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This is to certify that the

dissertation entitled

HIV and Health Care Workers: The
Measurement and Prediction of Compliance
with Universal Precautions

presented by
Barbara A. Schillo

has been accepted towards fulfillment
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HIV AND HEALTH CARE WORKERS: THE ASSESSMENT AND
PREDICTION OF COMPLIANCE WITH UNIVERSAL PRECAUTIONS

By

Barbara A. Schillo

A DISSERTATION

Submitted to
Michigan State University
in partial fulfillment of the requirements
for the degree of

DOCTOR OF PHILOSOPHY

Department of Psychology

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ABSTRACT

HIV AND HEALTH CARE WORKERS: THE ASSESSMENT AND
PREDICTION OF COMPLIANCE WITH UNIVERSAL PRECAUTIONS

By

Barbara A. Schillo

This study investigated current levels of compliance with universal precautions
among a sample of 160 health care workers in a hospital setting and explored the
relationships between knowledge and attitudes as predictors of universal precautions.
Results revealed high overall levels of compliance with use of routine universal
precautions, however, health care workers reported lower rates of compliance with the
use of barrier precautions other than gloves and were less likely to comply with the
guidelines for reporting occupational exposures. Participants reported several perceived
barriers for compliance with universal precautions. While greater percentages of
respondents reported perceived environmental barriers, individual-level barriers
accounted for a greater degree of the variance in overall compliance scores. Consistent
with previous research, current findings demonstrate that health care workers are
knowledgeable of the major routes of HIV transmission in health care setting, but greatly
overestimate the risk of becoming infected fi'om nonviable transmission routes. High
levels of perceived risk of occupational HIV infection were reported. Several between-
group differences by hospital unit were identified on the compliance, knowledge, and
attitudinal measures, suggesting differences in unit-specific dimensions that impact health

care workers in regards to these measures. Methodological analyses established that

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social desirability does not pose a significant threat to the validity of self-report
assessments of compliance with universal precautions and other predictor variables. Path
analyses were conducted using LISREL VIII to test different versions of the lnforrnation-
Motivation-Behavioral Skills Model of AIDS Risk Behavior Change as applied to
compliance with universal precautions. While the current study provides little support for
the predictive models, findings have useful implications for future research. This study
has important implications for the continued investigation of the issues that surround HIV

and health care workers, along with implications for training and policy.

As of the end of 1995, over 300,000 Americans had died of AIDS.
This work is dedicated to the families, lovers, and friends who miss them.

iv

ACKNOWLEDGMENTS

I would like to thank the many health care professionals, managers, and
administrators of the study hospital who assisting in making this research opportunity
possible. Drs. Jeffrey Taylor and Elaine Beane have provided me with a tremendous
employment opportunity which has allowed me to develop as a public health professional
while also being supportive, flexible, and understanding of the work on my dissertation. I
thank Lisa Fick, Monika Naegeli, and the rest of the MPI-II-DSET crew who kept me
going with their “cheerleading” during the hardest stretches of this process.

I have greatly benefited from the opportunity to work with Dr. Thomas Reischl
from the beginning of my graduate school career to the completion of my dissertation.
His support, enthusiasm, and attention to detail and quality serves as a true model of
graduate student mentoring. I also wish to thank the other members of my committee for
their insightful and supportive feedback - Drs. Peter Gulick, William Davidson, Galen
Bodenhausen, and Debbie Salem.

Finally, I would like to thank my family and friends for their support. To my
parents for their unending support and pride in my accomplishments; to my friend
Maureen who was always there with a healthy dose of perspective; and to my partner
Ann, who sacrificed much and supported me so patiently throughout the process. This

work would not have been possible without you.

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TABLE OF CONTENTS

LIST OF TABLES ..................................................... viii

LIST OF FIGURES ..................................................... x

INTRODUCTION ....................................................... 1

Review of the Literature ............................................ 2

Overview .................................................. 3

Compliance with Universal Precautions .......................... 8

Compliance with overall guidelines ....................... 8

Compliance with barrier precautions ....................... 9

Compliance with precautions for needles and sharps ......... ll

Intervention outcomes ................................. 12

Limitations of the research assessing compliance ............ 13

Factors Influencing the Use of Universal Precautions ............... 17

Environmental barriers ................................. 18

Individual-level barriers ................................ 21

Theoretical Frameworks for Investigating Compliance .............. 24

Implications ..................................................... 32

Current Study. ................................................... 34

Research Questions and Hypotheses ............................ 35

Testing a theoretically-based model ....................... 36

METHODS ........................................................... 44

Study Design and Setting ........................................... 44

Survey Procedures .......................................... 45

Sample Characteristics ....................................... 46

Measures ................................................. 47

Compliance Behaviors ................................. 49

Perceived Barriers .......................................... 52

Knowledge ................................................ 53

Motivation and Behavioral Skills .............................. 54

RESULTS ............................................................ 58

Data Analysis Strategy ............................................ 58
Assessment of Compliance, Knowledge, and Motivation Related to Universal

Precautions ...................................................... 60

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Compliance With Universal Precautions ......................... 60

Barriers to the Use of Universal Precautions ...................... 70
Knowledge ................................................ 73
Motivation ............................................... 75
Methodological Analyses Related to the Assessment of Compliance with
Universal Precautions ....................................... 79
Summary of Findings ........................................ 84
Predicting Compliance with Universal Precautions ...................... 85
Levels of Compliance by Procedure Type ....................... 85
Barriers to Using Precautions as Predictors of Compliance ......... 87
Exploratory Relationships .................................... 90
Between-unit differences. .............................. 90
Reported exposures. ................................... 93
Number of years worked. .............................. 94
Testing Theoretically-Based Models ............................ 94
Intercorrelations among variables in the path model. ......... 95
Tests of the interaction effect. .......................... 100
Path analysis of the IMB model. ........................ 101
Path analysis with the Theory of Reasoned Action. ......... 104
Path analysis with the Theory of Planned Behavior. ......... 107
Summary of path findings .............................. 109
DISCUSSION ........................................................ 1 10
Introduction .................................................... 1 10
Compliance with Universal Precautions .............................. 111
Perceived Barriers to the Use of Barrier and Needle/ Sharp Precautions
........................................................ 114
Knowledge and Motivation .................................. 118
Summary of Findings Related to Compliance, Knowledge, and
Motivation ............................................... 120
Discussion of Methodological Issues ................................. 121
Discussion of Analyses of Predictive Models .......................... 123
Methodological Limitations ........................................ 127
Study Implications ............................................... 129
Implications for Research ................................... 129
Implications for Training and Intervention Strategies .............. 130
Implications for Policy ...................................... 131
APPENDIX A - Cover Letter ............................................ 134
APPENDIX B - Survey Instrument ........................................ 135
REFERENCES ....................................................... 161

vii

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LIST OF TABLES

Table 1- Self-Reported Barriers for Compliance with Universal Precautions ......... 19
Table 2 - Measures and Item Numbers for the Self-Report Questionnaire ............ 50
Table 3 - Planned Data Analysis ............................................ 59

Table 4 - Number and Percentage of Health Care Workers in the Regular Nursery
(n=33) Reporting the Use of Precautions .............................. 61

Table 5 - Number and Percentage of Health Care Workers in the Labor & Delivery
(n=31) Reporting the Use of Precautions .............................. 62

Table 6 - Number and Percentage of Health Care Workers in the NICU (n=3 8)
Reporting the Use of Precautions .................................... 63

Table 7 - Number and Percentage of Health Care Workers in the Women’s Pavilion
(n=24) Reporting the Use of Precautions .............................. 64

Table 8 - Number and Percentage of Health Care Workers in the Emergency
Department (n=34) Reporting the Use of Precautions .................... 65

Table 9 - Responses to Items Assessing Compliance with Universal Precautions
in the Last 3 Months (n=146-157) .................................. 69

Table 10 - Reported Barriers to Using Universal Precautions ..................... 71

