1 INTRODUCTION

Hospital-acquired infections (HAIs) or nosocomial infections are localized or systemic. A healthcare worker (HCW) usually acquires these infections during their interaction with the patients during the examination and other day-to-day activities, including the collection of specimens, their processing and discarding, and handling of medical equipment. However, patients acquire these infections during their stay at the hospital.^{1, 2} The symptomatology of these infections appears 48–72 h after the patient's admission or within 10 days after the discharge from the healthcare facility.^2-4 People of all age groups are susceptible to these infections, whereas those with weak immune systems, the elderly, and children are the most vulnerable. These infections have been known to severely affect the quality of healthcare services.^{2, 3} According to 2011 reports from the US Centers for Disease Control and Prevention (CDC), there were 37,000 HAI-associated deaths in the US compared to 111,000 in Europe. These infections result in approximately 16 million hospital admissions every year, imposing significant costs and burdens on the healthcare system.⁵ Bacteria such as Escherichia coli, Staphylococcus aureus, Streptococcus, and Clostridium sp., along with other nonbacterial microorganisms such as viruses, parasites, and fungi, can cause HAIs due to their presence in the air or on various surfaces in healthcare settings. The worldwide estimated rate of these infections is estimated at 12.9% for urinary tract infection (UTI); 21.8% for surgical site infections; 4.0% for lower respiratory tract infections; 21.8% for pneumonia; 9.9% for bloodstream infections; and 5.6% for ENT and mouth infections. Other infections include skin and soft tissues infections accounting for 3.2%, cardiovascular infections 1.2%; bone and joint infections 1.0%; central nervous system (CNS) 0.8%; reproductive tract infections 0.6%; and systemic infections 0.2%.^{2, 3, 6} The global HCWs' knowledge scores for nosocomial infections remain unknown, despite being the most prevalent causative factor of poor healthcare quality. HAI infections mainly affect low- and middle-income countries (LMICs). Although the overall global incidence of nosocomial infections has reportedly declined over time, the pooled prevalence remains significantly higher in resource-constrained settings: 15.5% in LMICs compared to 7.6% in high-income countries. However, this picture of the endemic burden of infections in developing countries is extremely doubtful owing to the scarcity of reliable data.⁷

In recent studies in Pakistan⁸ and Iran,⁹ nurses scored only 43% on knowledge and practice regarding the prevention of HAIs. The lack of knowledge and practice in this area may be a key factor in the spread of these infections.¹⁰ India reported a 57.5% score,¹¹ while two Nigerian tertiary care hospitals orchestrated a 50.8% score for HCWs' practice in the prevention of healthcare-associated infections.¹² Two studies from Ethiopia, one conducted in Bahir Dar, revealed a 54.2% practice score of HCWs in the prevention of HAI.¹³ Another study from Amhara regional state referral hospitals in Ethiopia reported 40.7% knowledge scores and 48.7% practice scores for the prevention of nosocomial infections.¹⁴ Knowledge regarding infectious agents, their mode, and transmission route plays an important role in planning and executing infection control. While inadequate knowledge and incorrect attitudes among HCWs can directly influence their practices and lead to delayed diagnosis, poor infection control practices, and the spread of the disease.¹⁵ The risk factors for the increased rate of inadequate practice and knowledge toward preventing HAIs include the years of experience, gender distribution among HCWs, their understanding and educational status, and lack of training and adherence to guidelines and workload.¹⁰

The incidence rate of nosocomial infections in LMIC has been estimated to be very high due to the limited knowledge of professional risks, adherence to universal precautions, and limited availability of personal protective equipment (PPE).¹⁶ Several epidemiological studies have reported that physicians, nurses, dentists, and laboratory personnel are the main sources of transmission of nosocomial infections due to aseptic precautions during medical procedures. Based on the guidelines of CDC, nosocomial transmission can be efficiently prevented by personal hygiene, use of PPE and proper handling of contaminated beddings and clothing during direct contact with the patients. Another preventive measure could be environmental decontamination which includes utilizing superheated water and sterile patient equipment. Proper training in the prevention of healthcare-associated infections, incorporated into both preservice and in-service medical education for healthcare professionals, along with effective monitoring and evaluation methods, can play a crucial role in improving their understanding, awareness, attitude, and practice of universal precautions and infection control when handling patients.³ While guidelines are available for HCWs to reduce HAIs,^{5, 17} factors such as poor awareness, noncompliance, and logistical and organizational barriers have hindered their effective implementation.⁶ This can be compounded by inadequate knowledge and inappropriate attitudes of HCWs, leading to improper practices that can impact the quality of diagnosis, treatment, and infection control, as well as increase the potential for microbial transmission. Analyzing the knowledge, attitudes, and practices (KAP) of HCWs will assess the transmission risk of nosocomial infections. Additionally, it may help to estimate and compare the quality of treatments in remedial settings. In this regard, the current study envisioned evaluating the attitude, awareness, and practices toward high-risk microbial infections among HCWs in a global setting to indicate measures to be taken to address the problem.

