Healthcare Infection 2009; 14: 18

Healthcare providers knowledge of standard

precautions at the primary healthcare level
in Saudi Arabia

LY

Tarek Amin1,3 MD, MPH

Adel Al Wehedy2 MD, MPH
1

ON

Department of Family and Community Medicine, College of Medicine-Al Hassa, King Faisal University-KSA,
PO Box 400, Hofuf, Saudi Arabia.
2
Ministry of Health, Health Directorate-Al Hassa, Hofuf, Saudi Arabia.
3
Corresponding author. Email: amin55@myway.com

Abstract

PRO

OF

The aim of this study was to assess knowledge of standard precautions (SPs) and infection control by healthcare workers (HCWs) at
the primary healthcare level in Al-Hassa, and to define possible correlates that influence such knowledge. All HCWs at primary
healthcare centres in Al-Hassa were targeted for the survey. A self-administered questionnaire was designed and pre-tested. The data
gathered covered basic knowledge of components of SPs and infection control including objectives, hand hygiene, personal protective
equipment, sharps disposal, environmental sanitation and care of healthcare providers. Attitudes pertaining to implementation of SPs
and training needs were also assessed. Knowledge deficits of components of SPs were demonstrated, especially those related to hand
hygiene, sharps disposal, management of sharps injuries and environmental cleaning. Misconceptions were identified in the
management of HCWs after exposure to patients with communicable diseases and following sharps injuries. Age of providers,
speciality and previous on-the-job training did not influence the knowledge of the participants. Female gender, holding a
postgraduate degree and >5 years of experience in primary healthcare were positive correlates to the knowledge score. Lack of
resources and training opportunities, and excessive workload were the most frequent factors cited by HCWs for not implementing
SPs during routine tasks. The level of knowledge of SPs by HCWs in primary healthcare in Al-Hassa is low. Current training and
medical and nursing school curricula should therefore be revised.

Introduction

Healthcare workers (HCWs) are at risk of acquisition of

communicable diseases due to their exposure to blood and body
fluids.1 The United States Centers for Disease Control proposed a
series of procedures that HCWs should comply with for all
patients regardless of their diagnosis. These are known as
standard precautions (SPs).2 These precautions require the
application of basic principles of infection control through hand
hygiene, the use of appropriate protective equipment, safe
handling of needles and sharps devices and proper waste
disposal.1,2 SPs are important because they potentially provide
protection to HCWs and reduce the risk of illnesses and
manpower loss. Non-compliance may result in transmission of
infection to other patients, visitors and HCWs.2 Hospital-acquired
infections in primary healthcare are underreported and often
underestimated.3 5 Most studies have assessed infection
control and SPs at higher levels of care (i.e. hospitals), however,
the change of term from hospital-acquired infection to

 Australian Infection Control Association 2009

healthcare-associated infection acknowledges that a similar

burden may exist at the primary care level.5
The relatively recent SARS epidemic6 and the imminent
influenza pandemic highlight the potential risks to HCWs at
the primary care level.6 These events necessitate prompt
interventions to increase knowledge and subsequent improved
compliance to SPs by HCWs.
Non-compliance with SPs by HCWs has been postulated to be
determined by a range of factors including lack of knowledge,8
interference with flow of work,8 10 and perception of risk.10
Several studies reported that lack of appropriate knowledge of
SPs and infection control was the main predictor for poor
compliance,3,810 but studies at the primary healthcare level
are very few, especially in developing countries. The objectives
of this study were to assess knowledge of HCWs regarding
SPs and infection control at the primary healthcare level in

DOI: 10.1071/HI09107

Healthcare Infection

T. Amin and A. Al Wehedy

Al-Hassa and to define possible correlates that influence such

knowledge.

Methods

coefficient (Cronbachs a) was 0.62. Elimination of items related

to sterilisation procedures, methods of disinfection and detailed
inquiries about environmental sanitation, resulted in a final
form comprising 50 items, with a reliability coefficient of 0.72.