Table 11 - Responses to Items Assessing Knowledge of HIV Transmission in Health
Care Settings (n=158-160) ....................................... 74

Table 12 - Responses to Items Assessing Knowledge of Universal Precaution
Guidelines (n=160) ............................................. 76

Table 13 - Pearson Correlations Between Social Desirability and Outcome and
Predictor Variables .............................................. 80

Table 14 - Pearson Correlations Between Compliance Measures and Predictor
Variables ..................................................... 83

viii

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Table 15 - Means (and Standard Deviations) for Compliance Variables for Different

Units ........................................................ 91
Table 16 - Means (and Standard Deviations) for Knowledge and Motivation

Variables for Different Units ...................................... 92
Table 17 - Descriptive Statistics for Outcome and Predictor Variables .............. 96

Table 18 - Uncorrected Intercorrelations Among Constructs in the Path Model
(n=l44) ....................................................... 97

ix

LIST OF FIGURES

Figure l- The Information-Motivation-Behavioral Skills Model for AIDS Risk
Reduction ..................................................... 28

Figure 2 - Information-Motivation-Behavioral Skills Model Applied to Compliance
With Universal Precautions ....................................... 39

Figure 3 - Observed IMB Model Framing Motivation Within the Theory of Reasoned
Action ........................................................ 41

Figure 4 - Observed 1MB Model Framing Motivation Within the Theory of Planned
Behavior ...................................................... 43

Figure 5 - Path Analysis of Information-Motivation Behavioral Skills Model ....... 103

Figure 6 - Path Analysis of Observed IMB Model - Theory of Reasoned Action
(n=l44) ...................................................... 105

Figure 7 - Path Analysis of Observed IMB Model - Theory of Planned Behavior
(n=l44) ...................................................... 108

Chapter 1

INTRODUCTION

From issues of the treatment of infected individuals to the threat of transmission
in health care settings, the Human Immunodeficiency Virus (HIV) has had a significant
impact on the occupational behaviors of health care workers. One of the most important
changes has been the widespread institutional mandate that health care providers follow a
set of unimsal precautions developed by the Centers for Disease Control and Prevention
(1987). Although changes in the occupational behaviors of health care workers have been
witnessed throughout the history of the medical profession, universal precautions were
developed in response to HIV /AIDS, an epidemic surrounded by a tremendous degree of
fear and stigma within our society. Additionally, HIV represents the first significant
threat of occupational infection in the minds of many of the nation's health care workers.
In the decades prior to the emergence of HIV /AIDS, antibiotics, vaccinations, and the
elimination of many occupationally transmitted infections led many health care workers
to believe they were at zero risk for occupational infection (Gerberding, 1988). Given the
circumstances surrounding the introduction and implementation of universal precautions
guidelines, it is not surprising that numerous studies have reported findings which suggest
that compliance with universal precautions is poor (Turner, 1993).

The purpose of this research was to investigate current levels of compliance with

universal precautions among health care workers within a context of health behavior -

l

2

that is to examine the use of universal precautions as health behaviors engaged in for
purposes of preventing the transmission of HIV in the health care setting - and to examine
the specific factors thought to influence these behaviors. More specifically, the
relationships between knowledge and attitudes as predictors of use of universal
precautions were explored within a theoretical model of AIDS-preventative behaviors.
Furthermore, the methodology of the current study attempted to address several

limitations inherent in the design and implementation of previous research.

E . E I I .

This investigation is based on an extensive review of the literature generated from
the study of compliance with universal precautions among health care workers. This
review demonstrates the critical nature of the issues surrounding the threat of
transmission of HIV in health care settings and identify compliance with universal
precautions as a key strategy for responding to the fears and costs associated with these
issues. A review of research findings establishes a need for further assessment of levels
of compliance with universal precautions in order to address current gaps in existing
knowledge and methodological limitations within this area of research. Most
importantly, this review identifies a need to move beyond the traditional approach for
measuring the use of universal precautions as an index of compliance with infection-
control guidelines toward viewing these behaviors as preventative health behaviors. In
that regard, this review examines theoretical frameworks that are relevant for exploring
the factors that predict the degree to which health care workers are engaging in these

prevention behaviors. The following literature review summarizes the major findings of

3

the research that have been generated from the study of compliance with precautionary
behaviors among US. health care workers. An initial computer search using MEDLINE
was conducted using the keywords HIV and universal precautions. Additional studies
were cross-referenced from published research. Only those studies that assessed
behaviors of US. health care workers (dental health care workers were not included in
this review) were included for analysis of research findings; studies examining solely
knowledge of, or attitudes toward, universal precautions were not included.

This review of the literature is organized into four major sections. The first
section provides an overview of the issues surrounding the threat of HIV transmission in
health care settings and policies for universal precautions. The second section of this
review examines the findings and limitations of the research which addresses the degree
to which health care workers are complying with guidelines for universal precautions.
The third section of this review examines the research addressing the underlying factors
responsible for the reported levels and patterns of compliance with universal precautions.
The fourth section of this reviews focuses on the application of theory to this area of

research.

Mm

From its initial recognition in the early 19803, acquired immunodeficiency
syndrome (AIDS) has been identified as a potential occupational threat to health care
professionals. By the end of that decade, evidence of HIV transmission from an infected
Florida dentist to 5 of his patients and ongoing reports of health care workers becoming

infected through occupational exposures to the virus elevated this threat to an issue of

4

national concern. Fears surrounding the threat of HIV transmission in health care settings
among both health care workers (Gerbert, Maguire, Badner, Altman & Stone, 1988) and
the general public (Gerbert, Maguire, Hulley & Coates, 1989; Krantowitz, Springen,
McCormick, Reiss & Hager, 1991) have been well documented. In a more recent
national survey of over 6,000 adolescents, provider seronegativety was one of the leading
factors influencing adolescents’ decisions to seek health care (Ginsburg, et al., 1995). In
1992, the National Commission on AIDS reported that the level of public anxiety over
this issue, "...might have left one with the mistaken impression that HIV disease is an
illness largely visited upon dentists, surgeons or their patients" (p. vii).

The level of concern surrounding the transmission of HIV in health care settings is
in disproportion to the actual risk of acquiring HIV in these settings. Surveillance studies
have established that the risk of occupational transmission of HIV from infected patient
to provider as the result of a percutaneous injury by a needle contaminated with HIV-
infected blood is 0.3% (CDC, 1992). The risk following a single mucocutaneous
exposure (i.e., an exposure through non-intact skin or mucous membranes) to HIV-
infected blood or body fluids is even lower (Bell, 1990). Through the end of 1995, the
Centers for Disease Control and Prevention (CDC) has identified 49 documented and 102
possible cases of health care workers seroconverting following occupational exposure to
HIV (CDC, 1995). Although the precise risk of provider-to-patient transmission is
unknown, it too is estimated to be extremely low. Five cases involving HIV transmission
from a Florida dentist to his patients remain the only cases of provider-to-patient
transmission to date, despite several large retrospective studies of patients of infected

providers (CDC, 1991). To date, there are no documented cases of patient-to-patient

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transmission although a recent investigation of an infant with AIDS whose source of HIV
is unknown supports the possibility of patient-to-patient transmission of HIV during
medical care (Blank, et al., 1994).

The low probability of HIV infection following a discrete exposure to HIV-
infected blood and body fluids, however, should in no way be used to minimize the
significant potential for HIV transmission in health care settings. Over 800,000
needlestick injuries occur each year in the United States (Jagger, 1990), accounting for
1/3 of all work-related injuries among health care workers (Henry & Thum, 1991) and
injuring an estimated 10% of all health care workers (DeLaune, 1990). Several studies
have documented substantial rates of mucocutaneous exposures as well (Fahey, Koziol,
Banks & Henderson, 1991; Gerberding & Schecter, 1991; Stockta, Wong, Williams,
Stuart & Markowitz, 1991). With the prevalence of HIV infection among patient
populations increasing (Kelen, 1990), so too does the potential for exposure to HIV-
infected blood and body fluids. Unless infection control efforts are successful, the
cumulative risk for many health care workers will continue to increase substantially over
the next decade (Gerberding & Schecter, 1991).

