To prevent the spread of infection of tuberculosis (TB), sufficient knowledge and safe practices regarding occupational exposure are crucial for all employees working in TB hospitals.
To explore and describe the knowledge and practices of employees working in three specialised TB hospitals in Nelson Mandela Bay, Eastern Cape, regarding occupational exposure to TB.
A quantitative, descriptive and contextual study was conducted using convenience sampling to have 181 employees at the three hospitals elected to complete the self-administered questionnaire, which was distributed in December 2016. Three scores on a scale of 0–10 were calculated per participant:
Approximately, one-third (34%) of the participants were between the ages of 36 and 45 years. Most of the participants (63%) attended high school and less than one-third (28%) had a tertiary qualification. The majority of participants (62%) had not received any clinical training. Participants displayed high scores (> 6) for
Employees’ knowledge regarding occupational TB exposure was generally high, but they were not necessarily practicing what they knew. Further research is required regarding appropriate managerial interventions to ensure that employees’ practices improve, which should reduce the risk of occupational TB exposure.
Tuberculosis (TB) is currently regarded as the leading cause of death from infectious diseases. Tuberculosis is ranked ninth as the leading cause from a single infectious agent, ranking above the human immunodeficiency virus (HIV) and the acquired immunodeficiency syndrome (AIDS). The latest World Health Organization global report states that in 2017, there were approximately 10.4 million incident cases of TB alone, and approximately 1.6 million people died from this disease (World Health Organization
South Africa is among the top 30 countries with the highest burden of TB (World Health Organization
Tuberculosis is an infectious disease caused by the bacteria
Avoidable TB infections among employees can be prevented with good knowledge and practises related to infection control principles, underpinned by a good standard of hygiene. Of particular significance is having the personal discipline to undertake simple, repetitive tasks such as hand washing, frequently and thoroughly (National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention
There is an urgent need to improve existing TB infection, prevention and control measures in specialised TB hospitals by providing training to healthcare workers and ancillary staff to develop good practices in applying organisational infection control policies and procedures (Grobler et al.
In South Africa, the health and safety of all employees at work is covered by the
The hospitals in this study had active infection control programmes in place and were expected to provide the workers in these institutions with sessions where they are equipped with the relevant knowledge and practices to have information on infection control and occupational exposure to TB. However, the researcher observed discrepancies in terms of infection control practices. For example, employees only wore protective coats as protection against cold in winter but did not wear protective coats in summer. Because of lack of office space, there were no patient consultation rooms for part-time doctors which led to the nurse’s duty rooms being used for consulting patients. The same duty rooms that were used for patient consultations were used as dining rooms during tea and lunch breaks for staff. Even though there were hand-washing basins in all wards, employees seldom washed their hands. Furthermore, although patients are regarded as highly infectious during admission, neither of the employees who work in the admission desk wore a mask when admitting patients. General assistants, workshop employees and drivers also seldom wore masks even when working in the wards or while transporting patients. It was unclear whether workers had sufficient knowledge regarding these practices in order to prevent occupational exposure. Therefore, the researcher aimed to explore and describe the knowledge and practices of employees in three specialised TB hospitals in Nelson Mandela Bay in the Eastern Cape, South Africa, regarding occupational exposure to TB.
A quantitative, descriptive and contextual study was conducted in 2016 at three specialised TB hospitals in Nelson Mandela Bay, in the Eastern Cape, South Africa.
At the time the study was conducted, the three hospitals A, B and C had approved bed capacities of 350 with a total of 100 employees (hospital A), 333 with a total of 90 employees (hospital B) and 186 with a total of 63 employees (hospital C). During the period the study was conducted, the total number of employees in all three hospitals was 253 of which 137 were nursing and clinical personnel, with the remaining 116 being non-clinical personnel, such as cleaning, maintenance and administration personnel. The hospitals are all specialised TB hospitals admitting patients diagnosed with TB responsive to all drug therapy, whereas hospital C also admits patients with drug-resistant TB types such as MDR-TB and XDR-TB. As the population size was small, a convenience sample of the entire population (
A self-administered questionnaire was used, which was adapted and piloted with permission from a study that was conducted by Bhebhe, Van Rooyen and Steinberg (
To measure participants’ knowledge and practices on a quantitative scale, various techniques were used to convert the responses to questionnaire items to scores in the range 0 (all incorrect or inappropriate responses) to 10 (all correct or appropriate responses). The
Based on the guidelines of infection control practice, a judgement was made about whether an answer reflected sound, fair or poor knowledge and good, fair or bad practice. With the assistance of a senior statistician, it was determined that a high score was regarded as between 6.01 and 10.00, an average score from 4.00 to 6.00 and a low score from 0.00 to 3.99. These scores were calculated as follows: quartiles 1 and 3 were used to separate respondents into three groups: lower group: score less than quartile 1; middle or average group: score between (inclusive) quartiles 1 and 3; and higher group: score greater than quartile 3. This technique ensures that approximately 25% of the respondents are in the lower group, 50% in the middle group and 25% in the higher group.
