J Arab Soc Med Res 9: The Arab Society for Medical Research

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1 6 Originl rticle Assessment of complince to stndrd precutions mong surgeons in Zgzig University Hospitls, Egypt, using the Helth Belief Model Emn M. Mortd, Mrw M. Zlt b Deprtments of C ommunity Medicine b O ccuptionl nd Environmentl Medicine, Fculty of Medicine, Zgzig University, Zgzig, Egypt Correspondence to Emn M. Mortd, Deprtment of Community Medicine, Fculty of Medicine, Zgzig University, Zgzig, Egypt Tel: , e-mil: emnmortd@hotmil.com Received 6 November 2013 Accepted 30 December 2013 Journl of the Arb Society for Medicl Reserch 2014, 9:6 14 Bckground/im Although it is recommended tht helthcre professionls should comply with the stndrd precutions to prevent cquiring blood-borne diseses ( AIDS, heptitis B nd C), yet, they frequently do not comply with this recommendtion. Understnding the resons for complince nd noncomplince will help in designing eductionl progrms for hospitl stff nd in determining strtegy for improving helth behvior. The present study imed to ssess surgeons complince to stndrd precutions nd determine surgeons perceived beliefs ffecting their complince using the Helth Belief Model. Prticipnts nd methods A cross-sectionl study ws crried out t surgicl deprtments in Zgzig University Hospitls from December 2012 to My A questionnire on vrious spects of infection control nd stndrd precutions prctices ws provided to 307 surgeons, with response rte of 70%. Results Our fi ndings indicted tht 57.5% of the surgeons smpled in Zgzig University Hospitls were complint with stndrd precutions. 59.8% of complint surgeons hd been exposed to t lest one needle-stick injury in the previous 3 months, wheres slightly less thn hlf of complint surgeons (48.4%) hd been exposed to splshes, with highly significnt difference compred with nonexposed surgeons. All Helth Belief Model subscles were correlted directly with the surgeons complince, except perceived brriers. Conclusion There is dequte complince with stndrd precutions mong surgeons in Zgzig University Hospitls, especilly femle surgeons, with high level of knowledge mong complint compred with noncomplint surgeons. All Helth Belief Model subscles were correlted directly with the surgeons complince, except perceived brriers. Adequte trining of surgeons, provision of infection prevention equipment, regulr reporting, follow-up, nd ssessment of occuptionl exposures need to be introduced. Keywords: complince nd stndrd precutions, Helth Belief Model, surgeons J Arb Soc Med Res 9: The Arb Society for Medicl Reserch Introduction Helthcre workers (HCWs) re t n incresed risk of occuptionlly cquired infections trnsmitted from both blood-borne pthogens (BBP), such s heptitis B nd C nd HIV. Exposure to blood nd body fluids is mjor concern for HCWs; surgeons re especilly t n incresed risk of exposure to these pthogens during surgicl procedures. Surgeons hve been shown to hve four-fold to eight-fold higher incidence of exposure to ptients blood compred with internists [1]. Exposure cn occur through percutneous injury nd/or mucos exposure ( needle-stick or other shrps injury), mucocutneous occsion (splsh of blood nd body fluids into the eyes, nose, or mouth), or blood contct with dmged skin [2,3], nd presents mjor risk for the trnsmission of BBPs such s HIV, heptitis B virus ( HBV), nd heptitis C virus ( HCV). The highly significnt predictors for complince of surgeons were trining on stndrd precutions, knowledge level, perceived severity, perceived brrier, nd perceived cues to ction [4]. Stndrd precutions im to prevent the trnsmission of BBPs. The objective is to ssume tht ptients re infected with BBPs, nd ensuring tht helth stff minimizes the risk of exposure to infected body fluids [5]. The proper nd consistent use of personl protective equipment ( PPE) during opertive/invsive procedures by members of surgicl tems reduces the risk of cquiring blood-borne disese. Studies worldwide hve shown tht despite trining on universl precutions, vilbility of PPE, nd effective orgniztionl sfety climte, some surgicl tem members choose not to comply with regultions nd recommendtions relted to exposure to pthogens. Complince is the The Arb Society for Medicl Reserch DOI: /

