Healthcare workers (HCWs) means any person working in health care facilities and has the risk of exposure to infectious materials like body fluids, contaminated medical equipment, contaminated environmental surfaces or contaminated air [1] .

Physicians are generally skilled workers who handle patients and technical equipment, performing related procedures and are exposed to different kinds of hazards [2] . Physicians work in the frontiers of the battles against any infectious diseases around the world including the emergence, spread, control and resolution of infectious outbreaks [3] . Due to the front-line nature of their work physicians are at increased risk of healthcare-associated infections (HAI) [4] . Physicians are at an occupational risk of developing infectious respiratory disease, and they can also spread these infections to other employees and patients. Even if a physician has no symptoms when attending work, they have the potential to transmit respiratory infections to both co-workers and other patients [5] .

Following the standard precautions (SPs) is the most effective and simple way to prevent infection. SPs are a set of recommendations outlined to prevent or minimize exposure to infectious agents by physicians, patients and their attendants [6] .

In 1985, the United States’ centers for disease control (CDC) introduced universal precautions (UPs) to protect HCWs from the spread of nosocomial infections. As a result, in 1996, CDC revised the infection control practice from Universal precautions to Standard precautions (SPs). Standard Precautions are the minimum practices to prevent infection that should be practiced on all patients regardless of suspected or confirmed infection status of the patient in all health care facilities. The components of SPs include hand hygiene, injection safety, use of personal protective equipment (PPE) and environmental cleanliness, as well as waste management, and respiratory hygiene and cough etiquette [6] . These practices are outlined to protect both the physicians and the patients from healthcare associated infections (HAIs) [7] .

Respiratory diseases are responsible for a huge global health burden (Forum of International Respiratory Societies, 2017). Respiratory infections are the main cause of acute infections in humans [8] .

Physicians can act as a mechanical vector for the spreading of HAIs from patient to patient [9] . On exposure, physicians can equally transmit nosocomial infections to their patients and may be the source of infection for their families and communities. Many studies suggest that there is increased probability of physicians being infected from both invasive and non-invasive procedures [4] .

Standard Precautions are applied for all patients at all times to prevent healthcare-associated transmission of infectious agents among patients and healthcare personnel [10] . Therefore, physicians should have proper knowledge and awareness about SPs and they should be always compliant to the standard precautions to control infection [11] .

Healthcare associated infections among physician’s leads to an increased rate of illness, absenteeism and even death amongst physicians. And it a burden for the health care system that comes at a large financial cost [8] . Therefore, the risk becomes high if physicians do not have awareness and compliance of SPs [11] .

Lack of awareness of infection control among HCWs has been recognized to hamper compliance with SPs. Therefore, strengthening SPs’ training for HCWs is recommended as a major means of promoting adherence to SP and protecting physicians as well as patients from nosocomial infections [7] .

In spite of the fact that HCWs are aware of infection control measures, often it is seen that compliance with these SPs are low among HCWs [4] . Lack of awareness about infection control practices among physicians is one of the leading causes responsible for low compliance to SPs [7] .

Measurement of the awareness of SPs among physicians is important because many studies show that compliance or noncompliance with SPs in a healthcare facility is related to the awareness of professionals [12] . This is an effective way to protect health professionals, patients and the public and to reduce hospital infections. Failure to comply may be reflected in high incidence rates of occupational accidents with exposure to bodily fluids and sharps.

Identifying the causes of lack of awareness about SPs and factors influencing non-compliance with SPs is important to design public health programs that offer pragmatic strategies to ensure the adherence of SPs across all health facilities for the protection of physicians as well as safety of the patients.

This cross-sectional study was conducted to see the compliance of physicians with standard precautions of handling patients with infectious respiratory disease. Total population of the study was 285 which were selected purposively according to inclusion criteria. Data were cleaned, edited, analyzed using SPSS version 26.

The results are organized into following sections:

1) Socio-demographic characteristics of physicians.

2) Awareness of physicians with standard precautions of handling patients with infectious respiratory diseases.

3) Compliance of physicians with standard precautions of handling patients with infectious respiratory disease.

4) Reasons for non-compliance with standard precautions among physicians of handling patients with infectious respiratory disease.