This potential for exposure to HIV-infected blood and body fluids in health care
settings prompted the introduction of universal precautions by the CDC in the 1980's
(CDC 1985; CDC 1987; CDC 1988). Under universal precautions, blood and certain
body fluids of all patients are considered potentially infectious for HIV and other blood-
bome pathogens. Guidelines for universal precautions call for practices that include the
use of barrier precautions (e.g., gloves, masks, and protective eye gear), procedures

designed to prevent injuries from needles and other sharps (e.g., scalpels, broken glass, or

 

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any other object that can pierce, puncture or cut skin), and the reporting and medical
follow-up for all exposure incidents. Universal precautions are designed to prevent
percutaneous and mucocutaneous exposures to all bloodbome pathogens including HIV,
reducing the risk of HIV -transmission in the health care setting from patient-to-provider,
provider-to-patient, and patient-to-patient. Compliance with these guidelines became
mandatory in all health care settings in 1991 following the adoption of the "Bloodborne
Rule" issued by the Occupational Safety and Health Administration - OSHA (Department
of Labor, 1991).

Compliance with these CDC and OSHA guidelines represent significant changes
in the occupational behaviors of health care workers. For example, the standard practice
for disposing of used needles in many health care settings prior to the implementation of
universal precautions involved recapping the needle, carrying it to a central location,
removing the sheath, and clipping the needle (New York State Department of Health,
1992). Under universal precaution guidelines, needles and other sharp instruments
should not be recapped or clipped and should be disposed of immediately in puncture-
proof containers to be located as close as practical to the use area (CDC, 1987).

The guidelines for universal precautions also require that health care professionals
assess the potential for exposures to blood and body fluids prior to initiating medical care
procedures, as the level of protection must fit the expected exposure. For example,
gloves must be worn if a health care worker expects to have hand contact with blood or
other potentially infectious materials, while eye and mouth protection must be worn if

potentially infectious materials pose a hazard through the eyes, nose, or mouth. Even

 

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more extensive coverings such as gowns, aprons. surgical caps and hoods, shoe covers or
boots are needed when gross contamination of blood and body fluids is expected.

Turner (1993) reports that the reported and observed lack of compliance with
universal precautions has lead some researchers to abandon efforts to change behaviors in
favor of approaches designed to make the health care environment safer. For example, it
has been argued that only changes in needle hardware, rather than behavior modification,
will significantly impact needlestick injuries (Jagger, Hunt, Brand-Elnagger & Pearson,
1988; Edmond, Khakoo, McTaggart & Solomon, 1988). Indeed, recent evaluations have
reported significant reductions in needlestick injuries following the implementation of
needleless devices (Gartner, 1992; New York State Department of Health, 1992;
Skolnick, LaRocca, Barba & Paicius, 1993), however, many of these devices represent
first generation technology which will need improvement before their wide-spread use is
warranted (New York State Department of Health, 1992). In addition, initial evidence
reveals that devices with safety features that rely on the worker for operation are less
dependable than those devices in which the safety feature is automatically activated (New
York State Health Department, 1992). Thus, even with the expected widespread
implementation of safety devices, behavioral compliance will remain a salient issue in
reducing the threat of HIV transmission in health care settings.

Ensuring compliance with guidelines for universal precautions through the
modification of behavior remains an issue of critical importance. Universal precautions
are not 100% effective in preventing exposures to blood and body fluids in health care
settings, as some exposures to infected blood and body fluids have resulted even when

health care workers were applying appropriate barrier and sharp precautions (Marcus &

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the CDC Cooperative Needlestick Surveillance Group, 1988). Existing data, however.
suggests that most exposures to blood and body fluids would have been prevented if
proper precautions for the handling and disposal of needles and sharps or the application
of barriers precautions had been taken (CDC, 1992; Gerberding & Schecter, 1991;
Marcus & the CDC Cooperative Needlestick Surveillance Group, 1988). The human
costs of exposures to blood and body fluids in health care settings are tremendous in
terms of anxiety and disease transmission, as are the financial costs with medical follow-
up for needlestick injuries alone estimated to cost $3 billion per year (DeLaune, 1990).
Responding to the anxiety, fear, and costs surrounding occupational transmission of HIV
in health care settings hinges on the success of ensuring compliance with universal

precautions.

E l' .111. IE .

The major findings of studies assessing compliance with universal precautions
have been organized according to type of precautionary behaviors which have been
measured in these studies: 1) compliance with overall guidelines; 2) compliance with
barrier precautions; and 3) compliance with precautions for sharps and needles.
Following the review of these studies, a summary of the outcome evidence of evaluation
studies related to compliance with universal precautions is presented. Finally, the
limitations of this body of research are discussed.

W. The results of studies reporting a measure of
overall compliance with universal precaution guidelines suggest that compliance with

universal precautions is variable. These studies operationalized compliance as all or none

 

 

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- health care workers were assessed to be in compliance only if they used a_ll necessary
precautions during a specified procedure or situation defined by exposure to blood and/or
other body fluids. Baseline observational assessments revealed that infractions in
universal precautions occurred in 57% of procedures among surgical personnel at a
University of Florida hospital (Courington, Patterson & Howard, 1991). A similar study
revealed that prior to intervention efforts, surgical residents in a Miami, Florida hospital
were observed to be in compliance with universal precautions in only 16% of trauma
resuscitations (Hammond, Eckes, Gomez & Cunningham, 1990). Only 30% of hospital
personnel caring for HIV-infected patients at San Francisco General Hospital self-
reported proper use of universal precautions (Gerberding et al., 1987). Among the 70%
failing to comply, 56% reported using no precautions and 14% reported using excessive
precautions. Findings from self-report (Gruber et al., 1989) and observational (Denker,
Jensen & Galego, 1991) studies assessing precautionary behaviors among nurses have
revealed similar low levels of compliance with the exception of Conte (1992) in which
66% of neonatal nurses self-reported compliance with universal precautions.
W. A more detailed picture of the use of
universal precautions is found in studies that have examined compliance with the specific
components of universal precautions. Again, these studies operationalized compliance as
all or none - health care workers were assessed to be in compliance only if they used all
necessary barrier precautions during a specified procedure or situation defined by
exposure to blood and/or other body fluids. Among studies assessing compliance with
barrier precautions only, a survey of Michigan physicians was the only one to report that

the majority (60%) of providers were using proper barrier precautions (Heald, 1988).

 

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Findings from other studies assessing compliance with these precautions reveal that the
majority of health care workers are failing to protect themselves from exposures to blood
and body fluids by applying appropriate personal protective equipment. Only 22% of
directors of emergency medicine residencies reported that barrier attire was used during
major resuscitations (Huff & Basala, 1989). Kelen et al. (1989) reported that only 44% of
emergency personnel at Johns HOpkins Hospital were observed to be in adherence to
universal precautions policies for barrier precautions. Other studies have revealed that
less than 25% of surgeons (Mandlebrot etal., 1990) and 9% of nurses (Gorse & Messner,
1991) reported routine use of barriers.