Validity of the questionnaire was ensured in the current study by conducting a literature review and seeking the advice of experts such as the researcher’s supervisors and statistician to ensure that the questionnaire adequately covered the research question. Reliability was ensured by conducting a pilot study.
The data collection using the self-administered questionnaire was conducted by the first author in December 2016. Appointments with the hospitals were made prior to the data collection date. On the data collection date, all participants were gathered in one venue and were informed about the project, and the research process was explained to them. Data collection for the three hospitals took 3 days (1 day per hospital). The data collection was conducted on site, using the communal hall in each hospital, after obtaining signed, informed consent from each participant. The participants were requested to answer the questionnaires independently. The questionnaire took approximately 5–10 min to complete, and the questionnaires were collected on the same day. Questions were asked in English as this was the language the participants were proficient in.
The data were captured and analysed using descriptive and inferential statistics. A Microsoft Excel spreadsheet was prepared based on the pre-coding performed in the data-gathering instrument. Descriptive statistics, including frequency distributions, means and standard deviations, were used to summarise and describe the demographic profile of the sample and the knowledge scores obtained by the respondents. The following inferential statistics were used to investigate the relationships among variables: chi-square test, Pearson product moment correlation and analysis of variance (ANOVA).
To test the questionnaire, a pilot study was conducted over a 1-week period in November 2016, prior to the data collection. The pilot study utilised five employees from different areas of work, namely, administration, admissions, clinical, general assistant and nursing in one of the specialised TB hospitals in the Nelson Mandela Bay. After the pilot test, there were minor amendments to the questionnaire including adding extra options such as ‘I don’t work with TB patients’ and ‘I don’t know’ as these options were absent in the original questionnaire. The pilot study results were not included in the data analysis of the actual study.
Ethics approval was obtained from the Ethics Board of the Faculty Postgraduate Studies Committee (FPGSC) at Nelson Mandela University (ethics number H16-HEA-NUR-025) as well as from Eastern Cape Department of Health (ethics number EC_2016RP28_145). Permission was obtained from the Chief Executive Officers who acted as gatekeepers of the three TB hospitals included in the study. No names or identifiers were recorded in the questionnaires to ensure the anonymity and confidentiality of the employees. Individual written informed consent was obtained from each participant. The participants were informed that their participation was voluntary and that they had the right to withdraw at any time. A copy of the questionnaire was kept in a locked place and accessed by the second author only.
The overall response rate was high, with 181 out of a potential 253 employees agreeing to willingly participate in the study. The sample thus represents 72% of all workers employed by the three specialised TB hospitals in Nelson Mandela Bay. The results per section of the questionnaire will now be outlined.
The demographic profile of the sample is reflected in
Demographic profile of participants.
Variable | ||
---|---|---|
18–25 | 11 | 6 |
26–35 | 35 | 19 |
36–45 | 62 | 34 |
46–55 | 42 | 23 |
> 55 | 30 | 17 |
Not specified | 1 | 1 |
129 | 71 | |
Grade 1–7 | 1 | 1 |
Grade 8–12 | 113 | 62 |
Degree or diploma | 49 | 27 |
Other | 5 | 3 |
Not specified | 13 | 7 |
Clinical and nursing | 67 | 37 |
Non-clinical | 108 | 60 |
Not specified | 6 | 3 |
It was concluded from the demographic data that approximately a third (34%) of the participants were between the ages of 36 and 45 years and the majority were women (71%). Most of the participants (62%) indicated high school as their highest level of education and less than a third of the participants (27%) had a degree or diploma as the highest level of education. The majority of participants (60%) had not received any clinical training.