Physicians are usually exposed to various occupational hazards in healthcare setting, especially biological because they are directly in contact with patients or body fluids. The common occupational risk in a hospital setting is contracting any infection. Particularly, exposure to body fluids containing infectious agents has long been recognized as a potential threat to physicians. Among the hospital acquired infections respiratory infection is one of the most common as during history taking, examination of the patients and performing any procedures physicians come in very close contact of the patients. While performing such task physician have a high risk of exposure to the respiratory secretions and droplets produced by patient while taking, coughing or during some medical procedures. Then physicians can further spread these infections from patients to patients as physicians can act as a mechanical vector for the spreading of infectious respiratory diseases. They can also spread these infections to other employees and patients and also have potential risk of transmission of respiratory infection to both co-workers and patients, even when having no symptoms while attending work. To reduce such risk for both physicians and patients, authorities like WHO and CDC have strict guidelines. These guidelines are commonly known as standard precautions. Proper awareness of these standard precautions and strict compliance with them can protect both physicians and patients from the risk of hospital acquired infections specially the respiratory infections which can spread very easily without the knowledge of any one. It is often times seen that physician are not completely and correctly aware of these standard precautions and it is also seen that despite being aware of the standard precautions physicians are not compliant with these standard precautions.

This study was intended to assess the compliance with the standard precautions of the physicians handling patients with infectious respiratory diseases. This cross-sectional study was conducted among 285 physicians handling patients with infectious respiratory disease at M Abdur Rahim Medical College and Hospital, Dinajpur, Bangladesh and Rajshahi Medical College and Hospital, Rajshahi, Bangladesh.

In the present study, the mean age of the respondents was 36.42 ± 10.373 years and age ranged from 25 - 59 years. The major portion of the respondents 40.7% belong to the age group 25 - 31 years of age whereas 25.3% respondents were in 32 - 38 years’ age group. Among the respondents 68.4% were male and 31.6% were female.

Several studies have described about the importance of standard precautions for HCWs mainly physicians of handling patients with infectious disease. Arinze-Onyia, et al. (2018) [7] mentioned in their study that the mean age was 37.20 years and age range was 20 - 59 years which was more or less similar to this present study. According to the study of Honarbakhsh, Jahangiri and Ghaem (2018) [14] , the mean age of the respondents was 31.63 ± 8.27 years. Another cross-sectional study conducted by Yazie, Sharew and Abebe (2019) [9] , mentioned that the age ranges of the HCWs was from 23 - 59 years. In the present study, the age range was 25 - 59 years because maximum physicians completed their MBBS degree in 24 years of age and usually retires at age 59 years.

Arinze-Onyia, et al. (2018) [7] examined the knowledge and practice of standard precautions among health care workers by conducting a descriptive cross-sectional study which was done in October 2014 at University of Nigeria teaching hospital, observed that 73% of the respondents in their study were female. Arinze-Onyia, et al. (2018) [7] and Honarbakhsh, Jahangiri and Ghaem (2018) [14] also observed that majority of the respondents in their study were female. But in this current study only 31.6% were female and rest of them (68.4%) were male. It may be due to the fact that the present study only included physicians but in Arinze-Onyia, et al. (2018) [7] study, among 629 participants, 290 participants were nurses and also in Honarbakhsh, Jahangiri and Ghaem (2018) [14] study nurses were predominant. As nurses were not included in this study could be the reason behind the disparity of gender distribution among this study and the other two studies stated here.

Awareness of standard precautions is very much important to be compliant with the standard precautions. Despite the SPs guideline, awareness varied among physicians.

In the present study overall awareness of the respondents regarding respiratory hygiene and cough etiquette and hand hygiene was good but 71.9% of the respondents didn’t know when to use the alcohol-based hand products. Majority of the respondents were not aware about personal protective equipment. Nearly 60.7% of the respondents were not aware that medical mask provides protection from fine aerosol which is kept suspended in the air, but 70.2% of the respondents were aware about when to use of particulate respirator instead of medical mask. Majority (71.6%) of the respondents were not aware about the procedure of using double gloves. Maximum participants were not aware of the sequence of wearing and removing the different components of PPE. But in current COVID-19 situation, it’s really a burning issue, because if the physicians are not aware of the sequence of wearing and removing different components of PPE, then the infectious respiratory disease will transmit to the physicians and then from physicians to the other patients. Majority of the respondents that is 81.8% were not aware that needle should be never recapped and 76.8% of the participants did not know that needle should be never bent. Although overall awareness about disinfection of respiratory equipment and cleaning the patients care environment was 69.5%.