Assessments of compliance with barrier precautions broken down by type of
barrier suggest that the use of gloves to prevent exposures to blood and body fluids may
be the most consistently used component of universal precautions among health care
workers. In a random survey of registered nurses in Michigan, 71% of participants
reported wearing gloves "almost always" when handling blood or body fluids (Schillo &
Reischl, 1993). Likewise, Kelen et a1. (1989) reported that gloves were worn in 74% of
the emergency procedures observed. Observations of surgical personnel at San Francisco
General Hospital revealed even higher levels of glove use with 87% double or triple
gloving during surgical procedures (Gerberding, Littell, Tarkington, Brown, & Schecter,
1990). Compliance with the use of gloves, however, appears to be task-specific. Several
studies have reported levels of compliance that ranged within studies from as low as 35
percent to as high as 100 percent depending on the type of procedure involved (Baraff &
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Even when gloves are worn. findings suggest that other barrier precautions are
commonly ignored. Hammond et al. (1990) reported that prior to intervention, 37% of
breaks in compliance with barrier precautions were due to not wearing a mask, 33% were
due to failure to wear ankle protection, and 18% were due to failure to wear a gown or
apron. Kelen et al. (1989) reported that when barrier precautions were inadequate,
surgical masks (22%) were used least, followed by eye protection (45%), and gowns
(50%). In a nation-wide survey of certified nurse midwives, only 42% reported wearing
eyewear and 31% reported wearing masks during deliveries (Willy et al., 1990). The
lowest levels of compliance with these other barrier precautions were evident in
observations of emergency personnel performing trauma resuscitations at UCLA Medical
Center (Baraff & Talan, 1989). Low percentages of these providers were observed
wearing gowns (28%), protective eyewear (18%), and. masks (1%).

Limited evidence suggest that compliance with other components of barriers
precautions, such as handwashing and the use of resuscitation devices, is fairly common.
Gruber et a1. (1989) reported that 96% of nurses reported washing their hands following
exposure to blood and body fluids. Other studies reported that nearly all providers used a
protective device when performing mouth-to-mouth resuscitation (Schillo & Reischl,
1993; Smyser, Bryce, & Joseph, 1990).

WWW. While significant numbers
of health care workers are failing to comply with guidelines for barrier precautions,
research suggests that even fewer are adhering to guidelines for the handling of needles
and sharps. Findings, although variable, suggest that a significant proportion of health

care professionals are violating CDC and OSHA guidelines by recapping needles after

12
they have been used on patient, with self-reported rates of recapping ranging from 25-
71% (Gruber et al., 1989; Schillo & Reischl, 1993; Smyser, et al., 1990; Willy et al.,
1990). An 9123113191131 study by Edmond et al. (1992) found 94% of nurses recapping
needles prior to an intervention designed to reduce recapping. These high rates of
recapping are supported by findings from two studies that reported high percentages of
recapped needles observed in needle disposal boxes (Becker et al., 1990, Ribner &
Ribner, 1990).

Although the majority of health care providers are recapping needles, findings
suggest that they are much more compliant when it comes to other precautions for needles
and sharps. Several studies reported that nearly all providers disposed used needles in
puncture-resistant containers (Gruber et al., 1989; Schillo & Reischl, 1993; Willy et al.,
1990) and complied with policies prohibiting clipping, cutting, or bending needles (Gorse
& Messner, 1991; Willy et al., 1990).

W. Only a handful of evaluation studies assessing changes in
compliance with universal precautions following intervention efforts were evident in the
literature. Based on this limited body of research, the evidence for increases in
compliance with needle and sharp precautions following intervention efforts is mixed.
Edmond et a1. (1988) reported no significant decrease in rates of recapping following the
installation of a disposal system for needles sharps along with the implementation of
educational programming. Ribner & Ribner (1990), however, reported a significant
decrease in the percentage of recapped needles found in disposal boxes following

intervention efforts which included education and feedback. In contrast, those studies

that have assessed changes in the use of barrier precautions following various

13
intervention efforts have reported significant increases in compliance (Devries. Bumette
& Redmon, 1991; Hammond et al., 1990; Kelen etal., 1989, Talan & Baraff, 1990). It
should be noted, however, that even when studies reported increases in compliance with
the use of universal precautions, significant numbers of health care workers (ranging from
12-3 8%) were still failing to comply with universal precautions following these
intervention efforts.

WW. Although the above review
provides a useful summary of the research examining health care workers' compliance
with universal precautions, caution should be expressed about the comparability of the
findings across studies. These studies represent work undertaken prior to OSHA's final
ruling, at a time when many institutions had just recently adopted, or were in the process
of adopting, a policy of universal precautions. It is likely that there was a great deal of
variance in the degree to which these guidelines had been interpreted, implemented, and
enforced within study settings.

While assessments of compliance with universal precautions among health care
workers have focused on compliance with the use of barriers and precautions for
needle/sharps, there are several additional components of universal precautions for which
compliance has not been investigated. For example, an important and to-date overlooked
component of universal precaution guidelines involves compliance with a protocol for
medical evaluation and follow-up for incidents involving exposure to blood and body
fluids. These medical evaluations involve several elements, including the collection and

testing of the employee's blood for HIV antibodies and the administration of postexposure

 

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prophylaxis when medically indicated. Prior research has not focused on this important
component of universal precautions.

There are also several methodological limitations of the research which must be
acknowledged. These include limitations of each of the two major approaches to the
assessment of compliance with universal precautions evident in the literature: self-
administered questionnaires and behavioral observations. Recall bias is a potential source
of error for self-report measures. Studies utilizing self-administered questionnaires asked
health care workers to recall rates of exposures and patterns of behavior that occurred
over the past several months. Only one study reported efforts to reduce the potential for
this source of bias by limiting recall to the last working shift (Wong et al., 1991).

Self-report bias in the use of self-administered questionnaires represents another
potential source of error. In assessing compliance, health care workers were asked to
report on behaviors with which they were expected, or even mandated, to comply. For
studies conducted within the participants' place of employment, concerns over possible
identification and reprisals from their employers, despite assurances of anonymity, may
have influenced respondents to provide socially desirable responses indicating
compliance with guidelines. Voelker (1991) reports a pattern of findings which suggest
bias in self-reported levels of compliance. This study, which included 400 hours of
observation in 2 Midwestern hospitals followed by self-assessments of compliance from
more than 100 health care workers, found that health care workers report higher levels of
compliance than what they actually practice. For example, 81% reported that they used
gloves appropriately, while observations showed a 65% rate of compliance; 60% reported

recapping needles while 76% were observed doing so. The overall degree to which this

15

source of error threatens the validity of selflreported findings is unknown. as the Voelker
study remains the only investigation to include multiple methods of assessment.

The use of observational assessments eliminates these threats surrounding self-
report measures. However, observational measures are subject to other potential sources
of bias. The Hawthorne effect, or changes in behavior resulting from the participants'
awareness of an observer, is a source of error which may threaten the external validity
and generalizability of the findings from observational studies. Although descriptions of
observational studies identified efforts to ensure that participants remained blind to the
purpose of observations, it is likely that many respondents were aware of the presence of
an observer. Two studies may have actually unmasked the purpose of the observations by
disseminating pretest results to hospital personnel before posttest observations were
conducted (Courington et al., 1991; Talan & Baraff, 1990). If the presence of the
observer alone prompted participants to increase their compliance with the use of
universal precautions, reported levels of compliance based on observational assessments
would represent upper limits of compliance.

The lack of psychometrically sophisticated instruments is an additional concern
within this area of research. Many of the measures employed in these studies were
flawed in that they failed to adequately operationalize compliance. The use of
precautions is conditional on the potential for exposure to blood and body fluids.
Therefore, a valid measure of compliance is calculated by first determining if the
precaution is necessary, and then assessing whether or not the appropriate precaution is
used. Some of the instruments used in both self-report and observational studies failed to

first assess whether or not the respondent was involved in a situation warranting the use

16

of a precaution(s). As a result, it was recognized that some respondents may have
reported or have been observed to be noncompliant when in fact they were not involved
in a situation requiring the use of precautions (Baraff & Talan, 1989; Gruber et al., 1989;
Schillo & Reischl, 1993).

Additionally, only one study assessed whether or not failure to comply involved
the overutilization or underutilization of precautions (Gerberding et al., 1987).
Overutilization represents an important form of noncompliance. Although it can be
argued that health care workers who utilize excessive precautions are protected from
exposures, overutilization is wasteful - both in terms of the resources used and the
medical waste produced - and may have significant implications for quality of care when
unnecessary barriers are placed between health care workers and their patients. In
addition, none of the studies distinguished between proper and improper use in the
applications of precautions. In limiting assessments to use versus nonuse, it is not known
whether or not health care workers who reported or were observed using the required
precautions applied, removed, and/or disposed of protective equipment or medical
supplies appropriately.