2 Complince to stndrd precutions Mortd nd Zlt 7 extent to which certin behvior (e.g. following physicin s orders or implementing helthier lifestyles) is in ccordnce with the physicins instructions or helthcre dvice. To explin nd understnd the fctors tht influence n individul s complince, which my consequently contribute towrd the doption of certin behvior, the most commonly used model is the Helth Belief Model ( HBM) [6,7]. HBM ws originlly developed by group of psychologists in the 1950s; the model offers the bility to understnd the different behviors or ttitudes tht individuls my develop. It hs been used widely nd is considered one of the most useful models in helthcre prevention nd promotion [8]. Finding the resons for complince nd noncomplince with reporting needle-stick injuries (NSIs) will help in designing eductionl progrms for hospitl stff nd in determining strtegy for improving helth behvior [9]. According to the HBM, individuls re redy to tke ction if they believe tht they re susceptible to disese (perceived susceptibility), believe tht condition hs serious consequences (perceived severity), believe tht tking ction will reduce their susceptibility to the condition (perceived benefits), understnd tht the costs of tking ction (perceived brriers) re outweighed by the benefits, re exposed to fctors tht prompt ction (cue to ction), nd re confident in their bility to perform tht ction successfully ( self-efficcy). The model is bsed on the understnding tht n individul will engge in helth-relted ction if the individul: () Believes tht he or she cn void negtive helth condition (i.e. exposure to BBPs), (b) Hs positive expecttion tht he or she will void negtive helth condition by tking recommended ction (i.e. wering PPE to void exposure), nd (c) Believes tht he or she cn successfully tke recommended helth ction [10]. The im of this study ws to provide the foundtion for plnning progrm for prevention of BBPs mong surgeons. Objectives The objectives of the study were s follows: (1) Assess the surgeons complince with stndrd precutions. (2) Determine the surgeons perceived beliefs ffecting their complince using the HBM. Prticipnts nd methods Study design nd setting To fulfill our objectives, cross-sectionl study ws crried out t surgicl deprtments in Zgzig University Hospitls during the period from December 2012 to My Trget popultion nd smpling Surgeons in different surgicl deprtments nd surgicl subspecilties were selected becuse they hve the highest rtes of exposure nd re t n incresed risk of exposure to HBV, HCV, nd HIV while performing opertive or invsive procedures. There re eight surgicl deprtments; from these, only four deprtments were chosen rndomly (generl surgery, orthopedic, urology, nd obstetricl nd gynecologic deprtments). The trget popultion for the study included ll surgeons in the rndomly chosen deprtments (n = 410). In totl, 307 questionnires were completed by consenting clinicins who greed to prticipte in the study. After excluding incompletely filled questionnires from the finl nlysis, only 287 were included in finl nlysis, yielding 70.0% response rte (287/410). Instrument used for dt collection A questionnire [11,12] on vrious spects of infection control nd stndrd precution prctices ws devised nd modified fter being tested on smple of 25 surgeons to determine the cceptbility nd clrity of the questionnire nd to confirm its fce vlidity. The internl consistency of ech subscle ws mesured by Cronbch s α nd it rnged from cceptble to desire. The finl version included the following three prts: Personl nd job-relted vribles Personl nd job-relted vribles included sex, ge, surgicl specilty, recent qulifiction, yers of experience in prctice, nd whether they hd received trining relted to infection control nd stndrd precutions. Also, questions ddressed the history of HBV vccintion, including number of doses, nd postvccine serologic testing. In ddition, the questionnire specificlly sked prticipnts bout exposures to shrps injuries, nd splsh of blood nd body fluids during the previous 3 months. This 3-month time period ws used to minimize recll bis. Questions to ssess complince with stndrd precutions (desired behvior) Complince with stndrd precutions ws determined using the modified stndrd precutions questionnires. The items mesured how often these surgeons followed specific recommended work prctices, such s use