2 METHODOLOGY

A cross-sectional-descriptive research study was conducted globally between 2022 and 2023, with HCWs selected as the study population. The study utilized nonprobability sampling to collect responses from a global audience over a specific time interval using a web-based, and self-administered survey questionnaire. We distributed the questionnaire through various methods to reach a diverse group of healthcare professionals globally. These methods included online surveys sent to hospitals and healthcare facilities, social media platforms, and personal messaging to individual healthcare professionals. By utilizing these multiple channels, we aimed to capture a wide range of participants from different regions and healthcare settings. Sample size was calculated based on the following factors: Z = standard normal distribution value at 95% confidence level = 1.96, margin of error (d) = 5%, and good knowledge = 50%.

3 RESULTS

A total of 743 respondents participated in the study. Among them, 404 (4.4%) respondents were in 17–25 age bracket, 210 (28.3%) in 25–35, 73 (9.8%) in 35–45, and 56 (7.5%) in the 45–60 age groups. Other sociodemographic characteristics that were taken into consideration included years of experience (Figure 1), healthcare profession (Figure 2), and location/country (Figure 3). About 35.3% of the study participants had less than 1 year of experience, while 34.7% had between 1 and 5 years of experience (Figure 1). The majority of respondents (64.9%) were doctors, as shown in (Figure 3). We primarily obtained data from Saudi Arabia (26.78%), Iraq (25.84%), India (15.7%), the United States (15.2%), Africa (13.98%), Egypt, (0.7%), UAE (0.7%), Pakistan (0.4%), and Afghanistan (0.4%). Other countries accounted for 0.5% including Bangladesh (0.1%), Oman (0.1%), Qatar (0.1%), Russia (0.1%), and Canada (0.1%) (Figure 2). Figure 4 depicts the frequency of good KAP scores among physicians (KAP: 82.5, 80.66, and 70.5), nurses (KAP: 74.1, 73.07, and 88.7), medical practitioners (KAP: 87.2, 77.58, and 75.1), and technicians (KAP: 76.1, 74.38, and 89.6) (Table 1). With regard to experience (Figure 5), HCWs highlighted good KAP scores in 1–5 years (KAP: 82.4, 83.3, and 74.1), 5–10 years (KAP: 80.6, 74.54, and 83), 10–20 years (KAP: 74.7, 79.1, and 82.7), and >20 years (KAP: 84.6, 78.8, and 82.8) categories (Table 1, Figure 5).

There was a significantly favorable professional attitude of HCWs toward HAI prevention. They strongly rejected the reuse of catheters and surgical forceps, stressed the importance of glove use during patient contact, and acknowledged the high HAI risk (Table 2). The study also demonstrated a strong correlation between HCWs' experience levels and their attitudes (Table 3).