In addition to inadequate operationalization, there was also a great deal of
variability in the operationalization of compliance across studies. Several studies
reported a global measure assessing compliance with all aspects of universal precautions,
while other studies assessed compliance as a function of the specific components of
guidelines for the use of barriers and needles/sharps. Furthermore, some studies assessed
compliance during a specific medical procedure, while other studies summed compliance

across several different types of medical procedures. The development of measures that

l7

assess compliance with each component for universal precautions and are specific to
different types of procedures appears critical, in light of reported variability in compliance
across these dimensions.

Of additional concern is the lack of reported indices of reliability of instruments
used to investigate the use of universal precautions. The assessment of interrater
reliability for observational measures, in particular, is critical as assessing proper
implementation of universal precautions may involve a judgement call on behalf of the
observer (Gauthier, Turner, Langley, Neil & Rush, 1991). Gauthier et al. (1991) remains
to-date, the only measurement study designed to develop a reliable and valid
observational instrument for assessing compliance.

Finally, caution must be taken in generalizing the findings of these studies to all
health care workers. Most of the samples were comprised of nurses and physicians
working in acute care settings and the majority of studies were conducted within large
teaching-hospitals located in US. metropolitan areas. Additionally, many of these
settings were located in high prevalence areas for AIDS/HIV infection or were
specifically identified as AIDS referral centers. The generalizability of the majority of

these studies may be limited to similar groups of health care workers in similar settings.

E It] .111 [11' IE .

In her recent review of practices related to universal precautions among nurses,
Turner (1993) concluded that "at this point, it is unclear how to effect any consistent
changes in the use of universal precautions" (pg. 218). This lack of understanding is the

likely result of little investigation into the underlying factors responsible for the reported

18

levels and patterns of compliance with universal precautions. To date, research
examining the underlying factors responsible for the reported levels and patterns of
compliance has been largely limited to questions asking health care workers why they
failed to comply with guidelines for universal precautions. In response to these questions,
health care workers have reported several environmental and individual-level barriers to
the use of precautions (See Table 1).

Aside from the identification of self-reported barriers to the use of precautions,
there has been little systematic investigation into how these and other potentially critical
factors influence compliance with universal precautions. The following section critically
examines the limited evidence that surrounds the major self-reported environmental and
individual-level barriers to the use of universal precautions along with other critical
factors evident in the literature.

Enyirgnmentaflmrjm. It has been argued that health care workers in emergency
situations who feel forced under guidelines for universal precautions to make split-second
trade-offs between the patient's interest and their own, may forego the use of precautions
(Keames, 1988). There is some evidence to support health care workers' claims that
noncompliance is due, in part, to a perceived lack of time. Two observational studies
have established that compliance with barrier precautions is significantly lower during
emergency procedures (Wong et al., 1991) or major interventions which need to be
performed immediately (Kelen et al., 1989).

Findings from several studies are also consistent with providers' reports that the
use of certain precautions interferes with their ability to perform specific procedures. A

critical issue appears to be the loss of dexterity and tactile sensation when using gloves

 

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during phlebotomy or IV procedures. Studies have documented relatively lower levels of
glove use during these procedures compared to other procedures in which the use of
gloves in also warranted (Baraff & Talan, 1989; Voelker, 1991). Other researchers have
concluded that health care workers who otherwise comply with precautions do not
routinely use gloves for phlebotomy or the placement of IV catheters (Gerberding et al.,
1987; McNabb & Keller, 1991). Conte (1992) reported that the inability to perform tasks
while wearing gloves was the strongest predictor of use of universal precautions.

Findings reported in Kaczrnereck et al. (1991), however, call into question the
role that loss of dexterity plays in predicting compliance with the use of gloves. Health
care workers in this study reported much higher levels of compliance with the use of
gloves during arterial gas procedures (92%) than during phlebotomy (71%) procedures.
Both of these procedures involve drawing blood, the only difference being that blood is
drawn from the artery during arterial blood gas procedures rather than the vein, as is the
case during phlebotomy. Differences, therefore, in levels of compliance between these
two types of procedures would not be expected if loss of dexterity is the primary reason
for not using gloves. The authors of this study cite research demonstrating that health
care workers are more likely to be exposed to patients' blood during arterial blood gas
procedures than during phlebotomy (Marcus, Bell, Srivastava & Culver, 1990) in arguing
that differences in perceived risk of becoming infected, rather than loss of dexterity,
account for the observed difference in levels of compliance by type of procedure.

Although formal investigation is lacking, the literature offers several explanations
as to why so many health care workers continue to recap needles despite the danger

involved in this activity. Certain aspects of procedures involving needles may explain

 

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why some health care workers recap. Health care workers, for example, have reported
recapping needles for safe storage when the contents of the syringe are administered in
two or more doses over time (Jagger et al., 1988) or to protect themselves during the
disassembly of a device with an exposed contaminated needle (Henry & Thum, 1991).
The design of the environment may also impact a provider's choice to recap as providers
have reported recapping in order to transport a used needle to a disposal box (Henry &
Thum, 1991). As a result, several authors have concluded that the failure to effect
behavior change may be due to the perception on the part of some health care workers
that it is a greater risk to others, as well as to self, to handle and dispose of an uncapped
needle, than to risk an injury by recapping (Becker et al., 1990; Edmond et al., 1988;
Jagger, 1990; Jagger, Hunt, & Pearson, 1990; Ribner, Landry, Gholson, & Linden, 1987).

The need for continued research to identify other critical environmental factors
that influence the use of precautions is evident. Although health care workers cite lack of
accessible and adequate materials as a major barrier to compliance, the relationship
between this factor and compliance has yet to be investigated. Further research is needed
to determine the relative degree to which compliance is a function of the environment and
to understand these structural barriers.

Indiyidualfleyeflzam’ers. Investigation into individual-level factors related to
compliance with universal precautions has focused largely on the relationship between
HIV -related knowledge and precautionary behavior. Research has clearly documented
that providers have fairly high levels of knowledge about the etiology and viable modes
of HIV transmission (Richardson, Lochner, McGuigan & Levine, 1987; Schillo &

Reischl, 1993; Valenti & Anarella, 1986; Wertz, Sorenson, Liebling, Kessler & Heeren,

 

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1988) and are aware of the need to take precautions to prevent occupational transmission
(van Servellen, Lewis & Leake, 1988). Likewise, educational programs have been
evaluated to be effective in increasing health care workers' knowledge about AIDS
(O'Donnell & O'Donnell, 1987; Turner, Gauthier, Ellison, Greiner, 1988; Wertz et al.,
1987). However, given the current low levels of compliance with universal precautions,
the extent to which knowledge is translated into precautionary behaviors remains
questionable.

The results from studies testing this relationship between knowledge and
precautionary behavior are inconclusive. Willy et a1. (1990) reported that nurse midwives
who complied with universal precautions had significantly higher HIV-transmission
knowledge scores than those who failed to comply. Conte (1992), however, found that
neonatal nurses with higher levels of knowledge were less likely to report using
precautions. Similarly, Gruber et al. (1989) reported a nonsignificant, negative
relationship between knowledge and the use of precautions. Amow, Pottenger, Stocking,
Siegler & DeLeeuw (1989) found no significant relationship between knowledge and the
number of precautions surgeons reported that they would use.

The relationship between other potential individual-level factors and behaviors
remains, for the most part, unexplored. Despite documentation of substantial levels of
fear among health care workers, little is known about the relationship between perceived
risk of infection and precautionary behaviors. Willy et a1. (1990) reported that nurse
midwives who complied with universal precautions were more likely than noncompliers

to perceive themselves at risk for HIV. Gruber et al. (1989) reported a nonsignificant

 

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trend for lower use of precautions among RN 5 who believed their risk for HIV infection
was low.

