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J Edu Health Promot 2020,  9:122

Standard precaution adherence among clinical medical students in HIV and non-HIV ward in Indonesia

1 Department of Pharmacology, Faculty of Medicine Universitas Airlangga, Surabaya, East Java, Indonesia
2 Department of Public Health and Preventive Medicine, Faculty of Medicine Universitas Airlangga, Surabaya, East Java, Indonesia
3 Department of Orthopedics and Traumatology, Faculty of Medicine, Brawijaya University, Malang, Indonesia
4 Department of Cardiology and Vascular Medicine, Faculty of Medicine Universitas Airlangga – Dr. Soetomo General Hospital, Surabaya, East Java, Indonesia
5 Department of Biomedicine, Faculty of Medicine Universitas Airlangga, Surabaya, East Java, Indonesia

Date of Submission14-Jan-2020
Date of Acceptance01-Feb-2020
Date of Web Publication28-May-2020

Correspondence Address:
Mr Firas Farisi Alkaff
Jl. Mayjen, Prof. Dr. Moestopo No 47, Surabaya, East Java
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jehp.jehp_45_20

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INTRODUCTION: Health-care workers, especially medical intern, are at risk of exposed to blood and other body fluids in the course of their work. To reduce the risk, standard precaution (SP) is introduced. Among all communicable diseases that could be transmitted, human immunodeficiency virus (HIV) is the most stigmatized disease. However, there are some government hospitals that separated adult HIV patients with other patients to prevent additional infection. This study aims to evaluate the impact of ward separation on SP adherence.
MATERIALS AND METHODS: This was an observational study conducted in March 2017 in a tertiary referral hospital for the eastern part of Indonesia. The participants were 150 medical students who underwent the past year of their clinical rotation. They were given a three-part questionnaire, consisting of their background, their SP practice in the HIV ward and non-HIV wards, and their perception and attitude regarding SP. McNemar's test and Fisher's exact test were used for the statistical analysis, using SPSS version 23.0 for Windows.
RESULTS: Participants were more adhered to SP (hand hygiene, wear mask as indicated, and wear glove as indicated) in the HIV ward compare to non-HIV wards (P = 0.002, P = 0.001, and P = 0.001, respectively). Almost all participants were more careful in implementing SP in the HIV ward than in non-HIV wards and were more concerned of getting needlestick injury in the HIV ward than in non-HIV ward.
CONCLUSION: HIV and non-HIV ward separation negatively impact medical students' SP adherence.

Keywords: Human immunodeficiency virus, medical students, social stigma, universal precautions

How to cite this article:
Alkaff FF, Salamah S, Syamlan AT, Sukmajaya WP, Nugraha RA, Jonatan M, Sulistiawati S. Standard precaution adherence among clinical medical students in HIV and non-HIV ward in Indonesia. J Edu Health Promot 2020;9:122

How to cite this URL:
Alkaff FF, Salamah S, Syamlan AT, Sukmajaya WP, Nugraha RA, Jonatan M, Sulistiawati S. Standard precaution adherence among clinical medical students in HIV and non-HIV ward in Indonesia. J Edu Health Promot [serial online] 2020 [cited 2021 Mar 3];9:122. Available from: https://www.jehp.net/text.asp?2020/9/1/122/285153

  Introduction Top

Health-care workers (HCW) are exposed to blood and other body fluids in the course of their work. Consequently, they are at risk of infection with blood-borne viruses (BBV) including but not limited to human immunodeficiency virus (HIV), hepatitis B virus (HBV), and hepatitis C virus (HCV). Occupational exposure to BBV may result from percutaneous injury, mucocutaneous injury, or contact with nonintact skin.[1]

Standard precaution (SP) is designed to reduce the risk of transmission of blood-borne and other pathogens from both recognized and unrecognized sources. SP is a combination of major features from universal precaution that was introduced in 1985 and body substance isolation that was introduced in 1987.[2] Aside from protecting the HCW, SP is also intended to prevent the spread of infection from patient to patient. According to the latest guideline, it is recommended to apply SP for the care of all patients irrespective of their disease status.[3] In Indonesia, SP is adopted into the Infection Prevention and Control Guideline in Healthcare Facility.[4]

Although the guideline is already available, the compliance of HCW toward SP is relatively low, especially in the developing countries. The previous study in West Ethiopia found that only 12% of HCW always complies with SP.[5] Another study in Indonesia among HCW in the obstetrics and gynecology department of a teaching hospital found that 95% of the respondents have a low adherence toward precaution standards.[6] Among the HCW, medical interns are at great risk of occupational exposure because they are at a very early stage of their professional career, taking the maximum load of providing medical care in the in-patient and out-patient departments.[7]

Among the listed possible occupational exposures, HIV is the most stigmatized disease, although the infection rate is lower than hepatitis B and hepatitis C. The seroconversion rate of HIV is 0.3% compared to 30% for HBV and 10% for HCV.[8] Famoroti et al. found that stigmatizing attitudes of HCW to HIV patients is prevalent, although they have good knowledge/training.[9] In Indonesia, previous studies found that HIV-related stigma among HCW is high.[10],[11] Even though the stigma is high, there are some government hospitals that separates adult HIV patients with other patients in a different ward with the purpose of preventing additional opportunistic infections for HIV patients.

This study aims to evaluate the impact of ward separation on SP adherence. We hypothesized that the SP adherence is higher in the HIV ward compared to non-HIV wards because of the exaggerated fear of HIV infection resulting from the stigma.

  Materials and Methods Top

This study was an observational study conducted in March 2017. This study followed the principles of the Declaration of Helsinki. Ethical clearance from the Institutional Review Board had been obtained before the study began (Ethical clearance number: 375/Panke/KKE/V/2016). All participants gave their informed consent prior to their inclusion in the study. Information for informed consent was given before the participants signed the informed consent. Details that might disclose the identity of the participants were omitted. This study was conducted at tertiary level teaching and referral hospital, which act as the referral center for all hospitals in the eastern part of Indonesia. This study follows the STROBE guideline.

Participants of this study were medical students in their last clinical year. These students had worked in both HIV and non-HIV wards throughout their clinical years. This study used a population survey method, and the required sample size was calculated using EpiInfo .[12] Based on the calculation, from 246 final year clinical medical students, 150 students were needed to participate in the study. Participants were recruited with a simple random sampling. The instrument in this study was a three-part self-administered questionnaire. The first section assessed participants' background, the second section assessed their SP's implementation at both HIV and non-HIV ward, and the last section assessed their perception about SP.

The questionnaire data entry and analysis were performed using IBM SPSS Statistic for Windows version 23.0 (Armonk, NY: IBM Corp.). All necessary differences and errors were rectified before the processing. All variables presented were coded with numerical values. The data were then processed into tables to show the frequencies and percentages of the distribution. McNemar's test and Fisher's exact test were used for the statistical analysis in this study. The P < 0.05 was considered statistically significant.

  Results Top

Of 150 last year medical students participated in this study, the average age was 23 years old. There were more female participants (57.3%) in this study. The majority of the participant had a grade point average between 3.0 and 3.5 out of 4.0. Based on the family background, the ratio between participants from the HCW family and the non-HCW family was 1:2 [Table 1].
Table 1: Characteristics of study participants

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In daily practices, almost all participants always implement hand hygiene in both wards. The adherence to wearing masks and gloves, as indicated in the HIV ward, was higher than in the non-HIV ward. The comparison between SP practices in HIV and non-HIV ward was all statistically significant (all P < 0.05) [Table 2]. There was no significant difference in SP practices in both wards between participants with a family background of HCW and non-HCW (all P < 0.05) [Table 3].
Table 2: Comparison of standard precaution practices between in HIV and non-HIV ward

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Table 3: Comparison of standard precaution practices between at HIV and non-HIV ward among different family background

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There were 57 participants (38%) who felt safer in non-HIV wards, although they already implement the SP. Around 20% of the participants did not believe that SP can protect them from infection. Almost all participants were more afraid of getting needlestick injury in the HIV ward than in non-HIV wards. Other than that, almost all participants were also more concerned of getting needlestick injury in the HIV ward than in non-HIV wards [Figure 1]. No significant difference in SP perception was found between participants either from a family background of HCW or non-HCW (all P > 0.05) [Table 4].
Figure 1: Medical students' perception and attitude regarding standard precaution

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Table 4: Comparison of medical students' perception and attitude regarding standard precaution among different family background

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  Discussion Top

There were significant differences regarding SP practices among medical students between the HIV and non-HIV ward. It is suggested that the implementation of SP is proportionate to the fear of infection. Moreover, the negative stigma of HIV would also affect the quality of health-care provided.[13] Previous studies in Indonesia regarding HIV stigma among HCW discovered that the level of stigma is high.[10],[11] Thus, this discrepancy may be caused by the exaggerated fear of infection among medical students.

Another possible factor that may affect SP practice is the knowledge of health-care providers.[7],[14] The incomplete understanding of SP is identified as a hindrance to proper SP implementation.[15] On the contrary, higher knowledge regarding HIV does not always correlate to less stigma toward patients with HIV.[11],[16] This suggests that education regarding HIV to health-care providers would not always result in better SP compliance. Other than that, although the HCW had more knowledge regarding SP, it did not guarantee higher SP practice among them.[14] However, the authors did not evaluate the medical students' knowledge of SP in the present study.

The present study found no difference in the SP practice between the medical students from the HCW family and the non-HCW family. In this study, the HCW family background was defined as having at least one parent who works in the health-care sector (doctor, nurse, or midwife). The effect of higher education has been already elaborated in the previous study by Li et al., where higher education level was significantly associated with lower stigma attitude.[17] However, the impact of family background to SP adherence or to stigmatizing attitude is not yet elucidated in any study.

The previous study found that reluctance to care for patients with HIV was positively associated with prejudicial attitudes and negatively associated with confidence in personal safety precautions.[18] In this study, we found that there was a discrepancy between their attitudes in their practices. The confidence of the medical students in this study regarding their SP practice is questionable as 62% still felt safer while working in the non-HIV ward. Although we did not directly evaluate the fear among the medical students, 91.33% of them were more afraid of getting needlestick injury in the HIV ward. The discrepancy in this study could be caused by the projection of that fear to more fervent SP practice in the HIV ward. This was reflected by the fact that 93.33% of them practiced more meticulous SP in the HIV ward. The other reason behind low adherence to SP has been described. The heavier workload and the discomfort of protective equipment have been identified as obstacles to SP implementation.[19] However, most of the respondents in this study agreed that the SP would not delay their response time.

Haile et al. discovered that prior training and management support is an important determinant of SP practice. In their study, the prior training increased the SP compliance by almost 3 times, and the management support increased it by more than 2 times.[5] In the studied hospital, medical students did not receive any SP training prior to their rotation at the hospital. Moreover, medical students' SP practice is rarely supervised because of the high workload.

In this study, the authors did not directly observe the SP practice among medical students but relied on self-reported practice. The previous study has already shown that actual SP practice adherence was significantly lower than the self-reported one.[20] Therefore, our study design could be considered as the weakness of this study as it might not really describe the SP adherence on daily basis practice. However, considering that even in self-reported practice showed a significant difference between SP adherence in HIV and non-HIV wards, we argued that the difference on a daily basis was even greater.

To the best of our knowledge, this is the first study in Indonesia which evaluate the impact of ward separation between HIV and non-HIV patients on SP adherence. However, there are still some limitations in our study. SP knowledge and the magnitude of HIV stigma of study participants were not evaluated in this study. Other than that, other aspects such as prior training and supervision to the medical students were also not evaluated. Nevertheless, this study is important to give a perspective for the policymaker regarding the negative effect of ward separation to SP adherence.

  Conclusion Top

HIV and non-HIV ward separation negatively impacts medical students' SP adherence, regardless of their family background. We recommend the policymaker to re-evaluate the policy of wards separation between HIV patients and non-HIV patients in Indonesia.

Financial support and sponsorship

This study was privately funded by the authors.

Conflicts of interest

There are no conflicts of interest.

  References Top

Department of Essential Health Technologies World Health Organization. Health Care Worker Safety. Geneva: World Health Organization; 2003. Available from: https://www.who.int/occupational_health/activities/1am_hcw.pdf. [Last accessed on 2 January 2020]  Back to cited text no. 1
Broussard IM, Kahwaji CI. Universal precautions. Treasure Island (FL): StatPearls; 2019.  Back to cited text no. 2
Siegel JD, Rhinehart E, Jackson M, Chiarello L, Health Care Infection Control Practices Advisory Committee. 2007 Guideline for isolation precautions: Preventing transmission of infectious agents in health care settings. Am J Infect Control 2007;35:S65-164.  Back to cited text no. 3
Minister of Health of the Republic of Indonesia. Infection Prevention and Control Guideline in Healthcare Facility. Jakarta: Ministry of Health; 2017.  Back to cited text no. 4
Haile TG, Engeda EH, Abdo AA. Compliance with standard precautions and associated factors among healthcare workers in Gondar university comprehensive specialized hospital, Northwest Ethiopia. J Environ Public Health 2017;2017:8.  Back to cited text no. 5
Sari SY, Ibrahim K, Haroen H, Afriandi I, Sunjaya DK, Hinduan ZR. Knowledge attitude and perceived adherence with universal precautions among health care workers in the obstetrics and gynaecology department of an Indonesian teaching hospital. Int J Infect Control 2011;7:101-4.  Back to cited text no. 6
Mukherjee S, Bhattacharyya A, Biswanath SharmaSarkar, Goswami DN, Ghosh S, Samanta A. Knowledge and practice of standard precautions and awareness regarding post-exposure prophylaxis for HIV among interns of a medical college in West Bengal, India. Oman Med J 2013;28:141-5.  Back to cited text no. 7
Cheng T, Zhang XL, Hu JJ, Li B, Wang Q. The role of routine screening in blood-borne pathogens in Chinese patients undergoing joint arthroplasty. Bone Joint Res 2017;6:566-71.  Back to cited text no. 8
Famoroti TO, Fernandes L, Chima SC. Stigmatization of people living with HIV/AIDS by healthcare workers at a tertiary hospital in KwaZulu-Natal, South Africa: A cross-sectional descriptive study. BMC Med Ethics 2013;14 Suppl 1:S6.  Back to cited text no. 9
Harapan H, Feramuhawan S, Kurniawan H, Anwar S, Hossain MB. HIV-related stigma and discrimination: A study of health care workers in Banda Aceh, Indonesia. Med J Indones 2013;22:22-9.  Back to cited text no. 10
Waluyo A, Culbert GJ, Levy J, Norr KF. Understanding HIV-related stigma among Indonesian nurses. J Assoc Nurses AIDS Care 2015;26:69-80.  Back to cited text no. 11
Dean AG, Arner TG, Sunki GG, Friedman R, Lantinga M, Sangam S, et al. Epi Info™, a Database and statistics program for public health professionals. Atlanta, GA: Centers for Disease Control and Prevention; 2011.  Back to cited text no. 12
Li L, Liang LJ, Lin C, Wu Z. Addressing HIV stigma in protected medical settings. AIDS Care 2015;27:1439-42.  Back to cited text no. 13
Li L, Lin C, Wu Z, Guan J, Jia M, Yan Z. HIV-related avoidance and universal precaution in medical settings: opportunities to intervene. Health Serv Res 2011;46:617-31.  Back to cited text no. 14
Kotwal A, Taneja D. Health care workers and universal precautions: Perceptions and determinants of non-compliance. Indian J Community Med 2010;35:526-8.  Back to cited text no. 15
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Li X, Yuan L, Li X, Shi J, Jiang L, Zhang C, et al. Factors associated with stigma attitude towards people living with HIV among general individuals in Heilongjiang, Northeast China. BMC Infect Dis 2017;17:154.  Back to cited text no. 17
Wada K, Smith DR, Ishimaru T. Reluctance to care for patients with HIV or hepatitis B/C in Japan. BMC Pregnancy Childbirth 2016;16:31.  Back to cited text no. 18
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  [Figure 1]

  [Table 1], [Table 2], [Table 3], [Table 4]


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