3 8 Journl of the Arb Society for Medicl Reserch of protective brriers s (gloves, gowns, msks, nd goggles), disposl of shrps, nd needles. Response options included never, rrely, sometimes, often, nd lwys on five-point Likert scle rnging from 1 to 5. In ddition, three other questions ssessed vccintion sttus. We lso sked questions relted to the resons for noncomplince with stndrd precutions. Then, we clssified the results of the scoring nd the respondents were divided into two groups for the purpose of nlysis using medin s cutoff point (less thn medin s noncomplint nd more thn medin s complint). sfe stndrd precutions t your workplce? (not confident = 0, completely confident = 2). Ethicl considertion Ethicl permission to crry out the study ws obtined from the hospitl director before dt collection. Prticiption in the study ws voluntry nd informed verbl consent ws obtined before dt collection. The questionnires were strictly confidentil nd nonymous nd ech questionnire ws numericlly coded. Helth belief questionnire A helth belief questionnire included questions to ssess: () Knowledge of disese trnsmission nd stndrd precutions (12 items): A correct nswer ws ssigned score of 1, wheres n incorrect nswer ws ssigned score of 0. The men knowledge score ws computed by dding the number of correct nswers. (b) susceptibility of infection nd cquiring BBPs (one item) nd perceived severity of consequences of exposure to blood nd body fluids (one item). The response to perceived susceptibility nd severity ws on scle of 1 (being none) to 5 (being very high). (c) benefits of stndrd precutions (one item): to wht extent do you believe tht stndrd precutions prctices protect ginst blood borne infections? (very low = 1 to very high = 4). (d) brriers to prctice of stndrd precutions (seven items) (yes = 1, no = 0). (e) Cue to ction (five items) tht motivtes ction to be tken (yes = 1, no = 0). (e) self-efficiency (one item) re you confident in your bility to successfully prctice Sttisticl nlysis Dt were nlyzed using the sttisticl pckge for the socil sciences (SPSS, version 19.0; SPSS Inc., Chicgo, Illinois, USA) for Windows. Descriptive sttistics such s frequency, percent, men, nd SD were determined. Anlyticl sttisticl tests such s χ 2, nlysis of vrince, independent t-test, Mnn Whitney, nd Kruskl Wllis tests were used to compre continuous vribles. Person s correltion coefficient ws clculted to determine the ssocitions between surgeons complince nd HBM subscles. Logistic regression ws used to ssess predictors of complince; the threshold of sttisticl significnce ws set t P vlue less thn 0.05 (two-tiled). Results Of the 410 surgeons selected, 287 (70%) were included in the finl nlysis. Figure 1 shows the distribution of smpled surgeons ccording to their specilties; 37.9% were generl surgeons, 31.4% were gynecologists nd obstetricins, 18.1% were urologists, nd 12.6% were working in the orthopedic deprtment. Anlysis of dt showed tht 57.5% of the smpled surgeons in Zgzig University Hospitls were complint with stndrd precutions (Fig. 2). The men Figure 1 Figure 2 Distribution of the studied smple ccording to surgicl specil ty. Complince with stndrd precutions mong smpled surgeo ns.

4 Complince to stndrd precutions Mortd nd Zlt 9 score of complince mong surgeons ws 72.9 ± 7.3. The men score of overll knowledge level ws 14.3 ± 3.5. The Cronbch s α for internl consistency of knowledge items ws 0.79 (Tble 1). Tble 2 shows the reltionship between the demogrphic chrcteristics of the surgeons t risk of blood-borne occuptionl exposures nd their complince with the stndrd precutions. It ws found tht 54.9% of femle surgeons were highly complint with stndrd precutions. Of the complint surgeons, 46.7% were yers old nd 42.6% worked in the generl surgery deprtment; 39.3% of highly complint surgeons were lecturers in Zgzig University Hospitls nd 55.7% hd spent 10 or more yers in their current occuption. Forty-nine (40.2%) surgeons who hd received infection control trining were highly significntly complint