Further investigation is also needed to gain specific insight into the individual-
level factors that may predict recapping behaviors. Many providers have reported
recapping out of habit (Gruber et al., 1989; McCormick, Meisch, Ircink, & Maki, 1991)
or carelessness (Henry & Thum, 1991). Jackson, Dechario, & Gardner (1986) reported
that carelessness was perceived to be the most common reason for needlestick injuries
among medical personnel while lack of knowledge of proper disposal technique was
ranked last. These results suggest that recapping, may in part, be the result of well-
established patterns of behavior which are occurring at a subconscious level, having little
to do with either knowledge or attitudes.

Further research is needed to identify the important individual-level predictors of
compliance with barrier precautions. While most intervention strategies have operated
under the assumption that increases in general knowledge related to HIV would result in
increased compliance, there is currently no evidence to support this relationship.
Research suggests that despite adequate levels of HIV-related knowledge, health care
workers are failing to comply with universal precautions. While it has been argued that
perceived risk of occupational transmission may influence compliance with universal
precautions, the direct impact of these fears on these behaviors remains to be seen.

There are also several other potential individual factors that to date, remain
uninvestigated. Although health care workers have reported perceptions that precautions
were perceived as unnecessary, the factors behind this reported barrier have yet to be

identified. Keames (1988) argues that the perception that precautions are unnecessary

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may be related to different levels of perceived efficacy of universal precautions. Health
care workers may fail to comply with precautions if they believe that the threat of
contracting HIV has been greatly exaggerated and that universal precautions are therefore
unnecessary, or if they perceive that not enough is known about HIV transmission to
develop adequate precautionary guidelines.

In addition to the perception that precautions are unnecessary, health care workers
have cited interference with the patient relationship as another barrier to compliance with
universal precautions. Again, the extent to which perceptions that precautions are a
psychological and/or physical barrier between health care workers and their patients

contributes to noncompliance, is unknown.

11 'IE lfil";‘l'

To date, most research has framed compliance with universal precautions as an
issue of infection-control within the health care setting, rather than as individual-level
behaviors which could be viewed in a context of prevention or health behavior.
Advancing the use of theory within this field of research requires the incorporation of
applicable theoretical frameworks for understanding compliance with universal
precautions as a prevention behavior analogous to the adoption of safe sex behaviors, the
use of clean injecting drug needles/equipment, or other behaviors designed to prevent the
transmission of HIV. Refrarning compliance behaviors in this way allows researchers to
draw on the extensive body of knowledge generated through AIDS-prevention research.

To date, there has also been little overall application of theory to the investigation

of health care workers' compliance with universal precautions. Turner (1993) cites this

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deficit in the use of conceptual or theoretical models as a major flaw in the research
related to compliance with universal precautions. The development of a theoretical
framework in which to explore the issues surrounding compliance will be critical in
facilitating the development of future investigations and effective interventions. Without
theory, accounting for differences in compliance may contribute little to an understanding
of the underlying processes that account for these behaviors. The inconsistencies in the
research can appear random and it can be reasoned that if an environmental factor fails to
enhance compliance, an individual factor will (Leventhal, Meyer & Nerenz, 1980).

A review of the literature identified only three articles which addressed the
application of theory to the prediction of compliance with universal precautions. To date,
Meisenhelder & LaCharite (I989) remain the only researchers to propose an original
model specific to the prediction of compliance with universal precautions. This model of
fear arousal for health care workers illustrates the use of precautionary behaviors as an
affective response to the threat of AIDS. According to the model, fear of AIDS can
impact precautionary behaviors in three ways: 1) those who perceive a high level of risk
may overutilize precautions or engage in avoidance behaviors; 2) those who are not aware
or deny they are at risk may under utilize precautions; while 3) those who perceive a level
of risk similar to their actual level of risk may use appropriate precautions. Thus, the
appropriate use of universal precautions would be achieved when a provider's level of
perceived risk is brought in line with their level of actual risk. This proposed theoretical
model, however, has yet to be tested.

In a recent qualitative study, Reutter and Northcott (1994) argue that nurses work

to achieve a sense of control in dealing with AIDS through the use of different cognitive

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26

and behavioral mechanisms. Within this theoretical context, the use of universal
precautions is identified as a major coping strategy for dealing with the uncertainty and
fear surrounding AIDS. Again, this model remains to be empirically tested.

Becker et a1. (1990) examined noncompliance with precautions for needles/sharps
within the health belief model, one of the most widely used models in the study of
compliance with health behaviors (Janz & Becker, 1984). Applying this model to
providers' precautionary behaviors, the health belief model predicts that health care
workers are more likely to comply with universal precautions when they perceive
themselves as susceptible to occupationally-acquired HIV infection, perceive the
consequences of infection as severe, perceive that universal precautions are effective in
reducing the threat of HIV infection, and perceive few costs or barriers to the use of
precautions. The high levels of perceived susceptibility and perceived benefits for the use
of precautions, reported in this study by Becker et a1. (1990) did not correspond to
compliance by not recapping, as the model would predict. This finding, however, may be
explained by the fact that many of the providers were confused about the proper
procedures for the handling and disposal of needles/sharps, and were viewing recapping
as a protective, rather than a risk, behavior.

There are several other theories in addition to those mentioned above that may be
applicable to the investigation of compliance with universal precautions. In addition to
theories of fear arousal and cognitive-decision making, theories of interpersonal
relationships may be useful for examining how precautionary behaviors are influenced by

others in the environment (Levington, 1989). However, it is not clear at this point in the

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development of the research which of these major categories of theories will serve most
useful in understanding the dynamics of compliance with universal precautions.

There are several relatively new and general theoretical models that have been
successfully developed and/or applied to the study of AIDS-preventive behaviors among
HIV-infected individuals or those at risk for HIV infection that may have relevance for
addressing issues of compliance among health care workers. An example of such a
model is the Information-Motivation-Behavioral Skills Model for AIDS Risk Reduction
(IMB) proposed by Fisher and Fisher (1993) (See Figure 1). This conceptually-based and
highly generalizable model for understanding AIDS-risk behavior change was constructed
on the basis of a comprehensive, critical review of the AIDS-risk reduction literature
(Fisher & Fisher, 1992). Fisher and Fisher conclude that the most effective AIDS-risk
reduction interventions are those that are conceptually based, group specific, and focus on
providing AIDS-risk reduction information, motivation, and behavioral skills. Their
model includes three major components which determine AIDS-prevention behavior,
including: 1) information regarding AIDS transmission and prevention; 2) motivation to
modify AIDS risk behavior; and 3) behavioral skills for performing specific AIDS
preventive acts. Within this model, risk-reduction information and motivation serve to
activate behavioral skills that are used to initiate and maintain patterns of preventive
behavior. Although Fisher and Fisher (1993) propose that the presence of motivation and
information together make it more likely that behavioral skills will be used, they argue
that there is no necessary strong relationship between level of information and level of
motivation. In addition, information and motivation can also have direct effects on AIDS-

preventive behaviors when AIDS-specific skills are not necessary for the practice of

“I!

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of preventive behavior. Research has documented consistent empirical support for the
relationships hypothesized by the IMB model with both gay male and college student
samples (Fisher & Fisher, 1992; Fisher, Fisher, Williams, & Mallay, 1994).

In terms of information, this model posits that risk reduction information plays an
important role and must be relevant (same level of specificity and content domain) to the
preventive behavior in order to impact behavior (Fisher and Fisher, 1992). Thus a global
assessment of a health care worker's level of HIV-related knowledge may bear little
relationship to her/his compliance with guidelines for universal precautions while
' knowledge of precautions may. This may help explain the lack of a relationship between
knowledge and behavior apparent in the literature. According to the model, information
must also be coupled with motivation and behavioral skills in order to change and
maintain behavioral changes. Again, this argument would explain why one-time,

information—only interventions have had little impact on preventive behavior.