Questionnaire administration

Al-Hassa Governorate is located in the Eastern Province of

Saudi Arabia with a total population of about 1 million. Ministry
of Health is the biggest provider of healthcare in Saudi Arabia,
providing services through 186 of the countrys 314 hospitals
and 1756 of its 3756 primary healthcare (PHC) centres. The
medical consultations are overwhelmingly physician-oriented.
In Al-Hassa, there are 54 PHC centres. The total personnel
employed is 1840: 612 urban; 1079 rural; and 149 Hegar (Bedouin
scattered communities).

A series of orientation sessions were conducted by the

investigators at various PHC centres and local health directorates
to explain the objectives of the study, how to fill the questionnaire
and potential outcomes of the survey. The questionnaire was
administered on a solicited basis at the end of the sessions under
the supervision of the investigators.

Participants

ON

LY

Setting

A total of 1004 HCWs registered in 2008, including physicians,

dentists, pharmacists, nurses and midwives, laboratory
technicians, X-ray technicians and health inspectors, were
invited to participate in the study.

Data collection

Basic characteristics and demographic data: speciality,

location of PHC centres, age, gender, duration of work at
primary care level, educational attainments, nationality and
previous training in infection control and SPs.
Assessment of knowledge towards SPs and infection control
principles using 50 items to cover the following areas: general
concept of SPs and infection control; hand hygiene; personal
protective equipment; sharps disposal and environmental
sanitation; sharps injuries and occupational infection; and care of
healthproviders.Itemswereinthe formofclosed-endedquestions
(true or false, agree or disagree and multiple-choice options).
Attitudes towards implementation of infection control and
SPs at their health facilities, availability of resources and the
need for training were included in the final part of the
questionnaire.

PRO

A total of 817 forms were returned with a response rate of 81.4%;

31 were incomplete and therefore omitted. Collected data was
entered and analysed using SPSS version 12 (SPSS Inc. Chicago,
IL, USA). Frequencies and percentages, means and standard
deviations were used to summarise data, and Kruskall Wallis
and ManWhitney tests of significance were applied. To determine
the association between total knowledge scores, demographic and
basic characteristics of HCWs, multiple linear regression analysis
was performed with total knowledge score as the outcome
dependent variable, and demographic and basic characteristics as
predictor variables. Categorical variables were coded to generate a
dichotomy using the dummy coding scheme. A value of P < 0.05
was considered statistically significant.

OF

Self-administered questionnaires were distributed, the content

of which was adapted from the literature on SPs and infection
control guidelines.11,12 The final data collection form included
the following.

Data management and processing

A scoring system was assigned for the included items: 1, correct

response; 0, incorrect and do not know responses. The original
questionnaire form was in English; it was translated into Arabic with
back translation to English to ensure content validity. Both Arabic
and English versions were pre-tested and used for data collection.
Pilot testing was carried out with 26 health providers at King
Faisal University Medical Center, providing primary care to
the Universitys employees using the originally designed
questionnaire comprising 62 items, for which the reliability
2

Ethical considerations
The research proposal and questionnaire were approved by
both our institution as well as the local health directorate in
Al Hassa. Anonymity and confidentiality of the responses were
maintained, and voluntary participation and the right to nonparticipation was emphasised.

Results
The age of the respondents (n = 786) ranged from 20 to 59 years
(mean 32.7  19.4). Specialties included were as follows:
229 (29.1%) physicians (of which 29 were dentists), 389 (49.5%)
nurses and midwives, 61 (7.8%) pharmacists, 69 (8.8%) laboratory
technicians, 38 (4.8%) X-ray technicians and health inspectors.
Table 1 displays the demographic and basic characteristics of
the total manpower employed at PHC centres and those of
the participants. A total of 43% was trained for 12 days on the
basic principles of infection control in the form of lectures.

Knowledge of standard precautions

Tables 2 and 3 display the correct responses of the
participants regarding different features of SPs.

Healthcare Infection

Standard precautions and infection control

Table 1. Basic characteristics of surveyed primary healthcare providers.

Characteristics

Total population

Response %

surveyedA (n = 1004)
No.