In another cross-sectional study conducted by Akagbo, Nortey and Ackumey (2017) [19] among HCWs on standard precautions, only 39% of the respondents knew about respiratory hygiene and cough etiquette which is lower than the present study. Arinze-Onyia, et al. (2018) [7] and Ndu and Arinze-Onyia (2017) [15] study results about awareness of respiratory hygiene are also lower than the present study. The reason behind the increased awareness about the respiratory hygiene and cough etiquette among the participants of the current study could be due the fact that in this current COVID-19 pandemic situation the physicians are now more aware about this matter. But the awareness about prevention of injuries and other sharp instruments and also the awareness about how to discard sharps are very low compared to other study. In Ogoina, et al. (2015) [6] study more than half of the respondents didn’t know that sharp should never be recapped but very few only 12% didn’t know that, it was wrong to bend or break sharps or needles. Another study also revealed that 25% of the respondents didn’t recapped needles after use (Akagbo, Nortey and Ackumey, 2017) [19] . Compared with the present study, these study results are much better than present study; this could be due to the fact that none of the institutes where the current study was conducted had the facility of electric needle destroying machines in all working areas.

Compliance with hand hygiene after patient contact is one of the most important components of standard precaution. In the current study we found that 28.4% of the respondents sometimes performed hand hygiene immediately on arrival at workplace and 31.6% of the respondents performed hand hygiene before direct contact with patients, whereas 43.9% of the respondents always perform hand hygiene after contact with patients. 52.3% of the respondents always performed hand hygiene after contact with blood or body fluids or secretions. But surprisingly, only 36.5% of the respondents performed hand hygiene sometimes, 11.9% rarely performed hand hygiene after touching the patient’s surrounding environments which is more contagious for spreading infectious respiratory disease. 57.5% of the physicians had moderate level of compliance with hand hygiene which is not satisfactory during COVID-19 pandemic situation. The reasons may be the high workload, rigors of hand washing in between handling patients is considered burdensome and also may be lack of training on infection control.

Punia, Nair and Shetty (2014) [16] undertook a cross sectional questionnaire-based study among 162 HCWs in which 109 were doctors. Among them 95% of the respondents claimed to use hand rub after touching patients surrounding. 28% of the respondents in Ogoina, et al. (2015) [6] study practice hand hygiene after touching patient’s surroundings. But in the present study only 26.7% respondents perform hand hygiene after touching patient’s surroundings which is very low and not satisfactory during COVID-19 pandemic situation.

Ather, Khan and Shabnum (2020) [11] conducted a descriptive cross-sectional study which included 180 participants which also included physicians from Bahria International Hospital Lahore, Pakistan to assess knowledge and practice of health care workers regarding standard precautions. Ather, Khan and Shabnum (2020) [11] study revealed that 28.9% of the participants always washed their hands before and after patients care, 35.6% sometimes, which is more or less similar with the present study but the percentage of hand hygiene after touching the patient was higher (43.9%) in the present study. According to Ogoina, et al. (2015) [6] and Akagbo, Nortey and Ackumey (2017) [19] study, percentage of participants performing hand hygiene before touching any patients was 58.5% and 55% respectively which is higher than the present study. In Arinze-Onyia, et al. (2018) [7] study 52.1% of the respondents performed hand hygiene after contact with blood, body fluid or secretion which is more or less similar with the present study.

In the current study 37.5% respondents rarely and 16.8% never choose the right PPE before exposure to an infectious disease patient. But in Akagbo, Nortey and Ackumey (2017) [19] and Arinze-Onyia, et al. (2018) [7] study 61% and 53.4% of the participants wore the basic protective equipment respectively, which is very low in this present study. In the present study 12.3% respondents never changed their gloves between patients care and any procedure of another patient, only 23.2% always changed gloves which were very much lower than the Yazie, Sharew and Abebe (2019) [9] study. According to Yazie, Sharew and Abebe (2019) [9] study 64.5% and 88.7% of the participants changed gloves between patients care and during invasive procedure respectively. In Punia, Nair and Shetty (2014) [16] study 28.4% of the participants used protective gowns in case of risk of fluid splash. The present study revealed that 24% of the participants always wore plastic gown in case where there was risk of fluid splashes which is more or less similar to the findings of Punia, Nair and Shetty (2014) [16] study. In the present study 37.5% of the respondents sometimes removed all PPE as soon as possible after completing the health-care procedure which is more important for not spreading infection diseases through contaminated PPE. 48.8% of the physicians had moderate level of compliance with using PPE which is again not satisfactory in the current COVID-19 situation. The reason behind this finding could be due to the fact that most of the participants did not have any training on infection control. Arinze-Onyia, et al. (2018) [7] study revealed that those who were trained on SPs and PPE were significantly more likely to always use PPEs.

In the present study 79.3% respondents always covered their nose and mouth during coughing and sneezing and 49.8% respondents always used their upper arm in case of sudden episode of coughing or sneezing. 33% respondents always and 46.7% respondents most of the time performed hand hygiene after coughing and sneezing. 58.9% of the physicians had very good compliance with respiratory hygiene and cough etiquette. The reason behind the increased compliance with respiratory hygiene and cough etiquette among the physicians of the current study could be due the fact that in this current COVID-19 pandemic situation the physicians are now more aware about this matter.