 

29

Motivation within the [MB model is conceptualized within the framework of
Fishbein and Ajzen's Theory of Reasoned Action (Ajzen & Fishbein, 1980). Fisher and
Fisher state that the theory of reasoned action provides "... a well articulated social
psychological conceptualization that may be applied to understanding and changing AIDS
prevention motivation within diverse target groups" (p. 467). These authors cite
extensive evidence to suggest that motivation to engage in AIDS—preventive behaviors is
the function of two factors that affect motivation to act: 1) the individual's personal
attitude toward performing the act in question; and 2) the individual's subjective norm or
perception of what significant others think should be done with respect to performing the
act in question. These attitudes in turn predict behavioral intentions to perform a
specified behavior. In addition to personal attitudes toward preventive behavior and
perceived social support for such behavior, numerous other factors — such as perceived
vulnerability to infection - have also been investigated as possible motivators of AIDS
preventive behaviors. The authors argue that in accordance with the Theory of Reasoned
Action, these factors should be viewed as external motivators that operate through the
major components of the model.

Behavioral skills, the third major component of the IMB model, are presented
conceptually within the model as an AIDS-reduction behavioral sequence specific to
engaging in preventive behaviors related to sexual behaviors. The authors of this model,
however, are quick to point out that these behavioral sequences can easily be adapted to
different groups or different types of behaviors. Operationally, the authors propose the
measurement of behavioral skills through the assessment of self-efficacy with respect to

performing specific AIDS-preventive behavior, based on extensive research documenting

30
that a strong sense of AIDS prevention self-efficacy is strongly bound to the performance
of AIDS-preventive behaviors.

While the constructs of this model are general, its authors argue that these
constructs are expected to have content that is specific to particular groups and particular
behaviors. There are, however, two major shortcomings in the original model that require
attention before the model is applied to the investigation of compliance with universal
precautions. Although Fisher and Fisher propose using the theory of reasoned action to
assess motivation to engage in AIDS preventive behaviors, the theory of planned
behavior - an extension of Ajzen and F ishbein’s original model - may be more
appropriate for examining motivation to comply with universal precautions. The self-
reported barriers associated with the use of universal precautions, as evident in the
literature (See Table 1), suggest that some health care workers perceive that they have
little control over these behaviors. According to the theory of planned behavior,
perceived control over a behavior, that is the perceived ease or difficulty of performing a
particular behavior, plays a role in determining intentions and behaviors when that
behavior is not under complete volitional control (Ajzen & Madden, 1986). People who
believe that they have neither the resources nor the opportunities to perform a behavior
are unlikely to form strong behavioral intentions even when they hold favorable attitudes
toward the behavior and believe that others would approve of their performing the
behavior (Ajzen, 1988). Ajzen and Madden (1986) propose two versions of a model for
the theory of planned behavior. The first version assumes that the effect of perceived
behavioral control on behavior is mediated by intention and that intention is the

immediate antecedent of behavior. The second version of the model assumes that in

31
addition to indirectly influencing behavior via intentions, perceived control can directly
be used to predict behavior because it may be considered a partial substitute for a measure
of actual control.

The second modification of the model that must be considered involves the
relationship between motivation as assessed by behavioral intentions, behavioral skills,
and behavioral compliance. Fisher and Fisher (1992) propose that intentions predict
compliance by activating behavioral skills. Logically, however, it would appear that
behavioral skills (as assessed by perceived efficacy for performing the behavior) should
be viewed as preceding the formation of the intention or as moderating the relationship
between intentions and compliance.

Applying a modified version of the IMB model will serve to examine the utility of
flaming compliance with universal precautions as AIDS-preventive behaviors within this
particular theoretical model. Relationships between key factors that have been suggested
in previous research as important factors influencing precautionary behaviors can be
explored within this model. The role of perceived risk of HIV infection, along with other
attitudes toward universal precaution guidelines, in predicting behaviors can be
examined. In addition, a better understanding of the relationship between knowledge and
behaviors would be gained by examining both the direct and indirect effects of this
relationship. Results that support this model would identify which critical aspects of
information and motivation need to be addressed in ensuring universal levels of
compliance with these guidelines. A pattern of results that fails to support this model

would identify a need to reconceptualize future investigations of compliance with

universal precautions.

 

32
Implications
Research has documented levels of compliance with universal precautions that are
far from universal. Overall, intervention strategies to date, have failed to meet the
objective of achieving universal levels of compliance with universal precautions.

Substantial numbers of health care workers continue to recap needles and this behavior

appears most resistant to change, a finding of critical concern in light of evidence that the

majority of documented cases of occupationally-acquired HIV have resulted from
recapping (CDC, 1992). The low levels of use of barriers precautions, especially those
other than gloves, illustrates that significant numbers of health care providers are failing
to protect themselves from potential exposures to HIV (along with several other
bloodbome pathogens) in the workplace.

The preceding review of the research literature identified several gaps and
limitations in the research which warrant further investigation. These include:

1. A need to assess current levels of compliance with universal precautions in this
period following OSHA's final ruling on bloodbome pathogens. Although it was
perceived that this ruling would result in increased levels of compliance, research
has yet to substantiate this belief. In addition to further assessing compliance with
barrier and needle/precautions, investigation into health care workers' compliance
with protocol for exposure incidents - an area in which data are scarce - is
warranted.

2. A need to assess and study compliance with universal precautions among health
care workers who have not been typically represented in the research. The

majority of the existing research has been conducted with physicians and nurses in

33

acute care settings of large teaching hospitals in major metropolitan areas.
Additionally, many of these settings were located in high prevalence areas or
served as AIDS referral centers. As the epidemic of HIV is diffused from large
metropolitan to less urban areas, the need to determine levels of compliance with
universal precautions among health care workers in these areas is imperative
(Kaczmarek et al., 1991).

A need to conduct a program of research that addresses and or contributes
knowledge to the methodological limitations evident in previous studies.
Measures of compliance must be developed that are reliable, specific to both the
task and the type of precaution, and are operationalized to differentiate between
over and under utilization of precautions. Efforts to limit the period of recall and
reassure participants of the confidentiality of their responses are needed to assist
in limiting sources of bias surrounding self-reported assessments. In addition,
future research efforts should include an assessment of the degree to which social
desirability and other psychological defenses influence responses to self-report
assessments of compliance with universal precautions and other variables thought
to predict compliance.

A need to investigate compliance across types of medical procedures in order to
gain insight into how these factors are related to the use of universal precautions.
A need to systematically examine the relationships and contribution of perceived
barriers to the use of universal precautions.

A need to investigate the factors believed to influence these behaviors within the

context of a theoretical model. The development of effective intervention efforts

 

34
and decisions about how to best allocate resources to address the issues
surrounding the potential for HIV transmission in health care settings necessitate a
more in-depth understanding of the context in which compliance with universal
precautions occurs. Research is needed to assess current barriers to compliance
and examine the relative importance of environmental versus individual-level
barriers in predicting compliance. The nature of the relationship between
knowledge, attitudes, and precautionary behavior has been largely unexplored,
pointing to a need for the development and testing of a predictive model. In
relation, there is a need to assess these relationships within a theoretical context

that frames compliance as AIDS-preventive behaviors.

W

The major objectives of this study were as follows:

1.

To assess current levels and patterns of compliance with universal precautions
among selected groups of health care workers working in a hospital located in an
area with a rate of HIV infection at or below the national average. The three
general areas of compliance with universal precautions that were assessed within
this study included: 1) compliance with the use of barrier precautions;

2) compliance with guidelines for the handling and disposal of needles and sharps;
and 3) compliance with the protocol for the reporting and follow-up of exposure
incidents;

To contribute to the further development of methodology for assessing

compliance with universal precautions;

35

3. To assess variability in compliance with universal precautions across types of

medical procedures;
4. To assess current barriers to the use of universal precautions and examine the

relative importance of environmental versus individual-level barriers; and
5. To develop and test a model of the factors that predict compliance with universal

precautions.

F

Researchfluestionsandflmtheses

Based on the relationships and deficits revealed in previous research, the

 

following research questions and hypotheses were tested:

1.