244

24.3

29.1

503

50.1

49.5

78

7.8

8.8

114

11.3

7.8

65

6.5

4.8

Physicians and dentists

Nurses and midwives
Laboratory technicians
Pharmacists

ON

X-ray technicians and health inspectors

LY

Specialty

Primary healthcare centre location

Urban

520

51.8

59.8

358

35.7

29.9

126

12.5

10.3

457

45.5

50.3

547

54.5

49.7

437

43.5

44.4

5<10 years

218

21.7

20.1

10<15 years

189

18.8

18.2

>15 years

160

16.0

17.3

98

9.8

11.2

MB BCh

195

19.4

19.6

Technical diploma

662

65.9

66.9

49

4.9

2.3

Saudi

534

53.2

47.2

Arab non-Saudi

243

24.2

26.0

Non-Arab

227

22.6

26.8

438

43.6

43.1

Rural

Hegar (Bedouin scattered communities)

Gender
Male

OF

Female
Primary healthcare work experience
0<5 years

PRO

Educational attainments
Postgraduate

Secondary general education

Nationality

Previous training in infection control: Yes

A

Does not include clerical workers, servants and cleaning staff.

Only 19.5% correctly identified the duration recommended for

routine hand washing. Over 45.4% of participants did not
believe that hand hygiene was required during the care of
patients with influenza-like illness. The misconception that
personal protective equipment can eliminate the risk of acquiring

zan occupational infection was believed by 75.8% of participants,

whereas 40% thought that personal protective equipment was
protective to laboratory and cleaning staff because they are
more exposed to hazardous waste and sharps injuries, and that it
was optional for HCWs.
3

Healthcare Infection

T. Amin and A. Al Wehedy

Table 2. Knowledge of surveyed providers regarding concept of standard precautions, infection control, hand hygiene
and personal protective equipment.
Correct answers are given in parentheses: T, true; F, false (authors point of view).
Knowledge domains

Correct responses
No.

571

72.6

352

44.8

All patients are sources of infection regardless their diagnoses (T)

689

87.8

All body fluids except sweat should be viewed as sources of infection (T)

643

81.8

All health providers are at risk of occupational infections (T)

663

84.4

Hand washing minimises microorganisms acquired on the hands if soiled (T)

377

50.0

Hand washing reduces the incidence of healthcare-related infections (T)

705

89.7

Standard hand washing includes washing of both hands and wrists (T)

194

24.7

In standard hand washing: minimum duration should be >60 s (T)

153

19.5

Hand decontamination: includes forearms with antiseptic soap for 30 s (T)

481

61.2

Alcohol hand rub substitutes hand washing even if the hands are soiled (F)

498

63.4

Hand washing is indicated between tasks and procedures on the same patient (T)

571

72.6

Use of gloves replaces the need for hand washing (F)

499

63.4

Hand washing is indicated after removal of gloves (T)

633

80.5

Hand washing is needed with patients with respiratory infections (T)

318

54.6

PPE such as masks and head caps provides protective barriers against infection (T)

571

72.6

PPE should be chosen according to type of exposure and procedures (T)

616

78.4

Use of PPE completely eliminates risk of acquiring occupational infections (F)

190

24.2

PPE is exclusively suitable to laboratory and cleaning staff for their protection (F)

469

59.7

PPE should be used only whenever there is contact with blood (F)

669

85.1

Gloves and masks should be re-used after proper cleaning (F)

544

69.2

Used PPE are to be discarded through regular municipal disposal systems (F)

643

81.8

Gloves should be changed between different procedures on the same patient (T)

345

43.9

Masks made of cotton or gauze are the most protective (F)

313

39.8

Masks and gloves can be re-used if dealing with same patient (F)

466

59.3

LY

General concepts
The main goal of infection controlA

ON

Meaning of standard precautionsB

OF

Hand hygiene

PRO

Personal protective equipment (PPE)

A
B

To minimise or eliminate the risk of healthcare-associated infection to patients and healthcare workers.

A set of precautions designed to prevent the transmission of HIV, hepatitis B and other blood-borne pathogens in the healthcare setting.

Healthcare Infection

Standard precautions and infection control

Table 3. Knowledge of surveyed providers regarding sharps and waste disposal, environmental sanitation and care of healthcare workers.
Correct answers are given in parentheses: T, true; F, false (authors point of view). MRSA, methicilin-resistant Staphylococcus aureus.
Knowledge domains

Correct responses
No.