with stndrd precutions (P = 0.000). More thn hlf of the complint surgeons (59.8%) hd been exposed to t lest one NSI in the previous 3 months, wheres round hlf of the complint surgeons (48.4%) hd been exposed to splshes with highly significnt difference compred with nonexposed surgeons. On nlyzing the resons for noncomplince with the stndrd precutions mong surgeons, it ws found tht improper trining hd the most cumultive percentge, s shown in the Preto chrt in Fig. 3. On compring the knowledge nd beliefs scores of complint nd noncomplint surgeons, there were highly significnt men scores of wreness, perceived severity, nd perceived brriers mong complint thn mong noncomplint surgeons (Tble 3). In terms of the reltionship between subscles of HBM nd personl chrcteristics of the smpled surgeons, it Tble 1 Men, SD, nd Cronbch s α for the Helth Belief Model subscle Items Minimum mximum Men ± SD Cronbch s α Complince ± Knowledge level ± susceptibility ± severity ± benefi ts ± brriers ± self-effi ccy ± Cues to ction ± Tble 2 Personl nd occuptionl chrcteristics of the studied smple ccording to their complince with the stndrd precutions (n = 287) Vribles Ctegories Complint [N (%)] Noncomplint [N (%)] χ 2 Sex Mle (n = 178) 55 (45.1) 123 (74.5)* 25.8 Femle (n = 109) 67 (54.9) 42 (25.5) Age groups (yers) <35 (n = 60) 22 (18.0) 38 (23.0) (n = 131) 57 (46.7) 74 (44.8) (n = 81) 35 (28.7) 46 (27.9) 55 (n = 15) 8 (6.6) 7 (4.2) Surgicl specilty Generl surgery (n = 109) 52 (42.6) 57 (34.5) 5.25 Gynecology nd obstetrics (n = 90) 39 (32.0) 51 (30.9) Urology (n = 52) 15 (12.3) 37 (22.4) Orthopedic (n = 36) 16 (13.1) 20 (12.1) Job title Resident (n = 32) 11 (9.0) 21 (12.7) 9.07 Assistnt lecturer (n = 57) 23 (18.9) 34 (20.6) Lecturer (n = 108) 48 (39.3) 60 (36.4)* Assistnt professor (n = 63) 22 (18.0) 41 (24.8) Professor (n = 27) 18 (14.8) 9 (5.5) Yers of experience <10 (n = 128) 54 (44.3) 74 (44.8) (n = 159) 68 (55.7) 91 (55.2) Infection control trining No (n = 121) 73 (59.8) 48 (29.1) 27.2 Yes (n = 166) 49 (40.2) 117 (70.9)* Exposure to NSI No (n = 152) 49 (40.0) 103 (62.4)* 13.9 Yes (n = 135) 73 (59.8) 62 (37.6) Exposure to splshes No (n = 111) 63 (51.6) 48 (29.1) Yes (n = 176) 59 (48.4) 117 (70.9)* NSI, needle-stick injury; *Signifi cnce difference t P 0.05.

5 10 Journl of the Arb Society for Medicl Reserch Figure 3 Tble 3 Comprison of knowledge nd beliefs scores mong complint nd noncomplint surgeons Vribles Noncomplint (men ± SD) Complint (men ± SD) T-test Knowledge level 12.8 ± ± 3.4* 8.9 susceptibility 4.04 ± ± severity 4.06 ± ± 0.78* 2.6 benefi ts 2.99 ± ± brriers 5.6 ± ± 1.19* 3.01 self-effi ccy 3.2 ± ± 1.3* 4.3 Cues to ction 1.15 ± ± *Signifi cnce difference from the noncomplint group t P Preto chrt showing the resons for noncomplince. PPE, personl protective equipme nt. ws found tht there were significntly perceived benefits mong mle thn femle surgeons. Moreover, perceived self-efficcy nd cues to ction were lso significnt mong surgeons younger thn 35 yers old. brriers nd perceived self-efficcy were highly significnt mong gynecologists nd urologists thn other surgeons. Highly significnt cues to ction were found mong residents thn those with other job titles. Significntly perceived susceptibility ws found mong surgeons with less thn 10 yers work experience. Significntly higher perceived susceptibility, perceived self-efficcy, nd cues to ction were found mong surgeons who hd received infection control trining thn those who hd not. susceptibility, perceived severity, perceived brriers, nd cues to ction were significntly higher mong surgeons exposed to NSI compred with nonexposed surgeons, wheres only perceived brriers, perceived self-efficcy were significntly higher mong surgeons exposed to splshes (Tble 4). Tble 5 shows the correltion between surgeons complince nd HBM subscles. It is well evident tht ll HBM subscles were correlted directly with the surgeons complince, except perceived brriers. Knowledge of stndrd precutions, perceived susceptibility, nd perceived severity ws significntly correlted with complince. Discussion To our knowledge, this is the first reserch study crried out in Zgzig University Hospitls mong group of surgeons investigting the issue of complince with