Kotwal and Taneja (2010) [13] study evaluated the universal precautions perceptions on compliance and non-compliance of 96 participants, out of them 50 were doctors through a cross sectional study. According to Kotwal and Taneja (2010) [13] study 60% doctors admitted that they never recapped needles and 90% always disposed used needles in proper way. In Punia, Nair and Shetty (2014) [16] study 72.4% of the participants always recapped needle and in Fadeyi, et al. (2011) [1] study 56.9% of the participants recapped needle and 92.3% of the participants discarded needles and sharps in safety box. But in the present study majority (68.8%) of the respondent always recapped used needles which should never be done according to standard precaution protocol whereas only 13% never recapped and 22.5% of the respondents always and 15.8% never disposed syringes, needles, scalpel blades and other sharp items in appropriate puncture resistance container (red container).

In Punia, Nair and Shetty (2014) [16] study only 12.8% of the participants broke or bended needles by hand whereas in the present study 53% of the respondents always broke, bended and removed needles by their hand which is much higher than the findings of Punia, Nair and Shetty (2014) [16] study. Compared with the present study, the study results of Punia, Nair and Shetty (2014) [16] study are much better. This could be due to the fact that none of the institutes where the current study was conducted had the facility of electric needle destroying machines in all working areas. 60.7% of the physicians had moderate level of compliance with prevention of injuries from sharps and needles but 18.2% of the physicians had poor compliance which in regard to physicians is much higher.

In the current study, among 285 respondents only 27% of them sometimes cleaned and disinfected respiratory equipment between uses and 54% of the respondents never used PPE while cleaning and disinfection of respiratory equipment. 41.4% of the respondent rarely kept cleaned and disinfected items dry and in individual packages. 56.1% of the physicians had moderate level of compliance with regard to cleaning and disinfection of respiratory equipment.

In the present study, majority (53%) of the respondent always decontaminated cloths or dresses used by physicians by washing or autoclaving. Yazie, Sharew and Abebe (2019) [9] conducted a cross sectional in which 48.9% of the respondents always cleaned working environment at the end work. But in the present study 35.1% of the respondent sometimes cleaned the environment used by the patient and 25.6% of the physician rarely cleaned or disinfected examination table used by the patient which is much lower than the previous study. In present study 35.1% of the participants sometimes used techniques to avoid aerosolization of dust. 39.3% of the participants had moderate level of compliance with cleaning patient-care environment in present study.

The current study also assessed the reasons of non-compliance by a set of 10 fixed options. Maximum (86.7%) physicians in this study identified lack of adequate facilities and resources as the main reason of non-compliance with standard precaution. Non-availability of PPE was found to be one of the major cause of non-compliance with standard precautions (SPs) among the participants in the Arinze-Onyia, et al. (2018) [7] study, Ndu and Arinze-Onyia (2017) [15] study and Akagbo, Nortey and Ackumey (2017) [19] study. One study in India reported that, PPE not being readily available especially during emergency (Punia, Nair and Shetty, 2014) [16] and another study in Nigeria reported lack of adequate resources as a major reason for non-compliance with SPs [6] but surprisingly another study in India reported that availability of PPE was not the main cause of non-compliance with standard precautions rather lack of training was the main cause [13] .

Excess workload (76.1%), lack of training of infection control (63.2%) and time constrain (43.2%) were the other three main reasons that were considered by the physicians as reasons for non-compliance with standard precautions in the present study. One study in India reported that lack of training was the main reason but time constrain was another cause [13] and HCWs in Nigeria indicated that lack of training (51.9%) was a hindrance to compliance with standard precaution [6] .

Another barrier to adherence to SP in this study was found to be that PPE were not comfortable to use and it was stated by 49.1% of the respondents. This study finding is consistent with finding from other studies [6] [19] . HCWs in Ghana indicated that wearing PPE was uncomfortable (42%) [19] , HCWs (14%) in Nigeria mentioned the same reason [6] but in Fadeyi, et al. (2011) [1] study only 12.5% respondents felt uncomfortable to use PPE but surprisingly 60% respondents felt that it was not essential. Only 6.7% of the respondents in the present study considered that use of PPE may offend the patients. In a study in Ghana, HCWs mentioned that 63% patients felt panic if they wore PPE [19] .