Section B of the questionnaire had various questions to determine the knowledge of employees regarding TB and infection control, standard infection control precautions such as washing hands, as well as precautions for TB. The extent to which participants gave the correct responses to these questions is summarised in
Knowledge of tuberculosis (
Items | Correct response | Percentage correct |
|
---|---|---|---|
Waterborne | No | 177 | 98 |
Airborne | Yes | 140 | 77 |
Direct contact | No | 150 | 83 |
Sexual contact | No | 179 | 99 |
Blood contact | No | 178 | 98 |
All of the above | No | 168 | 93 |
I do not know | No | 178 | 98 |
Cough more than or equal to 2 weeks | Yes | 164 | 91 |
Blood in the stools | No | 172 | 95 |
Loss of weight | Yes | 149 | 82 |
Oral thrush | No | 176 | 97 |
Fever | Yes | 118 | 65 |
Chronic diarrhoea | No | 167 | 92 |
Night sweats | Yes | 140 | 77 |
I do not know | No | 179 | 99 |
Stool culture | No | 177 | 98 |
Sputum smear | Yes | 165 | 91 |
Pleural fluid aspirate | Yes | 22 | 12 |
Cerebrospinal fluid analysis | No | 170 | 94 |
All of the above | No | 180 | 99 |
I do not know | No | 177 | 98 |
TB meningitis | No | 162 | 90 |
TB pleuritis | No | 170 | 94 |
TB pericarditis | No | 176 | 97 |
TB lymphadenitis | No | 181 | 100 |
TB spine | No | 181 | 100 |
TB peritonitis | No | 179 | 99 |
Pulmonary TB | Yes | 146 | 81 |
I do not know | No | 164 | 91 |
TB is treated for at least 6 months | True | 168 | 93 |
TB is preventable | True | 159 | 88 |
HIV makes a person more vulnerable to TB | True | 153 | 85 |
Washing hands with soap reduces the spread of infection | True | 159 | 88 |
A person needs to wear a protective coat and gloves before entering the isolation ward or area | True | 160 | 88 |
A person needs to take off the gown and gloves before leaving the work area | True | 168 | 93 |
A person needs to wash hands before leaving the isolation ward or the work area | True | 169 | 93 |
Note: Items with less than 90% correct responses are in bold text.
TB, tuberculosis; HIV, human immunodeficiency virus.
As reported in
When asked about whether there is an infection control policy in the hospital, the majority of participants (78%,
The questionnaire items in Section C relating to practices were divided into personal and institutional practices. The extent to which participants gave the correct responses to these questions are summarised in
Practices of participants – correct responses (
Items | ||
---|---|---|
Windows are always kept open for ventilation and sunlight | 172 | 96 |
Hand washing is always performed after taking care of TB patients | 137 | 94 |
Masks are used at all times when in the hospital premises | ||
Protective gowns are always worn when attending to TB patients | ||
Availability of staff or employee dining hall | ||
Availability of consultation rooms in all the wards | ||
Availability of isolation glass (in patient vehicle) between the driver and the patients during the journey |
Note: Items with less than 90% correct responses are in bold text.
TB, tuberculosis.
According to
Descriptive statistics – Knowledge and practice scores.
Items | Mean | Standard deviation | Frequency distribution |
||||||||||
---|---|---|---|---|---|---|---|---|---|---|---|---|---|
Low (0.00–3.99) |
Average (4.00–6.00) |
High (6.01–10.00) |
Total |
||||||||||
B1 TB transmission | 7.27 | 4.20 | 41 | 23 | 17 | 9 | 123 | 68 | 181 | 100 | |||
B2 TB symptoms | 6.74 | 2.90 | 44 | 24 | 13 | 7 | 124 | 69 | 181 | 100 | |||
B3 TB diagnostic tool | 3.61 | 1.89 | 164 | 84 | 0 | 0 | 17 | 10 | 181 | 100 | |||
B4 Type of TB that spreads | 7.82 | 3.99 | 35 | 19 | 9 | 5 | 137 | 76 | 181 | 100 | |||
B5 General knowledge about TB and infection control | 9.23 | 1.57 | 4 | 3 | 3 | 2 | 168 | 96 | 175 | 100 | |||
B6 Availability of infection control policy | 5.42 | 3.03 | 77 | 48 | 0 | 0 | 83 | 52 | 160 | 100 | |||
Knowledge (average of B1–B6 scores) | 6.65 | 1.69 | 12 | 7 | 33 | 18 | 136 | 75 | 181 | 100 | |||
Practice personal | 6.12 | 2.03 | 38 | 21 | 23 | 13 | 120 | 66 | 181 | 100 | |||
Practice institutional | 6.15 | 2.02 | 24 | 13 | 66 | 36 | 91 | 51 | 181 | 100 |
TB, tuberculosis.