stndrd precutions to void occuptionl exposure to BBPs. The HBM hs been used previously s theoreticl frmework in mny studies, nd hs been successful in explining vriety of humn behviors nd ttitudes, including complince with universl precutions, the previous version of stndrd precutions. Therefore, the use of the HBM s sound nd useful theory improves the internl vlidity of this study nd enbles comprisons mong similr studies. This study exmined surgeons complince with stndrd precutions nd determined surgeons perceived beliefs ffecting their complince to void occuptionl exposure to BBPs. Using the HBM s theoreticl frmework, this study focused on the fctors tht ffect complince either negtively (brriers), leding to noncomplince, or positively, leding to complince. Stndrd precutions is system of brrier precutions to be used by ll personnel for contct with blood, ll body fluids, secretions, excretions, nonintct skin, nd mucous membrnes. It pplies to ll ptients receiving cre in hospitls, irrespective of their dignosis or presumed infection sttus [13]. Although this study supports previous studies in reporting less thn 100% complince rte with stndrd precutions, trend towrd improved complince is evident. The level of complince in this study is similr to finding from Alexndri Teching Hospitls (57.5, 46.3%, respectively) [11] nd higher thn the report from t he UAE (19%) [14], but lower thn the finding in Ethiopi (80.8%) [15]. The rte of use of stndrd precutions in teching hospitls in developed countries is considerbly higher thn tht in our hospitls [16,17]. In ddition, previous study mong medicl doctors working in tertiry cre hospitl in Pkistn reported tht complince with hnd wshing ws 86%, tht for wering gloves ws 79% nd msks 46%, nd 45% for the use of gowns/plstic prons. Prtil complince nd suboptiml prctices were lso reported in other countries such s Nigeri [18], Indi [2], nd the UK [19], where HCWs mke unjustified ssessments of risks from nd infection sttus of clients rther thn properly nd consistently pplying stndrd precutions. However, there re sometimes high rtes of noncomplince mong HCWs nd this my be

6 Complince to stndrd precutions Mortd nd Zlt 11 Tble 4 Reltionship between subscles of Helth Belief Model nd personl chrcteristics of the smpled surgeons Vribles Ctegories Men ± SD susceptibility severity benefi ts brriers self-effi ccy Cues to ction Sex Mle 4.0 ± ± ± ± ± ± 1.47 Femle 4.1 ± ± ± ± ± ± 1.38 T P vlue * Age groups (yers) < ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± ± 2.1 F b P vlue * 0.000* Specilty Generl surgery 4.01 ± ± ± ± ± ± 1.3 Gynecology nd 4.09 ± ± ± ± ± ± 1.5 obstetrics Urology 4.2 ± ± ± ± ± ± 1.6 Orthopedic 3.94 ± ± ± ± ± ± 1.6 F ± 1.13 b 0.56 P vlue * 0.011* 0.64 Job title Residents 4.18 ± ± ± ± ± ± 1.22 Assistnt lecturer 4.23 ± ± ± ± ± ± 1.03 Lecturer 4.05 ± ± ± ± ± ± 1.42 Assistnt professor 3.94 ± ± ± ± ± ± 1.58 Professor 4.06 ± ± ± ± ± ± 1.6 F b 5.63 P vlue * Yers of experience < ± ± ± ± ± ± ± ± ± ± ± ± 1.36 T P vlue 0.05* * Trining in infection No 3.9 ± ± ± ± ± ± 1.2 control Yes 4.2 ± ± ± ± ± ± 1.5 T P vlue 0.003* * 0.000* 0.000* Exposure to NSI No 3.69 ± ± ± ± ± ± 1.15 Yes 4.29 ± ± ± ± ± ± 1.49 T P vlue 0.000* 0.000* * 0.000* 0.000* Exposure to splshes No 4.01 ± ± ± ± ± ± 1.19 Yes 4.1 ± ± ± ± ± ± 1.67 T P vlue * 0.000* NSI, needle-stick injury; Mnn Whitney ws the test used; b Kruskl Wllis ws the test used; *Signifi cnce difference (P 0.05). becuse of lck of understnding mong HCWs of proper use of protective brriers. Furthermore, noncomplince mong medicl doctors nd nurses is ssocited with insufficient knowledge, work plce sfety, forgetfulness, nd worklod [20,21]. Among the demogrphic chrcteristics, only sex show significnt difference, where women were highly complint with stndrd precutions. Of complint surgeons, 46.7% were yers old, 42.6% worked in the generl surgery deprtment, nd 55.7% hd spent 10 or more yers in their current occuption, which differed from previous finding tht reported higher level of noncomplince mong older HCWs; this cn be ttributed to the fct tht yers of experience nd trdition my result in resistnce to chnging their behvior. We found tht 47% of the surgeons questioned hd sustined t lest one NSI in the pst 3 months preceding the study. A higher prevlence of NSI ws reported mong HCWs of University of Alexndri Hospitls nd Mlysin Teching Hospitls (67.9 nd 52.9%, respectively) [11,22]. However, in Vietnm, 38% of physicins reported sustining shrp stick injury in the previous 9 months [23]. Much lower finding of 1-yer prevlence of NSI ws obtined in report from the UAE by Jcob et l. [14], in which