4 DISCUSSION

Infection control is a critical issue in healthcare facilities, with HCWs being the primary transmitters of infections. Therefore, this study aimed to assess the KAP of HCWs toward nosocomial infection prevention. The doctors (77.9%), medical practitioners (80%), and other hospital staff (77.2%) exhibited high knowledge scores compare to their attitude and practice toward the prevention of HAI. Kareem et al. also reported similar findings with more than half the number of doctors having less than 50% practice in evidence-based medicine (EBM). Commonly reported impediments included the attitude of colleagues, inadequate skills, insufficient time, high flow of patients, and criticism fear.²⁰ Our study revealed significantly higher practice scores among nurses (88.7%), technicians (75.1%), and allied health professionals (85.5%). In contrast, Maurya et al. reported knowledge scores of 11.9 in their study.¹⁵ The former study is a reflection of a single hospital, whereas the current results are representing the global nurses, and this could possibly indicate the disparities between the studies. Concerning EBM, Kaseka et al. identified moderate practice scores (57.8%) among nurses and midwives in a central hospital in Malawi.²¹ Clinical experience and the types of hospitals were the chief contributors to these scores.¹⁵ Regarding Allied Health professions and technicians, Mukhopadhyay et al reported that the HCWs' that were directly or indirectly involved in the laboratory diagnosis of COVID-19 were more likely to exhibit good practices.²² These studies are evidence that the nature of profession and training plays a significant role in shaping the HCWs' practices.

Based on experience, the highest knowledge scores were spotted in highly experienced individuals (10–20 and >20 years). Among Nigerian HCWs, good knowledge was mainly observed in the 16–20 years experience category.²³ We found a significant degree of good attitude amongst individuals having 1–5 years of experience. These results are inconsistent with hospital reports of Odisha, where higher attitude scores were recorded in ≥16 years of experience.²⁴ The inconsistencies may be present due to the sample size distinction Concerning practice, we recorded peaked values in 10–20 years experienced HCWs, and lowest values in <1 years experienced HCWs. The overall KAP percentages were identified in HCWs with the highest experience. Indian researchers reflected a similar trend, where high practice scores were reflected in highly experienced HCWs.²⁵

Correlational analysis manifested that a significant proportion of global HCWs exhibited high levels of knowledge concerning the transmission of microorganisms such as HCV, HDV, chickenpox, and shingles, as well as the dissemination of soft tissue infections, and direct contact spread of respiratory infections. Moreover, the respondents' understanding regarding the standard precautions of infection control was comparable to that reported in a study conducted by Engda, T in 2020, Ethiopia. Specifically, 59.5% of the respondents received training on nosocomial infections, while only 35.5% demonstrated good knowledge of nosocomial infections, and 40% exhibited good knowledge of the modes of transmission and risk factors for nosocomial infections.²⁶ In another Ethiopian study, Bayleyegn et al. reported 90.2% of respondents with a high level of knowledge about preventing healthcare-associated infections.² Additionally, 96.6% of participants understood the imperative need to implement standard operating procedures (SOPs) to reduce HAI incidence. The statistics from Northwest Ethiopia manifested that 84.6% of respondents were knowledgeable about infection prevention.²⁷ Moreover, 93.33% of participants demonstrated awareness of disinfectants and antiseptic preventive measures in connection with HAIs. Comparably, Pakistan's statistics accentuated 70% (n = 115) good knowledge of standard precautions for controlling nosocomial infections.²⁸ The variation in the percentage of knowledge regarding the prevention of HAIs among HCWs can be influenced by the availability of educational programs and training, differences in the study population, and the priority placed on infection prevention by healthcare organizations.²

Findings from our study strongly indicated that HCWs possess a robust understanding of hand hygiene in infection prevention, and this knowledge tends to increase with years of experience. This finding is consistent with the study conducted in 2020 from northeast Ethiopia. Assefa et al. reported that 95.3% of the study participants had knowledge about the role of washing hands with soap or alcohol-based antiseptics in reducing the transmission risk of nosocomial pathogens. In addition, HCWs with more than 5 years of work experience were 1.5 times more likely to have adequate knowledge compared to those with less experience. As HCWs gain experience, they become more insightful and proficient regarding infection control techniques. Thus, respondents with older age, longer work experience, and higher educational status tend to excel in infection prevention.²⁹

Previous studies have reported substantial evidence of an association between professional work experience and knowledge regarding standard precautions. Specifically, as work experience increased, knowledge related to standard precautions also increased.²⁸ Likewise, this study found that HCWs with greater experience were more likely to translate their knowledge into practice, as demonstrated by their adherence to infection prevention activities such as frequent hand washing before and after aseptic procedures, after touching patients' immediate surroundings, and wearing masks.