Descriptive statistics for the various summated scores that were calculated to measure participants’ knowledge and practices are reported in
According to
The majority of the participants displayed a good knowledge of TB (
The relationship between participants’ knowledge and their personal practices was found to be non-significant (
The results of the ANOVA that was conducted to investigate the relationships between the participants’ socio-demographic characteristics and their TB knowledge and practice are summarised in
Analysis of variance results – knowledge and practice personal by demographic variables (
Items | Knowledge |
Personal practice |
||||
---|---|---|---|---|---|---|
Effect | df | df | ||||
Age | 2.78 | 3; 171 | 0.0430 | 0.29 | 3; 171 | 0.831 |
Gender | 2.19 | 1; 171 | 0.1400 | 2.23 | 1; 171 | 0.138 |
Education | 19.38 | 1; 171 | < 0.0005 | 0.21 | 1; 171 | 0.648 |
df, degrees of freedom,
It is concluded from
Age and knowledge: The 36–45 years age group (
Education and knowledge: The group with a degree or diploma (
Participants in this study generally displayed high knowledge and practice scores regarding TB and infection control, although scores for knowledge were generally higher than those for practices. Therefore, it can be concluded that participants in this study were knowledgeable about TB and infection control; however, they did not always practise what they knew. This is similar to the findings of a study conducted in Rarankuwa, which revealed that 93% of the participants had a good level of knowledge regarding TB-control measures, but the majority (about 70%) of participants did not comply with the correct practices in this regard (Mndzebele & Kandolo
Most employees in this study were aware of the availability of an infection control policy, but this policy was kept in the infection controller’s office, and therefore, employees did not always read the policy. Similar results to the current study were displayed in a qualitative study conducted regarding the TB infection prevention and control experiences of South African nurses. The results revealed knowledge about the availability of a TB infection policy at the hospital; however, most participants were unaware of its content (Sissolak, Marais & Mehta
Items on knowledge that specifically obtained lower scores included transmission of TB, symptoms of TB and diagnostic tools and the type of TB that spreads. Airborne and direct contacts as modes of TB transmission were not answered correctly by participants. Participants failed to identify loss of weight, fever and night sweats as symptoms of TB. Furthermore, participants failed to identify pleural fluid aspirate analysis as a TB diagnostic tool. Pulmonary TB as the type of TB that spreads from person to person was also not correctly answered by all participants. Some of the true or false statements were also incorrectly answered such as the statements on HIV making a person more vulnerable to TB, as well as TB being a preventable disease. A survey conducted regarding knowledge, attitudes and practices on TB among healthcare workers in Kingston & St. Andrews, Jamaica, yielded slightly different results (White
Practices that were particularly not adhered to and yielded a low score in this study included wearing personal protective equipment such as gowns and masks, which was also found in similar studies (Sissolak et al.
The current study indicated a strong association between knowledge and age (specifically the 36–44 age group) and knowledge and education level (specifically diploma and degree). Previous studies have shown that knowledge and practices can be improved with provision of appropriate supplies and strengthening training and supervision (Peta
In addition, management in specialised TB hospitals must ensure the availability of an infection control policy to all employees. The implementation of the infection control policy should be monitored by management. Furthermore, management should ensure the availability of masks as well as placing isolation glass in patient transport vehicles at all times, as these were the practices that were scored the lowest by the participants in this study.
Several limitations were observed. Questions, such as the Xpert as an option for the question how (extra)pulmonary TB is diagnosed as well as questions about respiratory precautions in the questionnaire, could have been included in the questionnaire. However, the questionnaire was developed for participants with both clinical and non-clinical backgrounds. An item establishing whether participants attended any information-sharing sessions on the knowledge and the expected practices was not included in the questionnaire, but would have added value. It is therefore recommended that the questionnaire should be further revised and tested.
This study was the first of its kind to explore and describe knowledge and practices regarding occupational exposure to TB in specialised TB hospitals in the Eastern Cape. Considering the limited research performed on occupational exposure to TB, especially in the Eastern Cape, further explorative studies could be conducted as to why certain knowledge and practices scored lower. Research in terms of impact studies can be performed to determine the effectiveness of the infection control training offered by the hospitals, particularly related to implementation of the knowledge. In addition, the current study can be replicated in all specialised TB facilities in the Eastern Cape, as this will allow for further validation of the questionnaire as well as be of benefit in determining the knowledge and practices of a wider population of employees in such facilities.
In conclusion, the knowledge of employees regarding occupational exposure in specialised TB hospitals in the Nelson Mandela Bay scored generally high. A strong correlation was found between knowledge and age as well as knowledge and education level. Further opportunities for education, practice and research to explore and investigate occupational exposure to TB were provided.
The authors would like to thank the participants for taking part in the study.
The authors have declared that no competing interests exist.
L.N. was involved in conception and design of the study; acquisition, analysis and interpretation of data; drafting of the article; and the final approval of the version to be published. M.W. and W.t.H.-B. were involved in the conception and design of the study, analysis and interpretation of data, revising the article critically for important intellectual content and the final approval of the version to be submitted. D.V. analysed and interpreted the data, revised the article critically for important intellectual content and accorded the final approval of the version to be submitted.
This research received no specific grant from any funding agency in the public, commercial or not-for-profit sectors.
Data will be available from the authors on request.
The views and opinions expressed in this article are the authors’ own and not an official position of the institution or the funder.