7 12 Journl of the Arb Society for Medicl Reserch Tble 5 Correltion between surgeons complince nd Helth Belief Model subscles Complince Knowledge susceptibility severity benefi ts brriers self-effi ccy Cues to ction Complince 1 Knowledge 0.293** 1 susceptibility 0.126* 0.235** 1 severity 0.13* 0.359** 0.839** 1 benefi ts ** 0.163** 1 self-effi ccy * brriers ** 0.563** 0.587** 0.099** 0.25** 1 Cues to ction ** 0.515** ** 0.623** 1 *Correltion is signifi cnt t the 0.05 level (two-tiled); **Correltion is signifi cnt t the 0.01 level. 19% of HCWs fced injury, but lower thn finding in northern Ethiopi [15], in which 3-month prevlence of 17.2% ws reported. The vrition in this prevlence my be relted to the different ctegories of HCWs involved in these studies. Physicins mostly do not dminister injections nd hence their risk of injury exposure is lower thn tht of nurses. Housekeepers clen nd collect wste without protective equipment nd hence re t high risk of exposure to injury. Accurte informtion on the risk of blood-borne trnsmission from occuptionl exposure to needle sticks is necessry nd should include informtion on the most effective mesures to control exposure nd infection. In greement with nother study mong HCW in Ethiopi [24], our study detected high level of self-reported exposure to blood nd body fluids (61.3%) tht ws significntly different mong noncomplint compred with complint surgeons. Trining nd eduction hve been found to be of prmount importnce in developing wreness mong HCWs s well s improving dherence to good clinicl prctice [25,26]. The level of trining in terms of stndrd precutions of the current prticipnts (57.8%) is higher thn finding obtined in study crried out in Indi [2], in which 36% HCWs hd received trining. Unfortuntely, receiving trining ws not found to be protective from occuptionl exposures such s NSI nd exposure to splshes of blood nd body fluid. This will be mjor chllenge to infection prevention efforts. This is similr to previous reports [27 29] in which trining to HCWs does not necessrily seem to led to protection from exposures. The reson for this my be tht the knowledge cquired my not necessrily trnslte into prctice of preventive mesures or tht the trining provided my be more theoreticl thn prcticl, nd the limited sources of continuous informtion on stndrd precutions. The lck of n enbling environment to comply with stndrd precutions my hve lso contributed towrd poor complince in these studies. Idelly, HCWs re expected to hve good understnding of the risk of BBPs t t he work plce nd of the preventive mesures for reducing risk. Also, this study found tht their knowledge ws dequte s the men score of the overll knowledge level of the surgeons ws high (14.3 ± 3.5) compred with tht (3.8 ± 2.3) in previous study t first cre fcilities in Pkistn [10], nd slightly high mong complint thn noncomplint surgeons, which indicted tht the consistent use of universl precutions cn prevent mjor exposure to BBPs. Similrly, previous studies in the university hospitl of the West Indies nd in Thilnd reported high knowledge of universl precutions mong medicl doctors [30]. The lower level of knowledge cn be ttributed to the incorportion of occuptionl sfety, lck of investment in stff trining, or limited understnding of HCWs sfe behvior in the clinicl setting [31,32]. The differences in the knowledge of universl precutions mong HCWs my be influenced by their different types of trining. Also, there could be methodologicl differences in the ssessment of knowledge levels in different studies. In ddition, HCWs commonly overestimte their knowledge nd prctices of infection prevention [2,33], the mgnitude of which is methodologiclly difficult to estimte. Providing regulr nd systemtic eductionl progrm my improve knowledge mong HCWs. This study prtilly supports the findings of n erlier study tht showed tht constructs of the HBM re pproprite to identify ttitudes of HCWs in terms of stndrd precutions [34]. Brriers to complince hve been reported extensively in previous studies. Some of these include lck of time (71 74%), perceived low risk of ptient (50 57%), PPE interfering with cre (55%), nd PPE not vilble ( %) [35]. This study shows tht ll HBM subscles were correlted directly with the surgeons complince, except perceived brriers. However, previous studies [35] hve concluded tht correltion exists between