Importantly, our findings indicate that working experience is a significant factor associated with infection prevention practices. Specifically, HCWs with increased years of experience are three times more likely to engage in infection prevention activities than those with less experience. Assefa et al. in Northeast Ethiopia reported that 55% of healthcare providers had safe infection prevention practices.²⁹ Agbana reported that only 53.4% of participants had received training on hand washing in the last 3 years of experience in Nigeria,³⁰ while Gasabaet al. from Zimbabwe found that 79.3% of participants washed their hands and 75.9% were aware that the infection control manual guideline was available in their workplace.⁵ Our findings align with a study conducted in Uganda which reported that nurses' attitudes improved with greater work experience, making them better models for younger employees.³¹ Similarly, a study in Ethiopia found that HCWs with 10 or more years of experience were three times more likely to practice infection prevention and control than those with less than 5 years of experience. Furthermore, participants who had a positive attitude toward infection prevention and control practice were 10 times more likely to follow safe practices.²²

Previous studies have reported mixed findings on infection prevention practices among HCWs. Some studies have shown good adherence to practices, such as wearing masks (83.7%) and hand hygiene (98.3%, 91.8%), while others found lower rates of compliance (45.5% in a study by SisayFogaSebro³²). Additionally, a study from Bahir Dar, Ethiopia, reported 54.2% of healthcare providers practicing nosocomial infection prevention,² and Gezie et al. in Northeast Ethiopia found less than one-fourth of the study population (23%) demonstrating good practices toward HAI prevention.⁶ These findings provide valuable context but should be interpreted cautiously as they may differ in population, methodology, and settings compared to our study.

The positive attitude of HCWs is an essential requirement for preventing nosocomial infections and a crucial aspect in preventing cross-infections. Our study's findings indicate that HCWs have a positive attitude toward their profession, as evidenced by their preference for using gloves (p < 0.001, Cramer's v = 0.197) during direct contact with patients, removing hazards immediately to protect others from risks, and their understanding that healthcare professionals are at high risk of nosocomial infections. Contrastingly, a study conducted in Nigeria by Babatola et al. identified only 56.7%³³ of HCWs with a good attitude toward preventing nosocomial infections. Similarly, a study from Bahir Dar city in Ethiopia reported 55.6% of HCWs that exhibited a good attitude²⁸ toward preventing such infections. Comparably, our findings are similar to a study conducted by Sai SubhakarDesu in India in 2023, which reported that 74.5% of participants had a positive attitude toward preventing nosocomial infections. Additionally, 89.2% of participants agreed that guidelines for preventing HAIs should be strictly followed, and hand hygiene measures should be taken to reduce the risk of infections after treating patients. A total of 80.8% of respondents often or always used gloves and practiced hand hygiene measures after removing gloves.³⁴ Similarly, a study from Northeast Ethiopia by Jemal S in 2019 reported that 69.23% of HCWs had a positive attitude toward infection prevention, while 30.77% had a negative attitude. However, the majority of study participants, that is, 71.43%, did not consider that all HCWs and the community are at risk of infection.³⁵ Engda et al. in Ethiopia revealed 36% of study participants with a good attitude toward preventing and controlling nosocomial infections.²⁶ In contrast, Alhassan et al. from Ghana, in 2021, reported that 97.4% (p ≤ 0.001) of respondents agreed to wash their hands following the removal of gloves. About 95.5% of respondents believed that following prevention guidelines would reduce HAI rates, and 86% agreed that following the SOPs would decrease the risk of contamination.³⁶

Furthermore, Unakal et al. conducted a study in three hospitals in Trinidad and Tobago in 2017, which indicated that 53.3% of participants had a positive attitude toward infection prevention and control. Additionally, 87.7% of HCWs agreed that a new pair of gloves should be worn for each new patient attended. This translated to a practice level of 56.0%, demonstrating the influence of attitude on practice.³⁷ The variations in research results can be attributed to several factors, including the academic background of the participants, the sample size, and the availability and implementation of protocols for preventing HAIs. In some settings, hand hygiene may be viewed as a minor concern and may not be given sufficient attention, particularly in nonsurgical and noninvasive procedures.

