ime w it ho ut los ing a ny be ne fits  or ser vices to w hic h I a m e nt it led. I 
under sta nd t hat a ny infor mat io n co llected w ill be trea ted co nfid e nt ia lly; I free ly a gree to  
participate in this study.  
S ign ature……………………………………. 
Date………………………………………… 
 
TO BE READ AND SIGNED BY THE INTERVIEWER  
I ha ve adeq ua te ly infor med t he part ic ip a nt a nd I cer t ify t hat t he p urpo se, proced ure s, pote nt ia l 
r isks a nd be ne fit s assoc iated w it h ha ve bee n e xp la ined to t he abo ve ind ivi d ua l to t he bes t o f my 
abilit y.  
Name of interviewer……………………………………………………………………………….. 
Signature…………………………………………… 
Date………………………………………………... 
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