Used needles should be recapped after use to prevent injuries (F)

511

65.0

Used needles should be bent after use to prevent injuries (F)

559

71.1

230

29.3

Dry sweeping is recommended twice a day for patients waiting area (F)

349

44.4

Transferring infection from instruments is procedure-dependent (T)

527

67.0

Disinfection means removal of microorganisms without sterilisation (T)

517

65.8

Blood-soiled stethoscope can be disinfected by using detergent and water (F)

283

36.0

Soiled sharps objects should be shredded before final disposal (T)

205

26.1

Gluterdehyde provides a high level of disinfection (T)

462

58.8

Multi-drug resistant tubercle bacilli require special disinfection (F)

257

32.7

505

64.2

Needle-stick injuries are the least commonly encountered in general practice (F)

296

37.7

Health providers with highest risk of exposure to tuberculosis include radiologists (T)

522

66.4

MRSA stands for multi-drug resistant Staphylococcus aureus organisms (F)

291

37.0

MRSA may be transmitted on hands of healthcare providers (T)

271

34.5

Immunisation history of providers should be obtained before recruitment (T)

705

89.7

Routine immunisations for healthcare providers include HIV, rubella and rabies (F)

342

43.5

Healthcare providers should receive annual influenza vaccine (T)

221

28.1

Healthcare providers should be tested annually by tuberculin skin test (T)

254

32.3

The risk for a health provider to acquire HIV infection after needle-stick injury is <0.5% (T)

203

25.8

Postexposure prophylaxis is used for managing injuries from a HIV-infected patient (T)

105

13.4

Postexposure immunisation prevents the risk of hepatitis B infection following exposure (T)

183

23.3

For the prevention of hepatitis B, immunisations are recommended for all healthcare workers (T)

278

35.4

Immediate management of sharps injuries includes washing in running water and soap (T)

617

74.5

Following exposure to a patient with flu, antibiotics are required for prevention of infection (F)

117

14.9

Sharps injuries and occupational infection

ON

Sharps container is labelled with cross (F)

LY

Sharps disposal and environmental sanitation

PRO

Care of healthcare workers

OF

Sharps injuries should be managed without the need of reporting (F)

Other misconceptions: 30.8% of participants believed gloves and

masks could be reused after cleaning and 56% approved using the
same gloves if dealing with the same patient but with different
procedures.

A total of 35% recapped needles believing that it prevented

sharps injuries and 28.9% believed that bending needles
prevented injuries (Table 3). Furthermore, 35% of participants
believed that they should manage their own sharps injuries
5

Healthcare Infection

T. Amin and A. Al Wehedy

A lack of resources at PHC centres to implement SPs was cited by

43.9%, lack of training by 33.2% and work overload by 42.9%.
These were the main factors deterring participants from
compliance during routine care.

Discussion

A study conducted among nurses and paramedical staff,

reported that only 61% of participants were aware of SPs and
infection control guidelines,13 whereas in Iran,8 78% of HCWs
were aware of SPs but their application was dedicated only
to patients with HIV and hepatitis B infections.

ON

Only 13.4% were aware of the role of postexposure prophylaxis

following a significant sharps injury from a HIV-infected patient,
and just 23.3% recognised the value of immunisation against
hepatitis B. A total of 85% of participants believed that antibiotics
could prevent influenza following exposure.

Possible correlates with knowledge

The need for on-the-job practical training in SPs and infection

control guidelines was cited by 53.7% of participants.

LY

without reporting the incident. Over 60% of the participants

could not correctly define the abbreviation MRSA as methicilinresistant Staphylococcus aureus. Only 28.1% of participants
recognised the need for annual influenza vaccination and 32.3%
agreed that HCWs should be screened annually for
tuberculosis.