The current study examined the awareness of the physicians handling patients with infectious respiratory diseases and classified them into very poor, poor, moderate and good awareness categories according the percentage of total awareness score. In this study we found that maximum (78.6%) of the physician had a moderate awareness about standard precautions and only 8.1% of the physician had poor awareness and 13.3% of the physician had good awareness about standard precautions. Honarbakhsh, Jahangiri and Ghaem (2018) [14] also classified the knowledge about standard precautions in the similar fashion and found that among the participants of their study 68.7% of the participants had moderate knowledge about standard precautions and only 9.5% and 21.8% of the participants had poor and good knowledge about standard precautions respectively which is more or less similar to the findings of the current study. The similarities between the findings of the two studies regarding awareness of standard precautions could be attributed to the fact that participants of both studies had more or less similar duration of service for current study the mean duration of service is 9 years and the mean duration of service of the participants in the Honarbakhsh, Jahangiri and Ghaem (2018) [14] study was almost 8 years.

The current study also classified the compliance of the physicians with standard precautions in the same categories that is very poor, poor, moderate and good. The current study found that majority (76.5%) of the participants had a moderate compliance with the standard precautions and 23.5% of the participants had good compliance with standard precautions. Honarbakhsh, Jahangiri and Ghaem (2018) [14] found in their study that less than half of the participants had moderate compliance and 36.6% of the participants had good compliance. Though percentage of participants having good compliance with standard precautions is more among the participants of Honarbakhsh, Jahangiri and Ghaem (2018) [14] study but 10.6% and 3.9% of the participants in their study had poor and very poor compliance with standard precautions. The disparity could be due to the fact that the current study only included physicians so none of them had poor compliance with standard precautions but Honarbakhsh, Jahangiri and Ghaem (2018) [14] study included nurses and janitor along with physicians and majority of the participants in their study were nurse and janitor so this could be the reason that some of the participants in their study had poor and very poor compliance with standard precautions.

The current study also found that with increased awareness of the participants regarding standard precautions their mean score of compliance with standard precautions increased which was statistically significant. Ather, Khan and Shabnum (2020) [11] also revealed similar findings. They found that good knowledge about standard precautions positively affected the compliance with standard precautions among the participants.

The present study found that there is no statistical difference of awareness of and compliance with standard precautions between participants having training on infection control and participants who did not have any training on infection control. From this finding inference could be drawn that training on infection control had little or no value on the awareness and compliance of the physicians regarding standard precautions. The reason behind this finding could be due to improper training or lack of monitoring of the physicians who were trained on infection control.

The purpose of this cross-sectional study was to assess the level of compliance of physicians with standard precautions of handling patients with infectious respiratory disease. Proper compliance with standard precautions is an important factor in regard to the protection of HCWs including physicians from their workplace occupational hazards especially infectious respiratory diseases. The findings of the current study revealed that most of the physicians handling patients with infectious respiratory diseases had moderate compliance with standard precautions. This study also revealed that most of these physicians had a moderate level of awareness of standard precautions. Physicians who had poor awareness of standard precautions did not follow the standard precautions protocols properly and with increased awareness of standard precautions, physician’s compliance with standard precautions also increased. Very few numbers of physicians had good compliance with standard precaution, which is not satisfactory. Overall compliance level of the physicians with different components of standard precautions which are important to prevent infectious respiratory diseases such as hand hygiene, use of PPE, needle safety, cleaning and disinfection of respiratory equipment and cleaning patient-care environment was also moderate, which begs the attention for improvement and emphasis should be given on the efforts to do it. Some of the main reasons for non-compliance or barrier to compliance with standard precautions pointed out by the participating physicians in this study were lack of adequate facilities and resources for practice of standard precautions, excess workload, lack of regular training on infection control and the fact that PPEs are not comfortable to use.

· The study place was selected purposively and as purposive sampling technique was applied so findings did not reflect the scenario of the entire physicians of country.

· Certain information was recorded by asking question not by observation, so the respondents may have intentionally modified the actual truth.

· There are many chances of recall bias in case of questions related to compliance with standard precautions during handling patients with infectious respiratory disease.

The authors declare no conflicts of interest regarding the publication of this paper.

Sharmin, T., Rahman, Md.S. and Sajj, A.B. (2023) Compliance of Physicians with Standard Precautions of Handling Patients with Infectious Respiratory Disease. Open Journal of Preventive Medicine, 13, 139-168. https://doi.org/10.4236/ojpm.2023.135010

Part 1: Socio-demographic characteristics:

Part 2: Assessment of awareness of physicians with standard precautions of handling patients with infectious respiratory disease:

Part 3: Assessment of compliance of physicians with standard precautions of handling patients with infectious respiratory disease:

Part 4: Assessment of reasons for non-compliance of physicians with standard precautions of handling patients with infectious respiratory disease: