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Ministry of Higher Education and Scientific Research Baghdad University Al Kindy College of Medicine Perceptions of SeniorstowardNosocomial Infections at College of Medicine-Babylon A study Submitted to the department of Community Medicine in Al Kindy College of Medicine, Baghdad University in Partial fulfillment of the Requirement for the Degree of High Diploma in Medical Education By Kareem Abed Mobashr MBChB Supervised by Assistant prof. Mohammed Asaad Ibrahim MBChB,FICMS/CM Baghdad 2013 A.D1434Hejri الر ِحيم م ِن ََّ س ِم ال ََّل ِه ََّ الر ْح َ ِب ْ ِ ََ َ []1 لق ِي خ الذ بكَ َّ ِ ر ِاسْن ْ ب َأ ْز اق َِّ ْ ََ ََ َأ ْز ٍ [ ]2اق لق ْ ع ِن ن ه ِن اْل لق خ ْسَاَ َ ْ ََّ لن ِي ع الذ ُ [َّ ]3 َم ْز اْلَك َر و بكَ ْ َ َُّ ََ ََّ ها َلن ِن اْل لن ِ [ ]4ع لن ِالق ب ْ ْسَاَ َ ْ ن َ ْ َْ ْ []5 لن يع َ صدق هللا العلي العظيم سورة العلق(ا)5- II Supervisor’s certification This is to certify that the preparation of this thesis entitled:''Perceptions of Seniors toward Nosocomial Infections College of Medicine- Babylon'' has been made by the student Kareem Abed Mobashr under my supervision at the Department of Community Medicine /Al-Kindy College of medicine, Baghdad University. AS a requirement for the degree of High Diploma in Medical Education. Signature Assistant prof.MohammedAsaad Ibrahim MBChB,FICMS/CM III Committee Certification We, the members of the examining committee certify this thesis entitled "Perceptions of seniors toward nosocomial infections at college of medicine-Babylon" was submitted by Kareem Abed Mobashr in Al-Kindy college of medicine and after reading the thesis and examining the student in its contents, it is accepted for Diploma degree in medical education in / / 1434 , / / 2013 (Head of examining) (Member) Professor Ibtesam Khalid Salih Assistant Prof. Yousif Abdul Raheem MBChB, PHDMBChB, FICMS/CM Date 20 / 10 / 2013 D ate (Member) 20 / 10 / 2013 (Supervisor) Lect.Dr. Ahmed Abed Marzook Assistant prof.MohammedAsaadIbrahim MBChB,FICMS/CM Date 20 / 10 /2013 Date 20 / 10 /2013 IV Dedication To my beloved family, friends and teachers who supported me to accomplish this diploma. To all people who believe that education does not stop at any point of our life and learning is infinity. V Acknowledgment First of all, I would like to thank "Allah'' for inspiring me the strength, willingness and patience to accomplish this work, and I pray that his blessings upon me continue throughout my life. A special piece is to our God messenger Mohammed( ṣallAllahuʿalayhiwa-’ālih - S.A.W.W). My sincere appreciation goes to Assistant Professor Dr.sadiq Al-Mukhtar, Dean of Al-kindy medical college, University of Baghdad for continuous supporting the graduate students. My sincere gratitude and deepest respect go to my supervisorAssistant prof. Mohammed Asaad Ibrahim for his guidance, kindness, support and continuous helpful advises throughout my study, his efforts is deeply appreciated. My grateful thanks go to all members of community medicine department in Al Kindy College to their efforts to implement and success of medical diploma. I would like to express my sincere appreciation to my entire colleague of medical diploma for their continuous helping and supporting me to accomplish this study. Special thanks and respect to scientific and serious man who I met him in my life Assistant Professor Dr. Yousif Abdul Raheem for his guidance, kindness, high ethics, support and continuous helpful advises throughout my study, his effort was deeply appreciated. VI Index Supervisor’s certification …………………………..…III Committee certification……………………………..…IV Dedication ………………………………………………. V Acknowledgement…………………………………….. VI Abstract ………………………….…………………..…... 1 Introduction ………….………………………….…..…... 2 Objectives&aims of study …………………………....… 5 Literature Review ……………………………………...... 6 Methodology ………………….…………………………19 Results ………..………………..…………………...…....23 Discussion…………………………………………...….…31 Limitations……..……………...…………………...….…36 Conclusion ........................................................................ 37 Recommendations ……………………………………... 37 References.…….…………………………….…….……. 38 Appendix ((Questionnaire)) ………………….…….…... 43 VII Abstract Background: This survey assessed knowledge, attitudes and behaviors of medical students toward nosocomial infections. Methods: This is a cross-sectionalstudythat wascarried out on final year medical (106)students from College of medicine, University of Babylon (Babil-Iraq).An anonymousquestionnaire consisted of four sections, with 30 items. Students‘ knowledge section was designed to explore students' knowledge toward nosocomial infections, while another section was designed to gather information about student's behavior, to explore student attitudes toward precautionary guidelines and perception of the risk of acquiring HCAIs by multiples questions and to evaluate advising information of some items on HCAIs for students. The Chi-square test was used for significance, a P-value (<0.05) is considered statistically significant and p<0.01 is considered highly significant. Results:The study showedthe overall average of the medical students' knowledge was (68.34%) about HCAIs, however, the knowledge regarding specific areas was weak, particularly concerning the risk of transmission of infection to the hospital personnel (41.5%) and stethoscope (43.86%) as a potential source of infections. In general, their behaviors wereadequate (69.38%)to reduce the risk of infections, whereas, wearing protective materials when contact with patient sometimes were only (49.06%) of them do that. Generally the attitudes werepositive (68.68%).Females had better attitudes than males. Advising information about some items of HCAIs were generally acceptable (50, 65%), however, they sometimes have just (39.62 %) been advised about safety (IV) inserted devices and have only (22.16 %) been advised about Stethoscope cleaning. Conclusions:The students have adequate knowledge, positive attitudes and acceptable behaviors to reduce nosocomial infections; however,advising information about some items of HCAIs was generally acceptable. These findings emphasize the need of stressing on education about this sort of infections in the health care curricula. ~1~ Introduction 2 Introduction Health care-associated infections have long been recognized as crucial factors bothering the quality and outcomes of health care delivery. "An infection is considered nosocomial if it becomes evident 48 hours or more after hospital admission or within 30 days of discharge following inpatient care" [1]. Healthcare-associated infections (HAIs) or nosocomial infections were not present or incubating at the time of admission, comprise a significant burden of illness[2]. HAIs are cause of a major and increasing morbidity and mortality in around the World as well as US. The mortality rates of Healthcare-associated infections (HAIs) are varying from 5% to 35% that making HAIs is among the ten top leading cause of death.Nosocomial infection is an identified public health problem world-wide with a prevalence rate of 3.0-20.7% and an incidence rate of 5-10 %[3, 4]. All admissions %5 to %10 percent are complicated by HAI in both the US and Western Europe. Annually, In the US alone 1.7 million infections resulting in approximately 99,000 deaths occur [5]. More than 177 000 potentially infections (HAIs) occur annually in Australia with sizable attributable mortality[6]. The World Health Organization (WHO) estimates an average of 9 million individuals are affected by nosocomial infections and approximately 1 million patients die each year because of these diseases [7]. Developing countries were reported to have up to 20 times the risk of contracting a nosocomial infection compared with developed countries [8]. Thus; spread of infection serves as a major source of worry for managers in health care practice, particularly in developing countries where the health care system is already overstretched. The prevalence rate in Africa of nosocomial infections stills high .The reported rates in Tunisia9.4% Algeria 16.2%, Gabon 11% and Mali 9.6 % [7]. The economic cost of nosocomial is highly increasing in the world due to increased rates of infections, long stay in hospitals and by multiple drugresistant organisms (MDROs) increases. More than 70% of the bacteria cause resistant to at least one of the drugs used to treat them.Only in USA according to health economist at the CDC has recently estimated hospital costs of HAIs costs $28–45 billion annually [9]. The most important types of healthcare‐associated infections are central line‐associated bloodstream infections, catheter‐associated urinary tract infections and surgical site infections (specifically those following abdominal hysterectomies or colon surgeries) during hospitalization. These account for a large proportion of illnesses and deaths associated with healthcare[10]. 3 Although infections occur in patients upon admission, healthcare workers among them medical students play a significant rule as potential factors for pathogenic agents' transmission pathway for spread of infections, due to poor infection control & prevention practices & overcrowding in the most clinical settings. In one survey, 27% of participating health care students reported insufficient teaching about infection control in their training study, whilst 50% expressed a desire for isolation procedures during their training [1].According to documentations the level of compliance with the use of proven HAIs measures by healthcare workers (HCWs) has been disappointing , in spite of the fact that evidence-based procedures promoting practices in HCWs environments are published, for example,compliance with hand hygiene among health care providers is as low as less than 40% [11,12]. This scenario should alert clinical teachers and supervisors to pay more attention to give their students throughout period of their study enough knowledge about measures to reduce nosocomial infections [13]. Thus efforts should be toward education of standard infection control in theory and practice as well as encourage the health care workers and students stick to aseptic practice technique, can reduce extension of nosocomial risks on patients, families and community. Knowledge; up-date information and self-learning, skills , a role modeling and compliance are necessary of the preventive measures to restrict the spread of nosocomial infections; in addition, Patient safety education can be made significant to students by placing the principles in context with their current and future practical roles[14]. Hypotheses of the study 1. The students' knowledge about HAIs was not assessed from different aspects. 2. Better understanding may help to decrease the morbidity and mortality rate of HAIs. 3. tries to decrease economic burden, hospital stay and drugs resistance. 4 Objectives of study The objectives of this study are; To assess the knowledge, attitudes and behaviors of medical students towardhealth care- associated infections (HCAIs) or nosocomial infections. 5 Literature Review 6 Literature Review 1.1DEFINITION AND SCOPE OF NOSOCOMIAL INFECTION Nosocomial infection, also known as hospital-based infection or health careassociated infection is a serious global public health issue, causing the suffering of 1.4 million people across the world at any given time [8].Infections are considered nosocomial when they become clinically evident during hospitalization and were not present or incubating before admission to the hospital; an infection acquired in hospital by a patient who was admitted for a reason other than that infection. An infection is occurring in a patient in a hospital or other health care facility in whom the infection was not present or incubating at the time of admission. This includes infections acquired in the hospital but appearing after discharge, and, also occupational infections among staff of the facility[15]. Health care-associated infection is such a severe problem that the World Health Organization (WHO) made it a priority in 2002, when member states approved a World Health Assembly resolution on patient safety[8].Deaths due to hospital acquired infections are the fourth leading cause of death after heart disease, cancer, and strokes[16]. According an excellent article, ―Diseases From Within Our Doors‖ gives three contributing factors to nosocomial infections: overuse of antimicrobials, which has led to resistant strains of ―super-bugs,‖ failure to follow infection control procedures, and aging hospitals being renovated, releasing dust and spores into the air[16]. 1.2 Health care-associated infection in developed countries (HAIs) HCAI affects 5–15% of hospitalized patients and can affect 9–37% of those admitted to intensive care units (ICUs). Recent studies had done in Europe reported hospital-wide prevalence rates of patients affected by HAIs ranging from 4.6% to 9.3% and about 5 million in acute care hospitals HAIs are estimated to occur in Europe annually that means around 25 million extra days of hospital stay and cost of €13–24 billion. In general, death rate due to HAIs in Europe is 1% (50 000 deaths per year)[17]. The estimated HCAIs incidence rate in the USA was 4.5% in 2002, and 1.7 million affected patients; approximately 99 000 deaths were due to HAIs. 7 The economic burden of HCAIs in the USA was approximately US$ 6.5 billion in 2004[18]. The position in other industrialized countries is similar as the USA. For instance,it is estimated that there is an overall infection prevalence of 2.8% was found and 3.5% of the elderly used antibiotics in Netherlands and about 4 million HCAIs per year in the European Union, leading to 37,000 deaths per year[19]. 1.2 Burden of health care-associated infection in developing countries The dimension of the problem is particularly relevant in settings where basic infection control measures are virtually nonexistent. This is the result of the combination of numerous unfavorable factors such as understaffing, poor hygiene and sanitation, lack or shortage of basic equipment, and inadequate structures and overcrowding, almost all of which can be due to limited financial resources. In addition to an unfavorable social background and malnutrition and other types of infection and/or diseases contribute to increase the risk of HCAIs in developing countries[17]. The extent and scope of the HCAI burden worldwide appears to be very important and greatlyunderestimated. The annual 5% of budget of a county hospital in Trinidad and Tobago and up to 10% of Thailand hospital budgets and 70% of the entire health budget for Mexico [23]. When referring to endemic HCAIs, many studies conducted in developing countries report hospital wide rates higher than in developed countries. Nevertheless, it is important to pay attention to most of these studies concern single hospitals and therefore may not be representative of the problem across the whole country. For example, in one-day prevalence studies recently achieved in single hospitals in Albania, Morocco,Tunisia,and the United Republic of Tanzania,HAIs prevalence rates were 19.1%, 17.8%, 17.9%, and 14.8%,respectively[17]. The risk of developing surgical site infection (SSI) in developing countries is meaningfully higher than in developed countries for instance 30.9% in a pediatric hospital in Nigeria,23% in general surgery in a hospital in the United Republic of Tanzania and 19% in a maternity unit in Kenya [17]. In Mali, earlier studies on nosocomialinfections revealed varying frequencies. The rate of HCAIS foundin the surgical and rehabilitation services of Gabriel Toure hospital and of the CHU Point G was 10.2% and 13.8%respectively[7]. The burden of device-associated infection rates is several-fold higher than in developed countries. Pediatric ICUs 3–20 times higher are among hospital-born babies in developing than in developed countries[17]. 8 HISTORY OF NOSOCOMIAL INFECTION CONTROL Active control of nosocomial infection has been a part of medicine for over 300 years. A Scottish doctor, Sir John Pringle, used the term ‗antiseptic‘ in 1750 and carried out experiments on septic substances during his career [18]. Ignaz Semmelweis (1818-1865), a Hungarian-born doctor who practiced in Austria as an obstetrician in Vienna, ―father of infection control,‖ observed that women who delivered their babies with midwives had a much lower rate (2%) of infection than those whose babies were delivered by doctorswhere rate death (13-18%) higher because of they did not wash hands after dealing with Cadaverbefore delivering babies, which lead to infection. Semmelweis implemented a case-control study that involved mandatory handwashing among medical students and washing of medical instruments, which lead to reduce the nosocomial infection rate below than of midwife-assisted delivery.He theorized that sterilizing hands could prevent transmission of infection from a diseased cadaver to a pregnant patient. Therefore, on May 15, 1847, he commanded all medical students and physicians to wash their hands with chlorinated lime before assisting in deliveries, which resulted in a dramatic outcome - deaths on the maternity ward fell fivefold.So he was the first healthcare professional to demonstrate through experiments that handwashing could prevent infections[20].Oliver Wendell Homes made this same discovery but sadly, both Holmes and Semmelweis were not believed by their peers at the time of their writings. Sir James Young Simpson, working in Scotland in the mid-1800s, derived a campaign against hospital cross-infection, or the transmission of infection from one patient to another via doctors and nurses[18]. Joseph Lister, a professor of surgery at Glasgow, Scotland, he observed high mortality rates from post-surgical sepsis during his professional in late1800s.Who is the first using sterilization with carbolic acid in the Operating Room Before surgery.The result was the mortality rate from amputation dropped from 45% to 15 %[21]. The first nationwide commitment to researching and eradicating nosocomial infection in the United States came in 1958, in the midst of the first antibioticresistant staphylococcus aureus pandemic [18]. During the 1960s, nurses became the primary infection control specialists due to their close contact with patients. Garcia and colleagues in the 1970s note that the expansion of using medical equipment's and treatment options, so he did the understanding of deviceassociated infection, such as catheter- and respirator-related infection. 9 In the early 1970s the database system was based to monitor the incidence of nosocomial infections, the responsible pathogens and the associated risk factors. The Healthcare Infection Control Practices Advisory Committee (HICPAC) was formed in 1991 by the CDC. Many guidelines have been produced by this group. Since the late 1990s, infection control has become a global issue, with the WHO instituting a Patient Safety Initiative in 2002. In 2005 hospitals began giving data to NHSN (National Healthcare Safety Network). . NHSN was developed for the purpose of accumulating, exchanging and integrating relevant information on infectious and noninfectious adverse events associated with healthcare delivery[22]. Many developing countries established national policies to promote infection control during the 1980s and 1990s. Over the past 25 years, CDC‘s National Nosocomial Infections Surveillance (NNIS) system has received monthly reports of nosocomial infections from many hospitals of United States; more than 270 institutions report. The nosocomial infection rate has remained notably stable (nearly 5 to 6 hospital-acquired infections per 100 admissions); however, because of progressively shorter inpatient stays over the last 20 years, the rate of nosocomial infections per 1,000 patient days has actually increased 36%, from 7.2 in 1975to 9.8 in 1995.It is estimated that in1995, nosocomial infections one death every 6 minutes [22]. All current organizations around the World can help us to avoid greater than 100,000 deaths of nosocomial infections annually. 10 2.1 What students need to know (knowledge requirements): Students should know the extent of the problem [23] ; A number of antimicrobial-resistant organisms found in hospital settings such as MRSA, (methicillin-resistant staphylococcus aureus) and VRE (vancomycin-resistant enterococcus) also make treatment extremely difficult. Many infected patients (about 25%) are in an ICU with more than 70% of the patients having micro-organisms resistant to one or more antibiotics. Today, antibiotics are often ineffective and more than 70% of hospital acquired bacterial infections are resistant to at least one of the drugs commonly used to treat them among health care-associated infections [23]. But 30.9% students did not know at least one multidrug-resistant bacterium[24]. In one study, the increased cost ofMRSA was calculated approximately$4000 per infection. In addition, another group of researchers recently found thatClostridium difficile is occurring almost as frequently in the hospital setting as MRSA and the costs ofC. difficile-associated diarrhea to be approximately $4500 per patient [9]. Students should usually know how to apply universal precautions as soon as they enter the hospital environment. It is better to learn how to do something right the first time than trying to reverse bad habits. A 2006 cross-sectional study of medical staff and medical students in Iran reported that 54% of students had not heard about universal precautions[23]. Students should know the main causes, types of infections and Factors that predispose to nosocomial infections. Nosocomial infections are caused by multiple pathogenic micro-organisms such as bacteria, viruses, parasites or fungi; the diseases can be spread from one person to another which is entering the body through one or more of the following routes. • Person–person via hands of health-care provider's patients and visitors; • Personal equipment (e.g. stethoscopes, computers) and clothing; a study conducted in Australia reported that 86.8% of all sampled health care equipment was contaminated, but with 70% alcohol reducing the levels of contamination on equipment by(82.1%), which is a significant source of NI[25], furthermore,in Turkey a study in 2011 found bacterial and fungal contamination on (76%) of the stethoscopes[26]. • Environmental contamination; • Airborne transmission; • Carriers on the hospital staff; • Rare common-source outbreaks. The following four types of infections account for more than 80% of all health care-associated infections: • Urinary tract infections usually associated with catheters: 11 - Catheter-associated urinary tract infections are the most frequent, accounting for about35% health care-associated infections; • Surgical infections: - these are second in frequency, about 20%; • Bloodstream infections associated with the use of an intravascular device: about 15%; • Pneumonia associated with ventilators: - about 15%[27]. The evidence shows that infections rates in thefirst two categories can be reduced when healthcareworkers comply with infection controlguidelines and patients leave hospital as soon aspossible. Factors that predispose to nosocomial infection Related to underlying health status areadvanced age, malnutrition , Alcoholism, Heavy smoking, chronic lung disease and Diabetes Related to acute disease process are Surgery, Traumaand Burns Related to invasive procedures are Endotracheal or nasal intubation, Central venous catheterization, extracorporeal renal support, surgicaldrains, Nasogastrictube, Tracheostomyand Urinary catheter Related to treatmentare, Bloodtransfusion, recent antimicrobial therapy, Immunosuppressivetreatments, Stress-ulcer prophylaxis Recumbent position, parenteral nutrition and Length of stay[28]. Students should learned the need to routinely undertake activities to prevent infection such as correct hand washing, effective sterilization procedures and correct gloving and gowning. Infections are preventable when the right techniques use by health-care workers and remain on the lookout for unclean and unsafe situations.Study conducted in Malaysia, showed that 80% of medical students washed their hands but only 41.6% performed effective hand washing[29]. Medical students should be understood why hands need to be decontaminated, Which refers to the process for physical removal of blood, body secretions and the removal or destruction of micro-organisms from the hands.one study conducted in Saudi Arabia was showed that the average awareness concerning the positive indications of hand hygiene was 56% And the 44% of students were either not sure or unaware of the indications of hygiene. Only 17%of students were Compliance as assessed during OSCE[12]. Students should be learned the safe use and disposal of sharps such as needle to avoid the significant problem for health-care workers caused by needle stick injuries, for instance blood borne viruses. The risk of HIV transmission through a needlestick to infected blood is nearly 0.3%; the risk of hepatitis C is 1.8% while the risk of hepatitis B is 6% to 30%. Susceptible individuals are (those who have not received the hepatitis B vaccination)[30]. 12 In addition, students need to: • know how to clean hands; • The rationale for choice of clean hand practice; • Techniques for hand hygiene; • How to protect hands from decontaminants; • promote adherence to hand hygiene guidelines 2.2 What students need to do (performance requirements): • apply universal precautions; • be immunized against Hepatitis B; • use personal protection methods; • know what to do if exposed; • encourage others to use universal precautions. Medical students should have effort to reduce the spread of infection and to encourage patients and other health-care workers to actively engage in practices that reduce the spread of infection in the community, hospitals and clinics sittings. Students need topractise universal precautions;be immunized against Hepatitis B;use personal protection methods;know what to do if exposed to infection andencourage others health care workers to use universal precautions. Practise universal precautions WHO has developed the following checklist for health-care workers. Students must hand wash after any direct contact with patients. Before contact with each and every patient a student should clean their hands before touching a patient. This is to protect the patient against harmful micro-organisms carried on the hands of Students during travelling on a bus before entering the hospital and the ward where they engage with a patient to take history, perform a physical examination and so on. A student should clean hands before an aseptic taskto protect the patient against harmfulmicro-organisms, including the patient‘s ownmicro-organisms, entering his or her body. Students must protect against transmission through contact with body secretions. After contact with each and every patient a student should clean hands after any risk of exposure to body fluids. Students should usually clean their hands immediately after an exposure risk to body fluids and after glove removal.Retrospective studies indicate that percutaneous exposure incidents (PEIs) would be reduced by more than 50% by behavioral interventions, either through education or adoption of new techniques[31]. Students should wash hands after actual patient contact. 13 All students should clean their hands after touching a patient and his or her immediate surroundings. Forgetting to wash hands (health care providers) due to rash in work can lead to get the student an infection and increasing the chances of the microorganisms spreading throughout the environment Students must handwash after contact with patient surroundings Students should clean hands after touching any object or furniture in the patient‘s immediate surroundings when leaving them, even without touching the patient. Students should be immunized against Hepatitis B Students are at risk of infection with blood borne viruses, like all health-care workers. So it is important to be immunized as soon as they start seeing patients in hospitals, clinics and the community. The annual number of occupationally acquired hepatitis B infection has decreased 95% since the introduction of the hepatitis B vaccine. Students should use personal protection methods They should use needle stick prevention devices where possible and Provide feedback to the health-care team about the personal protective equipment. Students should know what to do if exposed If a student is mistakenly exposed or becomes infected they should immediately tell the appropriate staff in the hospital or clinic as well as a supervisor to receive appropriate medical attention. Students should encourage others to participate in infection control Students should act as a role model to encourage each other to use correct handwashing techniques. Students can be leaders in this respect to help another health-care provider have poor technique. Also Students can teach patients about the importance of handwashing. It is also a good time to practise their skills on educating patient about health care and prevention. Addition things might students to do • Needles should never be recapped; • All sharps should be collected and safely disposed; • Students should use gloves when in contact with bodily fluids, non-intact skin and mucous. • Students should wear a face mask, eye protection and a gown if there is the potential for blood or other bodily fluids to splash; • Students should cover all cuts and abrasions including their own; • Students should always clean up spills of blood and other bodily fluids; • Students should make themselves aware of how the hospital waste management system works. Learning sources information of HCAIs. 14 Strengthening the contribution of medical doctors and medical students to HCAIs prevention programs should include measures that enhance knowledge, improve practice and develop appropriate attitudes to the safety and quality of patient care(32). In the existing traditional curriculum, the topic of nosocomial infections is taught through an instructive lecture on facts related to the etiology, pathogenesis and control measures. However there is neither a module which involves practical training of students to acquire skills of hand washing and waste disposal, nor any method to evaluate these skills. This creates a big gap in the constructive years of undergraduate studies, as the students are likely to undervalue the importance of these preventive measures and a lack of compliance in adhering to these measures leading to the spread of nosocomial infections[33]. Although HCAIs is taught in most medical schools around the world, but HCAIs prevention or infection control is largely ignored or insufficiently addressed in the curricula of most medical schools. For instance, The Hospital Infection Society (HIS) funded a review of medical education on HCAIs throughout medical schools in the UK and the Republic of Ireland. The prevalence and transmission of HCAI were taught by 97% and 100% of medical schools, respectively, but the importance of HCAI as a quality and safety issue was covered in only 60% of medical schools [32].Likewise, in china, health-care associated infections are introduced only briefly to preclinical students in the Infection and Immunity module. There are neither formal lectures nor bedside teaching on ward rounds for clinical students during their study[34]. Effective student learning depends on teachers using a range of educational methods such as shared knowledge, demonstrating skills, introduce gradually attitudes—all are essential for patient safety education [35]. Teachers of patient safety should use according to ''The WHO Patient Safety Curriculum Guide for Medical Schools''. • Problem-based teaching (facilitated group learning); Small group discussion session. The class can be divided up into smallgroups be asked to lead a discussion about the causes and types of infection.The tutor facilitating this session should also be familiar with the content so information can be added about the local health system and clinical environment. • Simulated-based learning (role plays and games); • Lecture-based teaching (interactive/didactic);Use the accompanying slides as a guide covering the whole topic. The slides can be PowerPoint or converted to overhead slides for a projector. Start the session with a case study selected from the Case Study Bank and get the students to identify some of the issues presented in the story. 15 • Mentoring and coaching (role models).Educators may adopt a variety of styles including roles as information provider, role model, facilitator, assessor, planner and resource provider These activities can start from the very first years in the hospital and clinic environments, In addition to, Self-learning by reading current scientific articles, online material and log books which has a positive influence on the knowledge and practice of HCWs[23, 35]. The Patient Safety Curriculum Guide for Medical Schools has been implemented in curricula across the world.one study confirmed that Faculty who participated in the study have approved that the Curriculum Guide was an important resource and helped them implement patient safety teaching in their curricula. Students reported positive awareness to patient safety and that their knowledge of patient safety increased after the teaching [36]. A study reported in UK that Lectures, discussion of cases and practical demonstrations were considered useful by >90% of respondents and online material and log books by 67% and 60%, respectively. An agreed curriculum should be developed for educating medical students in HCAI prevention and control, to outline optimum methods for assessment and develop a shared unite of educational resources[32]. But the questions are all medical schools or medical doctors and supervisors around the world emphasis on encouraging and enhancement the medical students to learn about HAIS, have they professionalism competences, are they perform and implement what they are learned. For instance, a study was conducted in Serbian at School of Medicine; University of Kragujevac revealed that about (54.4%) of the students knew that contact was the most frequent mode of NI transmission while hand washing as preventive measure was quoted by only 18.8% of student. It means the students need more information and practical intervention to get complete knowledge about nosocomial infections[24]. Moreover a study was doneat University of Sri Jayewardenepura revealed that participants had adequate knowledge (77%) but attitudes, practices of all the participants was overall weak (<50%). However the nursing students had better knowledge (p=0.023), attitudes (p<0.001), practices (p<0.001 [37]. 16 Medical teacher on-the-job role model of learning(role model) The importance of the teacher as a role model is well documented. The General Medical Council (1999) in the UK acknowledges that '' the example of the teacher is the most powerful influence upon the standards of conduct and practice of every trainee, whether medical student or junior doctor'. The teacher as a clinician should model or illustrate to students what should be learned. Students learn by observation and imitation of their clinical teachers they respect not just from what they say but from what they do in their clinical practice and the knowledge, skills and attitudes they exhibit [38]. The student needs expert coaching rather than a knowledgeablephysician talking about supporting theories. When teachers observe and give feedback about student performance the student will continuously improve and [23] eventually master many of the patient safety skills . Role modeling is one of the most powerful means of transmitting values, attitudes and patterns of thoughts and behavior to students. In fact, role modeling may have a greater effect on the student than other teaching methods; for example, found role modeling to be educationally more effective than lecture/discussion sessions in enhancing the students‘ ability to communicate with patients about immunodeficiency virus[38]. The importance of the role model was emphasized too by Sir Donald Irvine (1999), President of the General Medical Council in the UK. He suggested that '' the model of practice provided by clinical teachers is essential because students learn best by good example'[38]. ―We need to teach medical staff — especially medical students — about the importance of hygiene, and we need experienced physicians who will serve as good role models for proper infection control later on,‖ Ralf-Peter Vonberg, MD, of Hannover Medical School, told Infectious Disease News. Further, medical students tended to believe that more experienced physicians conformance toward hand hygiene would decrease[39]. Squires (1999) noted that '' it is important to identify modeling as a distinct function and heading in order to draw attention to what is a pervasive but sometimes unconscious, and even denied process in education. Teachers may not see themselves as models, and may even regret the very idea as pretentious and paternalistic, but it is difficult for learners not to be influenced by the living example set before them''[38]. 17 Shouldn’t Medical Students Be Taught Hygiene? What else needs to be done?Medical students as the future clinicians andleaders in health care system. They will need to know aboutpatient safety, the qualityand safety of health care system and management of these challenges. Medical students learn very quickly about how doctors behave and what is expected of them, and because they are novices they wish to fit in as soon as possible. Many students and junior doctors think their survival of the early years and their careers depends on their fitting in. The system of medical progression relies on reports from supervising clinicians about the performance and development of students and young doctors. Medical students are low in the medical hierarchy and very dependent upon supervisors for their instructions and learning[35]. Medical schools should be teaching future doctors the precautions they must take to from infection. It‘s hard to believe, but most medical schools commit actually no timeto showing their students how bacteria are transmitted from patient to patient on clothing, equipment, and gloves, and what they should be doing to prevent transmission of infections. Dr. Frank Lowey, a professor at the New York-Presbyterian Hospital at the Columbia University Medical Center says, ―It’s something we should have done quite a while ago.‖ Lowey says it‘s ironic that ―there are curriculum committees devoted to making sure that bioterrorism is covered, and the risk of nosocomial infections far outweighsthat "but some medical schools are stressing the importance of restraining the use of antibiotics. That is nice, because overuse of antibiotics lead to waste money and cause bacteria to change into new, drug resistant strains. But that is not stopping hospital infections. Patients who adhesion MRSA get it from bad hygiene for instance unclean hands, contaminated equipment, clothing and not from taking antibiotics. No hospital can ever eradicate infection only by controlling the use of these drugs. When students put on their white coats and swear theHippocratic Oath, they should be taught how to do no harm. The essential issue isof topic that is preventing the spread ofinfected bacteria. Medical students should learn it before they go out on the hospital floors and touch their first patient. Medical schools should be teaching their students the precautions of infections that will be help to protect them and patients from each other's [40]. 18 Methodology 19 Methodology Study design The research is a cross-sectional study to assess knowledge, behavior, attitudes of medical students. Settings: The study was conducted during the period from January to October 2013 at teaching hospitals, (al Hilla teaching hospital), (maternity&children hospital) and (Margan teaching hospital), located at Babil. It was carried out on one hundred and six (106) students; assess knowledge, behavior and attitude of medical students on nosocomial infections, in addition to their information resources of nosocomial infections. Participants The study carried out on final year students of college of medicine, University of Babylon, located at Babil. They were separated to four main groups, medicine, surgery, pediatric, gynecology and obstetrics on the main hospitals at Babil. The questionnaire was distributed to the students after consent was sought and obtained from head master of medical college of medicine of Babil and all departments' masters at different hospitals where the students presented. Prior to the study, participants were given a brief introduction to the purpose of the study, after which their consent was sought and obtained. The participants did not all complete and return the questionnaire. About ten students did not return the questionnaire. Survey instruments The Infection Control Questionnaire prepared by researcher according to international guidelines and another questionnaire on standard isolation precautions, hand hygiene, prevention and control measures of nosocomial infections and resources of information was used in this study[41,44,47,48,49,50].The questionnaire consisted of four main domains, with 30 items. Students‘ knowledge section was designed to explore student's knowledge related to health care associated infections (HAIs) or nosocomial 20 infections. For each statements are whether student agree, uncertain or disagree.it consisted of (10 items).Response to each item was coded and scored as a correct answer (2), uncertain (1), incorrect answer (0).The second section was behaviors section which consisted of (10 items).This section is designed to gather information about student's behaviors. For each statement check whether student always sometimes never adopt each of the practices to reduce the risk of HAIs. Responsive scored was (2), (1), and (0) consequently. The third was Attitude's section (5 items) of the questionnaire, was designed to explore student attitudes toward precautionary guidelines and perception of the risk of acquiring HAIs by multiples questions. Each item was scored (2) for correct answer and (0) for incorrect answer. The last information's section (5 items) was designed to ask questions about sources of student's information on nosocomial. For each statement check whether student always sometimes never learned about HAIs during curricula implementation through their study. Response to each item was coded and scored (2), (1), and (0) consequently. The equation (NO x0 +NO x1+NO x 2/ 2 x106) x100%, (NO=number) was used to estimate the mean percentage of any question in the research that needs to assess results of the questionnaire. The Iraqi grading rate system was used to interrupt any grading scale anywhere in the study as following: Excellent………….. 100-90% Very good………….80-89% Good……………….70-79%, Adequate………….60-69% Acceptable………. 50-59% Weak…………….. 0-49%[51] The content of the questionnaire was validated after interviews and discussions with three experts in the field, and it was modified where necessary. 21 Ethical consideration The study protocol as well as the questionnaire was authorized by Ethical Committee of the Al kindy college of Medicine, Baghdad University Statistical Analysis Data was analyzed by Minitab 13.1 software. Calculation of the Chi-square test for significance was used. P-value of less than (0.05) is considered statistically significant, and less than 0.01 is considered highly significant.Tally test from Minitab also was used in calculation the percentage and the number of males and females together of answered question while Cross tabulationused in calculation the percentage and the number of males and females separately of answered question.Variables data presented as tables and figures in the study. 22 Results 23 Results: Table no.1 Demographic characteristics Student NO % Male 37 34.91% Female 69 65.09% Total 106 100% The number, gender and percentage of students included in the study are shown in table (1), the sample is composed of 106 students from sixth year, and the number of females is two third more than the number of males. 24 Table no (2) Knowledge about health care-associated infections and control measures Question 1.Hand hygiene measures before and after dressing 2.Your stethoscope is a potential source of infections. 3.Healthcare workers caring of patient with MRSA 4.Changes in antibiotics use lead to antibiotics resistance 5. The risk of transmission infection to the hospital personnel. 6.The environment is source nosocomial infection. 7.prevalence of Nosocomial infection in the world 8. the risk of Invasive procedures on nosocomial infection 9.Duration of intubation and mechanical ventilation related to Ventilator Associated Pneumonia. 10. Gloves do not obviate the need for hand hygiene. Disagree No % 0 0 Uncertain No % 7 6.60 36 33.96 47 44.34 29 27.36 47 44.34 14 13.21 17 16.04 59 55.66 11 10.38 25 23.58 11 10.38 8 7.55 65 61.32 4 3.77 14 13.21 2 1.89 14 13.21 35 33.02 14 Agree NO % 99 93.4 0 23 21.7 0 30 28.3 0 75 70.7 5 36 33.9 6 70 66.0 4 33 31.1 3 88 83.0 2 90 84.9 1 13.21 57 53.7 7 N0 (CA) & % NO % 205 96.69 93 43.86 107 50.47 167 78.77 83 41.50 151 71.22 131 61.79 190 89.62 194 91.50 128 60.37 Note; correct answers (CA). Answers concerning the knowledge of HCWs are shown in table 2. Themajority (96.69%) knew about hand hygiene measures before and after dressing changes by health care workers and also toward the risk of Invasive procedures (89.62%) and duration of intubation (91.50%) related to Ventilator Associated Pneumonia. But only 83 (41.5%) recognized the risk of measles & chickenpox more than hepatitis B and HIV transmission infection to the hospital personnel. Furthermore, Just 93 (43.86%) knew that stethoscope is a potential source of infections. The overall average of the medical students' knowledge is (68.34%) about HAIs. 25 Table no (3) Behaviors distribution of the students practices to reduce the risk of HCAIs Never Sometimes Always N0 of (CA) & % NO % No NO % No % 98 46.22 % Question 1.Wearing protective materials/eyewear & mask 2.handwashing/moving From infected to clean site 3.handwashing/before &after gloves wearing 4.disposal materials Needle or sharp 5.stay home / infectious illness 6.hepatitis B/ Vaccination 7.role model /prevention measures 8.handwashing/before &after dressing 9.role educator /clients 10.respiratory hygiene/cough etiquette 31 29.25 52 49.06 23 21.7 16 15.09 27 25.47 63 59.43 153 72.16 22 20.75 26 24.53 58 54.72 142 66.98 12 11.32 24 22.64 70 66.04 164 77.35 24 22.64 51 48.11 31 29.25 113 53.3 17 16.04 23 21.70 66 62.26 155 73.11 14 13.21 51 48.11 41 38.68 133 62.73 6 5.66 17 16.04 83 78.30 183 86.32 7 6.60 20 18.78 79 74.53 178 83.96 9 8.49 42 39.62 55 51.89 152 71.69 Thetable no (3) of behavior is showing that respondents wearing protective eyewear & mask when contact with patient sometime was only (49.06%). Hands washing after hands move from infected body site to clean site, before and after wearing gloves was ( 59.43%), (54.72%) respectively but, hand washing after dressing changes and any contact with the surgical site was (78.30%). The respondents sometime (48.11%) stayed home when they have infectious diseases such as respiratory illnesses or diarrhea. They sometime took (62.26%) vaccination against hepatitis B, however, they reacted just (51.89%) toward respiratory hygiene/cough etiquette during period of increased prevalence respiratory infections in the community. They sometime played (48.11%) as a role modeling to health care providers, clients and families with regard to infection prevention and control strategies; in 26 contrast, they played an educator role (74.53%) to encourage patients to report to their health-care provider any changes in their catheter site or any new discomfort. In general, the students behaviors were(69.38%) toward prevention and control of nosocomial infections. Table no (4) Attitudes distributiontoward precautionary guidelines and perceptions of the risk of acquiring HCAIs Question Female (CA) male (CA) Total (CA) NO % NO % NO % p-value 55 51.89 33 31.13 88 83.02 0.215 2.Handwashing with 47 alcohol hand gel 44.34 9 8.49 56 52.83 0.000 3.cleaning spoiled 58 floor 4.disposing medicals 40 materials 54.72 18 16.98 76 71.7 0.000 37.74 15 14.15 55 51.89 0.087 5.protactive materials 55.66 30 28.3 89 83.96 0.554 1.surplus budget 59 CA ;( correct answer) In table no [4] is shown that the overall perceived of medical students was (68.68%) about HAIs.females are (48.87%) more than males (19.81%) concerning the perceived risk of acquiring a HAIs. Their attitudes were (83.02%) when they act as hospital manger to Organize financially supported courses with training to support behaviorsfighting infections and when they are in the surgical emergency unite attendance ( 83.96%) to be always wearing gloves and mask whatever the case. However, they showed acceptable perceived( 52.83%) ,(51.89%) respectively towardhands washing with alcohol hand gel after any events of examination despite of overcrowding and disposing medicals waste always making sure of disposing by yourself. 27 90 80 70 60 50 40 30 20 10 0 female surplus budget Hand wasing Cleaning floor male Disposing of waste medical materials Protective materials correct answer% Figure no(1) Demographic Attitudes'distribution and correct answers In general, the figure no (1) shows that females had more correct answers than males in all questions. 28 Table no. (5)Curriculum evaluation of advising information ofsome items of HCAIs Question Never Sometimes Always Total Answering No &% F No, % M no,% F no,% M no, % F no,% M no,% 6 11 27 16 36 10 1.standard handwashing 2. standard precautions 5.66% 10.38% 25.47% 15.09% 33.96% 9.43% 63.67% 6 4 36 5.66% 3.77% 33.96% 25.47% 25.47% 5.66% 60.84% 3. safe (IV) or inserted devices 4.stethoscope cleaning 17 12 27 5. contact precaution 27 15 27 25 6 10 153 129 112 16.04% 11.32% 25.47% 14.15% 23.58% 9.43% 52.84% 43 25 6 3 40.57% 23.58% 18.87% 8.49% 5.66% 2.83% 22.16% 12 21 7 8 11.32% 7.55% 20 9 36 22 47 114 33.96% 20.75% 19.81% 6.60% 53.77% The table no 5 shows that the females students have been advised always (33.96) about standard hand-washing measures, while, males were (9.43%).Advising toward standardprecautions was that femalessometimes(33.96%)were advised, whereas, males (25.47%). Most of males (40.57%) and females (23.58%) were neverbeen advised of stethoscope cleaning. Female Students sometimes(33.96%), males (20.75%) advised aboutcontact precaution. The overall advising information of medical students to some items of HCAIswas(50.65%). 29 Figure no (2)shows the advising Information receiving on HCAIs during college courses The figure no (2) is showing the responsive of medical students toward some items of getting their information's about HCAIs during graduation both clinical and classroom sessions. Only (43.40%) always of students have been advised about the standard hand-washing, while, sometime (59.43 %) heard about precautions standard. They sometimes have Just (39.62 %) been advised toward safe intravenous (IV) cannulation or inserted devices. The students have never (64.15 %) been advised about Stethoscope cleaning during courses of their study, furthermore, they sometimes (54.72%) have been informed of contact precaution measures. 30 Discussion 31 Discussion Medical students need to learn how to convey safer care due to the growing identification of the harms caused by health care. Knowing" what "is advancement to know“how” and ultimately to “doing”. Through hands-on experience with feedback from trainers is the best learning, along with mentoring and coaching.Students need to learn safe health care practice even if the current medical culture is not supportive of this, and deal with the conflicts this may produce[14]. In this survey participants‘ knowledge concerning the various aspects of HCAIs was generally adequate (68.34%), however, there are many areas where the knowledge was excellent (93.4%)especially regarding hand hygiene measures before and after dressing, the risk of Invasive procedures were very good (89.26%) on nosocomial infection and duration of intubation and mechanical ventilation was excellent (91.5%).In contrast, there are other areas where the knowledge was weak, particularly concerning the risk of transmission of infections to the hospital personnel(41.50%)and stethoscope as a potential source of infections(43.86%). Established upon these considerations, these medical students need to learn more in order todiminish the rate of HCAIs. According to another studies conducted in same field they foundin Italyhigh (very good)knowledge (86.3%)of medical students about HCAIs[41].While another studies found good knowledge(70.58%) of nosocomial infections among medical students at the College of Health Sciences, University of Ghana. Another study was conducted at Qazvin University of medical science in Iran revealed that the students'goodknowledge (79.9%)on nosocomial infections [1, 42], furthermore, at the Medical University of Graz in Austria, a study found the knowledge on hygiene guidelines appears to be good(70%) among medical students[43]. In contrast, a study carried out among medical students attending Shantou University Medical College (SUMC) in China, demonstrated that medical students have limited (acceptable) knowledge (52.5 %)[34], Moreover, 32 another study achieved to measure students‘ knowledge of infection control measures and their sources of information, at Rouen University (Rouen, France), found the knowledge of nursing students was better than medical students in three areas, hand hygiene, standard precautions, and nosocomial infection also the same results were found in Italy [41,44]. In general, students' behaviors in current study were adequately (69.38%).Results from this study indicated that most respondents always performed hands hygiene measures after dressing changes and any contact with the surgical site were very good( 86.32%) attendance for the prevention of the HCAIs. They showedvery good (83.96%)desirefor encouraging patients to inform their health-care providers any changes in their devices or any new discomfort. Whereas, they perceived acceptable (62.73%) manner to act as a role model to health care providers, clients and families with regard to infection prevention and control strategies, however, they need to be more encouraged to play this role by their teachers and expert staffs in classrooms and bedside teaching. The students responded to take vaccination against hepatitis Bwas good(73.11%). Thehepatitis Bvirus (HBV)considers the most common occupational viral infections; however, it can be prevented by vaccination. For instance, in 1990, the HBV infection rate among unvaccinated US healthcare personnel was three to five times greater than in the US general population while the rate was reversed in 2010 five times less than in the US general population due to the introduction of routine HBV immunization and comprehensive occupational health and safety policies[31]. The students reactedgood (72.16%)to hands washing after hands move from infected body site to clean site andadequately (66.98%) before and after wearing gloves.The hand hygiene, wearing gloves and protective materialsconsider the corner stone in preventive pathogens transmission but not all students or health care workers are disposed to it, for instance, a study carried out in Tikrit,Iraq revealed (75%) of medical staff and [52] employees had contaminated hands . According toSulaiha S A, et al, that most of students either fail to wash their hands or fail to follow the correct steps in effective hand washing during clinical practice, the overall frequency of hand washing before and after contact with patients were (6.7%) and( 23.7%) respectively which are mostly very weak[29]. Another study conducted in Qassim College of Medicine, Saudi Arabia to evaluate the consciousness, and compliance of hand hygiene among 33 undergraduate medical students during their clinical study. It had revealed the average awareness regarding the positive indications of hand hygiene was (56%) while the(44%) of students were either not sure or unaware of the indications of hygiene [12]. Generally compliance rates of hand hygiene (HH) among healthcare providers (HCPs) stay low, in spite of, identifying that HH is very important in reducing infection rates. In a recent systematic review by Mukerji A,et al, of 96 studies (with 65 studies in intensive care settings) on HH compliance of HCPs from developed nations, it was found that compliance rates were as weak as 30– 40% in intensive care settings compared with 50–60% in other settings[45]. In this study the students reacted weakly (46.22%) towardwearing protective eyewear and/or mask when they were at direct contact with a patient. Eyewear protects transmission infections trough out cornea of the eye by droplets or splashes of body fluid secretions or blood such as HIV &HBV. The awareness was acceptable (53.3%)regarding staying home when they have infectious diseases such as febrile respiratory illnesses, Cold sores or diarrhea so that they will be a potential source of causing iatrogenic nosocomial infection for their colleagues and patients in clinical sittings. They need to learn when they had infectious illnesses then they must stay home by their teacher's advice or consider as medical schools protocol. The British General Medical Council (GMC) in its booklet, serious communicable diseases, states that ―You must always take actionto protect patients when you have good reason to suspect thatyour own health, or that of a colleague, is a risk to them. Youmust consider how any infection you have may put patients atrisk‖ [46]. According to several researches there were weak practices and adherence regarding HCAIs prevention measures among medical students, for instance, in Iran, and China practices toward standard isolation precautions were weak (33.3%) ,(44.5% ) respectively and also in Austria adherence is limited( weak) ( 49%) and requires improvement due to only( 43%) performed hygienic hand disinfection according to WHO guidelines[ 34,42,43]. The attitudes of students toward nosocomial infection in this study wereadequate (68.68%), since there were significant trendedvery good (83.02%) to support training of medical providers to fight infection when they are at the top of administration pyramid during their career. They showed positively perceivedvery good (83.96%) through compliance using of protective materials to control infections transmission in the surgical emergency unite. In another hand, they were acceptable(52.83%) tendency toward hand washing with alcohol gel after any event of examination during overcrowding situations and also they exhibitedacceptable (51.89%) attitudes about disposing medicals waste by their self, whereas, it is considered as a part of the duty of medical staffs to 34 preserve perfective cleaning environments in clinical sittings. The medical students must take responsibility as early as possible in controlling infections because they are tomorrow doctors. Females were statistically significant differences (P =0.000) than malesgender in some aspects; for e.g. females were noted highly significant attitudes in hand washing with alcohol hand gel and cleaning spoiled floor (p=0.000). This outcome seems to be nearly the same with findings by Barikani A,et al, who reported that medical students had positive attitudes (73.7%)toward Standard Isolation Precautions[42]. In contrast, a study was done at University of Sri Jayewardenepura revealed that participants had weak (<50%) attitudes.The study shows the need for further improvement of the existing hand hygiene training programs to address the gaps in knowledge, attitudes and practices [37]. The outcome of this study exhibited that advising information of students' knowledge about HAIs were generallyacceptable (50.65%), since, majority of them werewhere just only (22.16%) advised to clean their stethoscope. In addition to, they sometimes had been advised about safety (IV) cannulation or inserted devices (52.84%),whereas,Batool A. Al-Shawii, et al found all neonates (100%) who had invasive procedures (cannula or intravenous set) or received oxygen therapy (O 2) had bacterial infection and out of the total neonates, 9.3% had bacterial infection in the Neonatal Intensive Care Unit (NICU) of the Baghdad Teaching Hospital, Iraq [53]. In present study also approximately half of students had not been informedregarding contact precaution measures (53.77%), whereas, these subjects are considered crucial foundations in preventive measures and control of HCAIs. The problem seems due to defect in curriculum which may be not properly covered or neglected this topic, in another hand, clinical teachers have not acted as a role model in transfer knowledge and practices about preventive nosocomial infections to their students. The results of advising information during college courses of this study followed with findings by other researches, for instance,Yuanchun Huang et aldemonstrated that medical students have limited knowledge and practice (52.54%) regarding HCAIs due to substantial deficiencies in their learning resources[34]. Herbert VG, et al found (79%) of the respondents asked to an obligatory course on hygiene standards in medical education and the demand for an optimum education in hygiene is high[43]. Barikani A,et al, clarified the necessity of standard isolation in prevention of disease in patients in all duration of education must be emphasized and facilities should be improved[42]. 35 Our students should know the extent of problem regarding nosocomial infections in our society for e.g. a study was done in Basrah General Hospital, Iraq, found (65%) patients were suffering from Pseudomonas aeruginosa infectionwhich considers a high antibiotic resistant microorganism [54]. Another study by Alrifai S.B.et al carried out in Tikrit, Iraq, found nosocomial diarrhoea in children (32.4%) aged < 5 years, which emphasis on personal hygiene and improved care practices[52]. Merdaw M. A. found in the surgical wards of 4 hospitals in Baghdad city between 2010 -2011,the incidence ofpostoperative infections78.43% was from the 102 admitted patients.The most frequent microorganism presented in the wards, Pseudomonas aeruginosa (23.3%) in the internal wards, in Gynecology wards Coagulase positive Staphylococci(25.0%), in Urology wards the Escherichia coli (27.2%) and Orthopedics wards Acinetobacter baumannii (27.2%).The study was emphasis on shortening the hospitalization time,permanent education, strong application of protocols and urging the implementation of strict infection control policy frequent [55] . WHO emphasizes oncontinuing medical benefits in the hospital environment require continuing educational input [14]. Limitations 1. The time of the questionnaire distribution was not sufficient and suitable because it was coincident with hot fasting month (Ramadan), so that, the students looked upset during answering the questionnaire. 2. Some students demonstrated unseriousness during answering the questionnaire. 36 Conclusion The consequences of the current study demonstrate that: 1. The overall medical students' knowledge about nosocomial infectionswas adequate, in spite of this; the knowledge was weak, particularly concerning the risk of transmission of infections to the hospital personnel and stethoscope as a potential source of infections. 2. They had positive attitudes, while, students revealed acceptableattitudes about disposing medical wastes by their self. 3.Practices to reduce the risk of nosocomial infection were adequate, however, reacted weaklytoward wearing protective materials when they are at direct contact with a patient. 4. The overall advising information of medical students to some items of HCAIs was acceptable; however, majority of themhad not been advised to clean their stethoscope. Recommendations 1. encouraging an adherence regarding HCAIs among students in order to reduce the prevalence of infections and compliance with intervention are mandatory. 2. For final (senior) students it is best to do extra courses on nosocomial infection prevention and control measures during clinical training to stick the information in their mind for long period. 3. Encouraging and inducing clinical teachers to act a role model for students to comply on HCAIs prevention and control measures. 4. Other researches in different medical schools in Iraq prefer to be done to explore knowledge and awareness toward HCAIs among students to give us clear view of our educational system. 5. 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Awatif I H, Mona H.AL-HA Madani, Al-Hafaza A.et al, Incidence of Nosocomial infection of Pseudomonas aeruginosa in General Basrah Hospital in Basrah City / IRAQ Qatar University Science Journal(1999) 18;105-110 available from ;qspace.qu.edu.qa/handle/10576/9641 55. Maysoon A. Merdaw Postoperative Wound Infections and the Antimicrobial Susceptibility in Baghdad Hospitals, Iraqi J Pharm Sci, Vol.20 (2) 2011 available from; www.iasj.net/iasj?func=fulltext&aId=4316 42 APPENDEX The nosocomial Infections Control Questionnaire 1. Hand hygiene measures before and after dressing changes and any contact with the surgical site reduce HAIs. 2. Your stethoscope is a potential source of infections. 3. Healthcare workers with eczema or psoriasis should not be involve in the care of patient with MRSA 4.Changes in antibiotics use patterns lead to parallel changes in prevalence of antibiotics resistance 5. Measles & chickenpox more than hepatitis B and HIV risk of infection transmission related to the hospital personnel. 6. The environment (air, water, inert surfaces) is the major source of bacteria responsible for nosocomial infection. 7. Nosocomial infection has a prevalence of 7-10% in the world. 8.Invasive procedures increase the risk of nosocomial infection 9. Reduced duration of intubation and mechanical ventilation may prevent Ventilator Associated Pneumonia. 10. Gloves do not obviate the need for hand hygiene. 43 Disagree female□ Knowledge'ssection of the questionnaire This section is designed to explore your knowledge related to health care-associated infections (HAIs) or nosocomial infections. . For each statement check whether you agree, uncertain or disagree. Uncertain male □ agree Gender: Behavior's section of the questionnaire: 1. Wearing protective eyewear and/or mask when at direct contact with a patient 2. Decontaminate hands if hands will be moving from a contaminatedbody site to a clean-body site during patient care. 3. Decontaminate hands before doing gloves and after removing gloves. 4. Never uncap a needle or sharp unless y I know where I will dispose immediately after use 5. Stay home when I have febrile respiratory illness, Diarrhea, Cold sores 6. I take vaccinations against hepatitis B & Annual influenza immunization 7. I act a role model to health care providers, clients and families with regard to infection prevention and control strategies 8. Perform hand hygiene before and after dressing changes and any contactwith the surgical site. 9. Encourage patients to report to their health-care provider any changes in their catheter site or any new discomfort 10. Respiratory Hygiene/Cough Etiquetteduring periods of increased prevalence of respiratory infections in the community Information's section of the questionnaire This section is designed to ask questions about your sources of information. In the course of your medical education (lectures & clinical teaching): In the course of your medical education (lectures & clinical teaching): 1. Have you been advised about standard hand-washing? 2. Have you been advised about precautions standard? 3. Have you ever been advised about safe intravenous (IV) cannulation or inserted devices? 4. Have you ever been advised about stethoscope cleaning? 5. Have you ever been advised about contact precaution? 44 never Some times Always Never Alway s Some Times This section is designed to gather information about your behaviors. For each statement check whether you Always Sometimes Never adopt each of the following practices to reduce the risk of HAIs nosocomial Attitude's section of the questionnaire This section is designed to explore your attitudes towards HAIs. Choose your proper answer? 1. You are now a hospital manger with an annual budget surplus and with increased incidence of HAIs; you suggest a. Increase thepurchaseoffurniture b. Increase buysantibiotics c. Organize financially supported courses with training to support behaviorsfighting infections 2. You are now in the outpatient with a lot of patients waiting your examination. You have alcohol sterilization as hand gel a. you will wash your hand after an examination of a patient with infectious diseases only. b. you will wash your hands whenever you have an opportunity because of overcrowding. c. you will wash your hand after any events of examination despite of overcrowding 3. You are now in the ward and it is not your duty time. You see some Spots of blood on the floor a. you will leave the place because you are tired and try to take a rest b. you will inform the hospital administration c. you will inform cleaning workers and make sure that they manage the situation properly 4. Now you have national campaign to vaccinatepoliovaccine; and you are the General Supervisor Campaign. At the end of the each campaign day you must disposed medical waste a. you will try to send anyone to make sure of disposing b. sometimes you will do that by yourself c. you will always making sure of disposing by yourself 5. Now you are in the surgical emergency unite a. you are wearing gloves and mask only when you deal with a wound of patients b. you are not wearing gloves and mask because the paramedical suturing the wounds c. you are always wearing gloves and mask whatever the case 45 الوعً لدى طلبة المرحلة المنتهٌة من كلٌة طب بابل حول عدوى المستشفٌات بحث مقدم الى كلٌة طب الكندي /جامعة بغداد كجزء من متطلبات نٌل درجة الدبلوم العالً فً التعلٌم الطبً من قبل د .كرٌم عبد مباشر بكالورٌوس طب وجراحة عامة بأشراف االستاذ المساعد الدكتور محمد اسعد ابراهٌم 1434 2013 46 خالصة البحث: اسس البحث: ْزا انثحس نرمٛٛى انًعشفح ,االذداِ انشعٕس٘ ٔانًٕٛل انعًهٛح نذٖ طالب انًشحهح انًُرٓٛح نكهٛح طة تاتم حٕل عذٖٔ انًسرشفٛاخ تاإلضافح نًعشفح يصذس انًعهٕياخ انر ٙنذٓٚى حٕل انعذٖٔ. طرق البحث: ْز ِ دساسح ٔصفٛح ٔيشحهٛح اخشٚد عهٗ 106يٍ طالب كهٛح انطة ف ٙخايعح تاتم انٕالعح فٙ يحافظح تاتم .اسرخذو فٓٛا اسرثٛاٌ يكٌٕ يٍ أستعح اخزاء .اندزء االٔل خصص السرمصاء انًعشفح انًعهٕياذٛح حٕل عذٖٔ انًسرشفٛاخ تًُٛا اندزء انًخصص نهًٕٛل انعًهٛح نذٖ انطالب خصص ندًع انًعهٕياخ حٕل كٛفٛح ذصشف انطالب نردُة االصاتاخ انًشضٛح انًعذٚح .أيا اندزأ ٍٚاٜخشًْٔ ٍٚا أٔال انًٛم انشعٕس٘ ٔكٛفٛح يٕٛل انطالب نردُة اإلصاتح تأيشاض عذٖٔ انًسرشفٛاخ ٔاندزء اٜخش ْٕٔ حٕل يصذس انًعهٕياخ نذٖ انطهثح حٕل اإلصاتاخ انًعذٚح اسرعًم فْ ٙزا انثحس انً ُٙٛذاب ٔ13.1اسرخذو يُّ ٔ Chi – squareال ٔ P- valueانرٙ اعرثشخ يًٓح إرا كاَد الم يٍ ٔ 0.05ذعرثش عانٛح األًْٛح إرا كاَد الم يٍ 0.01 . النتائج -: (68.34حٕل عذٖٔ أظٓشخ ْزِ انذساسح انًعذل انعاو نهًعشفح انًعهٕياذٛح نذٖ انطالب (% انًسرشفٛاخ يع ْزا ذعرثش ْزِ انًعشفح ف ٙخٕاَة يعُٛح ضعٛفح ٔخصٕصا حٕل احرًانٛح اَرمال اإلصاتاخ إنٗ أعضاء انفشٚك انصحٔ ٙكاَد انُسثح 41.5 %كزنك حٕل احرًانٛح كٌٕ انسًاعح 43.86%.تصٕسج عايح كاٌ انرصشف انعًه ٙنهطالب يرٕسطا انطثٛح كًصذس نُالهههعذٖٔ ( )%69.38يٍ انًٛم نهرمهٛم يٍ َسثح اإلصاتاخ ٔنكٍ ف ٙخٕاَة يعُٛح ضعٛفح يثال عذو اسذذاء انًٕاد انٕالٛح نهرمهٛم يٍ االصاتاخ ٔ كاَد انُسثح .49.06%كًا أظٓشخ انذساسح انًٕٛل انشعٕس٘ انعاياٚداتٛا ٔتُسثح ٔ 68.68 %كاٌ انًٛم انشعٕس٘ نإلَاز أفضم يٍ انزكٕس نردُة اإلصاتاخ .أيا يصادس انًعشفح انًعهٕياذٛح نذٖ انطهثح تصٕسج عايح يمثٕل ( )%50.38حٛس كاٌ أحٛاَا 39.62% 64.15%نى فمظ يُٓى لذ َصح تانطشق اٜيُح نٕضع أخٓزج اإلعطاء انٕسٚذ٘ ٔيا شاتّ تًُٛا ُٚصحٕا ترُظٛف سًاعاذٓى انطثٛح. الخالصة-: انًعشفح انًعهٕياذٛح نذٖ انطالب يرٕسطح ٔاالذداِ انشعٕس٘ كاٌ اٚداتٛا ٔذصشفٓى انعًه ٙيرٕسطا نهرمهٛم يٍ االصاتاخ يع ْزا يصادس يعهٕياذٓى كاَد ضعٛفح خذا ف ٙعذج خٕاَة ْ.زِ انُرائح ذؤكذ انحاخح انًاسح إنٗ انرشذد انرعه ًٙٛحٕل عذٖٔ انًسرشفٛاخ ف ٙانًُٓاج انذساس ٙانطث ٙانعًهٙ ٔانُظش٘. 47