8 Complince to stndrd precutions Mortd nd Zlt 13 brriers nd complince. In ddition, perceptions of risk, severity, nd benefits lso exert n influence on complince s reported by previous study mong operting room nurses in Austrli [36]. It is cler from the dt nlysis nd discussion tht mesures must be implemented to increse surgeons complince with stndrd precutions. Stndrd precutions re guidelines developed to protect the HCW from occuptionl exposure. The commonly recommended preventive strtegies for incresing conformity with stndrd precutions include eduction, wreness cmpigns, use of riskreducing devises such s single-use needles, reduction of unnecessry injections, legisltive ction, provision of PPE, introduction of sfety guidelines nd reporting mechnisms, nd creting complince-enbling environment [37,38]. The involvement of HCWs in infection control decisions is considered importnt [39]. The best wy to enble the stff to comply with written policies is to llow the stff to develop the policy. The more the input tht stff members provide into policies on the unit, the more likely they re to comply with stndrd precutions [40]. Noncomplince is determined by rnge of fctors including lck of knowledge [17], interference with work skills [33], risk perception, conflict of interest [17,33], not wnting to offend ptients [39], lck of equipment nd time, uncomfortble PPE [33], inconvenience, work stress [20], nd perceiving wek orgniztionl commitment to sfety climte [20,21]. In our study, nlysis of findings from the Preto chrt guided us on how to solve the 80% noncomplince problem by providing PPE to the surgeons, trining courses for the surgeons, nd incresing their informtion b out MOHP guidelines. Similrly, nother study crried out t first-level cre fcilities in Pkistn [10] reported tht lck of knowledge, poor qulifictions, bsence of system for prevention of BBPs nd lck of trining, equipment, nd postexposure prophylxis re mjor determinnts for noncomplince. The differences in complince between studies my be ttributed to the differences in infection control polices mndted by ech hospitl or fcility. The BBP prevention system is present in few tertiry cre hospitls nd none of the first-level cre fcilities. First-level cre fcilities in the privte sector re completely different from hospitls becuse of their si ze, orgniztion, mnpower qulifictions nd trining, nd vilble finnces. All these fctors influence the BBP prevention progrm t these fcilities nd rise importnt prgmtic nd ethicl questions. As this is cross-sectionl study, the limittions tht come with this type of design need to be tken into considertion when interpreting the findings. There ws fewer thn expected prticiption by surgeons s most of the time, they were busy t the clinics or operting rooms, which introduces possibility of selections bis. Reporting of prctices hs been known to be ffected by socil desirbility towrd better prctices. In conclusion, this study showed tht there is dequte complince with stndrd precutions mong surgeons in Zgzig University Hospitls, especilly femle surgeons. Knowledge of the mode of trnsmission of BBPs nd precutions ws high mong complint thn noncomplint surgeons. All HBM subscles were correlted directly with the surgeons complince, except perceived brriers. Therefore, it is necessry to determine more fctors tht influence complince (positively nd negtively) nd develop plns to eliminte those tht do not llow the implementtion of stndrd precutions nd promote those tht do. Our findings suggest tht trining of surgeons to increse their knowledge of BBPs nd universl precutions could improve their use of universl precutions. 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