In Saudi Arabia, it was reported that there was a lack of

knowledge of infection control measures by HCWs in hospitals
as well as at a primary care level.13

In our study, only 44.4% of HCWs identified the objectives of SPs,

a lower rate than previously found.13 This may be explained
by the fact that SPs are not recognised at a primary level of care
compared with hospital care. The curricular content of medical
and nursing schools in Saudi Arabia as well as in other
developing countries does not emphasise the role of SPs and
infection control. In developing countries, SPs are often
practiced incompletely, with limited understanding of SPs and
thus suboptimal compliance.13,14

PRO

OF

The total knowledge score of the participants was 27.8  5.9

(median 28, minimum 22 and maximum 37 out of 50). Physicians
and dentist demonstrated total higher scores (31.8  3.7)
compared with other specialties (P = 0.001). Laboratory
technicians showed a higher score for sharps management,
whereas nurses and midwives were more knowledgeable
around the care of HCWs (P = 0.001). Those at Hegar and
rural health centres had a score of 31.5  5.1 and 30.2  4.5,
respectively, compared with 29.1  6.6 for those at urban centres
(P = 0.001), and were more knowledgeable of hand hygiene
and sharps management. Females achieved a higher score for
knowledge of hand hygiene, sharps sanitation and care of
HCWs compared with males (30.1  5.1 v. 29.4  6.5, respectively).
PHC centre work experience influenced knowledge scores,
as those with <5 years experience had the lowest score (28.7  6.8).
Those with postgraduate degrees showed a higher score
compared with other categories (31.6  4.0). Non-Arab HCWs
achieved the highest score (33.5  3.3), followed by Arab nonSaudi HCWs (31.2  3.7), with Saudi HCWs achieving the
lowest score (28.2  6.2). Previous training in infection control
guidelines affected the total knowledge score of participants
(29.9  5.2 for previously trained compared with 29.6  6.4).
Table 4 demonstrates the results of a multiple
regression model where total knowledge scores were the
dependent variables against possible demographic and basic
characteristics of the surveyed providers. Total knowledge
score was positively correlated with the location of PHC (rural
and Hegar), female gender, >5 years working experience at a
PHC centre, postgraduate studies and non-Saudi nationality;
it was not affected by age, speciality and previously received
training.

Attitudes towards standard precautions

and the need for training
The importance of SPs when caring for patients with known
infectious conditions was appreciated by 53.8% of participants.

Our study revealed a lack of knowledge of basic procedures

involving routine tasks and related to hand hygiene,
environmental cleaning and sharps management. This is
consistent with the results of other studies.10,1517 Participants in
primary care are underresourced with regard to education about
occupational hazards,8,13,14,16 mode of transmission of bloodborne pathogens,17 barrier protection and manipulation of
injection equipment. These factors contribute to a higher risk of
injuries for HCWs and the potential risk of infection with bloodborne pathogens such as hepatitis B and C, and HIV.15
In one study, only 8.4% of participants reported compliance
with infection control procedures,13 and compliance was
associated with knowledge and experience in years.
Our results are consistent with previous findings. Considering
the diversity of nationalities represented in the work force,
different background knowledge and qualifications and training
may influence overall knowledge and thus subsequent compliance.
Physicians and nurses at secondary and tertiary levels are at
potentially greater risk of exposure to a wide variety of infection
control practices compared with those at a primary level of
care.16,17

Healthcare Infection

Standard precautions and infection control

Table 4. Multiple regression analysis model of the total knowledge score in relation to the included demographic and basic
characteristics of primary healthcare providers.
Outcome dependent variable:
total knowledge score

Unstandardised
1.100

Speciality
Other specialties

2.565

Primary healthcare centre location

5 years
Educational attainment
Non-postgraduate
Postgraduate
Nationality

Non-Saudi

0.284 to 1.916

0.471

4.481 to 9.612

0.169

0.007*

1.557 to 7.853

0.084

0.020*

1.229 to 4.377

0.110

0.033*

1.418 to 5.212

0.054

0.013*

1.538 to 4.373

0.311

0.001*

4.293 to 16.430

0.240

0.192

3.214 to 6.313

Reference group
1.128

Reference group
1.419

Reference group
1.397

Reference group

PRO

Saudi

2.150

OF

>5 years

0.183

Reference group

Rural and Hegar (Bedouin scattered

communities)

Working duration

0.065

ON

Urban

Female

0.158

Reference group

Physicians and dentists

Male

95% Confidence
intervals

LY

Age

Gender

P value

coefficient

10.362

Previous training
No
Yes

Reference group
1.532

Constant = 79.643; r = 0.473; *P = 0.004, statistically significant and P without.