Organizational support factors, such as the presence of an infection control team, supply of disinfectants, and visible information (leaflets and posters) about HAIs, play a significant role in shaping behavior. It puts HCWs into a reminder about the threats and the impact of HAIs in line with the health beliefs model, increasing the “willingness to act.” The majority of HCWs in our study wore gloves while having direct contact with patients, indicating a positive trend toward safe practices. In contrast, a study from Italy reported that only 57.3% of HCWs changed gloves to prevent the transmission of infection.³⁸ The availability of gloves may reflect these inconsistencies, as improved availability allows more accessibility. Adherence to safe infection prevention practices is mandatory for both patients and HCWs, as it reduces the incidence of HAIs. However, a recent study reported unsatisfactory levels of good practice, indicating the need for continued efforts to improve infection prevention and control measures.²

It is important for hospital administrators to foster a culture that prioritizes adherence to recommended hand hygiene practices and infection prevention measures. This can be achieved by providing visible support and adequate resources for continuing education programs that are tailored to the specific needs of healthcare personnel. Despite the fact that most healthcare providers in our study had good knowledge and a favorable attitude toward HAI prevention, there is still room for improvement. Therefore, ongoing efforts are needed to ensure that infection prevention practices are consistently implemented in healthcare settings.

5 LIMITATIONS

There are certain limitations to our study, such as the use of a self-administered survey questionnaire as it may introduce the potential for response bias (participants may not respond truthfully or accurately due to social desirability bias, where they provide socially acceptable answers rather than their true perceptions), and the exclusion of housekeeping staff who may also be a source of transmitting HAIs. Additionally, social desirability bias may have influenced the results to some extent. To address these limitations, large-scale multicenter studies are needed. The predominance of doctors in the study sample may lead to an overrepresentation of their perspectives, and not knowing the specific departments where HCW work could limit the generalizability of findings to different healthcare settings. Additionally, cultural norms and beliefs shaping attitudes toward practices like mask-wearing or glove use, resource availability affecting adherence to guidelines in resource-limited settings, communication barriers hindering information dissemination, and organizational support may impact infection control programs' effectiveness, leading to disparities in training opportunities and cultural attitudes toward infection control, thereby affecting KAP levels. Understanding and addressing these factors are crucial for designing targeted strategies to enhance infection prevention practices among HCWs globally, ultimately reducing nosocomial infections.

6 SUGGESTIONS

7 CONCLUSION

In summary, our study accentuated the impact of HCWs' knowledge regarding the mode of infection transmission on their infection prevention practices. The study provides valuable insight into the KAP scores of HCWs, based on years of experience and profession. The study findings indicate that HCWs globally, including doctors, medical practitioners, nurses, and other hospital staff, have a good understanding and positive attitude toward the prevention of HAIs or nosocomial infections. Moreover, their knowledge was observed to be reflected in their practices. However, it is recommended that educational seminars and awareness programs be conducted annually to ensure the retention of knowledge, attitudes, and practices among HCWs of different categories. These educational programs would help improve adherence to barrier protection measures such as hand washing, the use of gloves, and hand disinfection. It is also important for every institution to have proper guidelines for HCWs, and a regular system of monitoring infection rates and disseminating data to form a link between the management and the HCWs to improve strategies for HAI prevention.

AUTHOR CONTRIBUTIONS

Elham M. Khatrawi: Conceptualization; data curation; formal analysis; investigation, Visualization; writing—original draft; writing—review and editing. Priyadarshi Prajjwal: Conceptualization; data curation; formal analysis; investigation; visualization; writing; original draft; writing—review and editing. Muhammad Farhan: Formal analysis; investigation; visualization; writing—original draft; writing—review and editing. Pugazhendi Inban: Formal analysis; investigation; visualization; writing—original draft; writing—review and editing. Shraddha Gurha: Visualization; writing—original draft; writing—review and editing. Saud M. S. Al-ezzi: Writing—original draft; writing—review and editing. Mohammed D. M. Marsool: Writing—original draft; writing—review and editing. Prerna Ahuja: Writing—original draft; writing—review and editing. Mohammed A. Mateen: Writing—original draft; writing—review and editing. Felix O. Aina: Writing—original draft; writing—review and editing. Omniat Amir: Writing—original draft, writing—review and editing.

CONFLICT OF INTEREST STATEMENT

The authors declare no conflict of interest.

TRANSPARENCY STATEMENT

The lead author Elham Mohammed Khatrawi affirms that this manuscript is an honest, accurate, and transparent account of the study being reported; that no important aspects of the study have been omitted; and that any discrepancies from the study as planned (and, if relevant, registered) have been explained.