One aspect of reduced compliance is the lack of reporting of

sharps incidents10,16,17 at higher levels of care. Lack of
awareness of occupational exposure management was also
demonstrated in our survey.
The SARS experience revealed substandard epidemic
preparedness and contingency plans among practitioners at a
primary level, coupled with inadequate knowledge and training.18
With the probability of an influenza pandemic,7 compliance with
hand and respiratory hygiene may be the only means for
controlling its potential impact, particularly at the primary
healthcare level in some countries.6,7

In Riyadh,13 it was found that those aged <40 years, of Arabic

descent with <15 years experience were significantly less
compliant compared with those aged 40 or more, non-Arab, and
with >15 years experience, whereas in Pakistan,16 it was reported
that knowledge was greatest among 3040-year-old practitioners
with university diplomas. This included laboratory workers and
female participants.
Our results show that experience, gender and educational
attainments are determinants of the level of knowledge. In Saudi
Arabia, as in many other developing countries, undergraduate
curricula do not emphasise the role of infection control and SPs.

Healthcare Infection

T. Amin and A. Al Wehedy

6.

Goh LG, Cheong PY. The pandemic influenza threat: a review

from the primary care perspective. Prim Care Respir J 2006; 15: 2227.
doi:10.1016/j.pcrj.2006.04.193

7.

Wilson N, Baker M, Crampton P, Mansoor O. The potential impact

of the next influenza pandemic on a national primary care
medical workforce. Hum Resour Health 2005; 3: 712. doi:10.1186/
1478-4491-3-7

8.

Motamed N, BabaMahmoodi F, Khalilian A, Peykanhertitati M,

Nozari M. Knowledge and practices of health care workers and
medical students towards standard precautions in hospital in
Mazandran Province. East Mediterr Health J 2006; 12: 65361.

LY

Lack of resources, lack of training and excessive workload were

the major factors preventing HCWs at the primary level from
practicing SPs. This is consistent with other studies.16,19 Some
studies,6,17,19,20 have shown that incorrect perceptions of HCWs
deterred them from practicing hand hygiene. Workload, lack of
institutional guidelines, lack of knowledge and/or experience,
lack of role models and a sense of reward contributed to a lack
of compliance. Annual educational programs highlighting
SPs and infection control guidelines have been shown to increase
retention of knowledge and improve attitudes, with an overall
improvement in compliance and a decrease in the risk of
exposure at the primary level of care.4,5,19,20

10. Ayranci U, Kosgeroglu N. Needle-stick and sharp injuries

among nurses in the health care sector in a city of western Turkey.
J Hosp Infect 2004; 58: 21623. doi:10.1016/j.jhin.2004.06.029

None declared.

Funding

PRO

None.

11. World Health Organization. Practical guidelines for infection

control in health care facilities. Regional office for South-East Asia
and Western Pacific. SEARO Regional Publication No. 41. Geneva:
WHO; 2004. pp. 449.
12. Siegel JD, Rhinehart E, Jackson M, Chiarello L, Healthcare Infection
Control Practices Advisory Committee, 2007. Guideline for isolation
precautions: preventing transmission of infectious agents in
healthcare settings 2007. Atlanta: Centers for Disease Control and
Prevention; 2007. Available online at: http://www.cdc.gov/ncidod/
dhqp/gl_isolation.html [verified May 2009].
13. Maqbool A. Knowledge, attitude and practices among health care
workers on needle-stick injuries. Ann Saudi Med 2002; 22: 3969.

OF

The level of awareness of SPs among providers at PHC centers

in Al-Hassa is low, with several misconceptions and a
perception of low risk. Current training, including medical and
nursing school curricula, should be revised to include the
epidemiology of blood-borne infections, ergonomics and
increasing the perception of risk.

Conflicts of interest

Stein AD, Makarawo TP, Ahmad MF. A survey of doctors and

nurses knowledge, attitudes and compliance with infection
control guidelines in Birmingham teaching hospitals. J Hosp Infect
2003; 54: 6873. doi:10.1016/S0195-6701(03)00074-4

ON

Conclusion

9.

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