2.

What are current patterns of compliance with universal precautions?

Is social desirability a significant source of response bias in the assessment of

compliance with universal precautions and other HIV -related constructs?

Do different approaches (measurement methodologies) to assessing self-reported

compliance with universal precautions yield different results?

Are there significant differences in levels of compliance by medical procedure?

a. Findings from several studies are consistent with providers' reports that the
loss of dexterity and tactile sensation when using gloves during
phlebotomy or IV procedures is a significant barrier to the use of gloves
(Baraff & Talan, 1989; Conte, 1992; Gerberding et al., 1987; McNabb &
Keller, 1991; Voelker, 1991). Findings reported in Kaczrnereck et a1.

(1991), however, call into question the role that loss of dexterity plays in

36

impacting compliance with the use of gloves. On the basis of these

findings, the following hypotheses were tested:

Hypothesis 1: Compliance with the use of gloves will be lower during
procedures involving a high degree of dexterity compared
to other procedures.

Hypothesis 2: Compliance with the use of gloves will be higher during
procedures in which there is a greater likelihood for
exposure to patients' blood and body fluids compared to
procedures with a lower level of risk.

Hypothesis 3: The likelihood of exposure to blood and body fluids will be
a stronger predictor than loss of dexterity in predicting
compliance with the use of gloves.

5. There has been little systematic investigation into the barriers related to levels and
patterns of compliance with universal precautions. As a result, it is currently
unknown to what extent these behaviors are influenced by environmental-level
barriers relative to individual-level barriers. This study examined whether self;
reported environmental-level or individual-level barriers are a stronger predictor
of compliance.

W. The current study also tested the utility of
framing universal precautions as AIDS-preventive behaviors in understanding the factors
that predict compliance. The relationships between several key factors and these
behaviors were tested using a modified version of the Information-Motivation-

Behavioral Skills Model of AIDS Risk-Behavior Change (Fisher & Fisher, 1993). For

 

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37

the purposes of this study, information was operationalized as the specific knowledge
domains of 1) knowledge of HIV transmission in health care settings and 2) knowledge of
universal precautions. These measures of knowledge were intended to measure
knowledge at the same level of specificity and with a similar content domain as the
behaviors in question. This approach was designed to address one of the cited
methodological reasons for the failure to observe a consistent relationship between AIDS-
related knowledge and AIDS-preventive behavior (Fisher & Fisher, 1992).

Motivation was assessed in accord with the principles of the Theory of Reasoned
Action (Ajzen & Fishbein, 1980) and the Theory of Planned Behavior (Ajzen & Madden,
1986). Scales assessed the following: 1) behavioral intentions to appropriately utilize
universal precautions; 2) beliefs about the perceived efficacy of universal precautions;
3) subjective norms for compliance with universal precautions; and 4) perceived
behavioral control, operationalized as the perceived ease or difficulty of using universal
precautions. Perceived risk for occupational transmission was also assessed and applied
to the model as an external factor which works to indirectly impact preventive behaviors
by acting on the intention, attitudes, and normative components of the model. Finally,
behavioral skills were operationalized as perceived self-efiicacy for performing medical
procedures when complying with guidelines for universal precautions.

Three different versions of the model were tested. The first version of the model
tested the theoretical model proposed by Fisher and Fisher (1993), examining the
relationships between the latent variables within the IMB model as applied to this study

to determine the overall utility of this theoretical framework in understanding the factors

38

that predict compliance (See Figure 2). Within this model, the following hypotheses were

tested:

Hypothesis 4:

Hypothesis 5:

Hypothesis 6:

Hypothesis 7:

Higher levels of information will predict a significantly higher
level of behavioral skills for complying with the guidelines for
universal precautions. Knowledge may have direct effects on
behavior, however, it is predicted that this relationship, if
significant, will be weaker than the effect of information on
behaviors as mediated through behavioral skills.

Higher levels of motivation will predict significantly higher levels
of compliance with AIDS-preventive behaviors, with this
relationship being moderated by level of behavioral skills for
complying with the guidelines for universal precautions.

Higher levels of behavioral skills for complying with the guidelines
for universal precautions will predict significantly higher levels of
compliance with AIDS-preventive behaviors.

Within this model, information and motivation are each thought to
influence the likelihood of preventive behavior, but are viewed as
separate constructs that influence behavior differently (Fisher and
Fisher, 1992). It is predicted that information and motivation will
be statistically independent factors, and will therefore not be highly

correlated.

The second and third models examined the relationships between the observed

variables within the theoretical model, in an attempt to further explore the relationships

39

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among the observed variables and to compare different versions of the model (Theory of

Reasoned Action versus the Theory of Planned Behavior) for goodness of fit with the

data. The model illustrated in Figure 3 assessed motivation using the conceptual

framework of the Theory of Reasoned Actions as originally proposed by Fisher and

Fisher (1993). In this version of the model, the predicted relationships were as follows:

Hypothesis 8: Higher levels of HIV knowledge and knowledge of universal
precaution guidelines will predict higher levels of perceived
efficacy for performing procedures while using universal
precautions. The two knowledge measures will also correlate
positively with compliance with universal precautions, however,
the strength of these direct relationships will be lesser than the
indirect effects of knowledge as mediated through perceived
efficacy for performing procedures while using universal
precautions.

Hypothesis 9: Perceived efficacy of universal precautions and subjective norms
for complying with universal precautions will be positively
correlated with behavioral intentions for complying with universal
precautions. The relationship between perceived risk for HIV
infection and the other motivational variables will be explored.

Hypothesis 10: Higher levels of behavioral intentions for complying with universal
precautions will predict significantly higher levels of compliance

with universal precautions, with this relationship being moderated

 

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42

by level of behavioral skills for complying with the guidelines for
universal precautions.

Hypothesis 11: Higher levels of perceived efficacy for performing procedures
while using universal precautions will predict significantly higher
levels of compliance with universal precautions.

The third version of the model (See Figure 4) assessed motivation using the
conceptual framework of the Theory of Planned Behavior, with the addition of the
variable of perceived behavioral control. The relationships laid out in this model are
consistent with those in hypotheses 8-11, with an additional hypothesis predicting the
relationship of perceived behavioral control to compliance with universal precautions.
Hypothesis 12: Higher levels of perceived behavioral control will predict higher

levels of compliance with universal precautions. (Both the direct
and indirect [i.e., as mediated by intention] effects of perceived
behavioral control on compliance with universal precautions were

examined.)

43

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Chapter 2

METHODS

S l E . l S .
This investigation into compliance with universal precautions was conducted as a
point-in-time correlational study utilizing self-report data collection techniques. This
research was conducted on 5 different acute-care units in a midsized (400-600 bed)
teaching hospital. This hospital is located in a midsized city (population 100,000-
300,000) in a state with annual rates of reported cases of AIDS less than half the national
rate (CDC, 1995). Guidelines for universal precautions were implemented in this
hospital in 1987 along with yearly in-house trainings. Continuing efforts have also been
made to provide protective equipment, to implement an exposure control plan that
includes the use of AZT, and to implement needleless systems and other engineering
controls. The responsibility for ensuring compliance with the guidelines for universal
precautions lies primarily with department managers and other supervisory staff.
Employees who are observed to be noncompliant with guidelines are counseled with
additional disciplinary actions taken by supervisory staff when deemed appropriate. Self-
report data were collected anonymously from nursing and other direct care staff on the
following units: 1) the neonatal intensive care unit (NICU); 2) the regular nursery; 3) the
emergency department; 3) labor and delivery; and 4) the women’s pavilion - a medical

surgical unit serving women. These units were a convenience sample - chosen on the

44

 

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45

basis of willingness on the part of deparrnent managers to participate and in part, by the

need to ensure some degree of comparability of procedures across units.

Smflrucedm

Self-report questionnaires were distributed between at the end of August and
beginning of September, 1995, to all eligible staff in the 5 study units. Professional staff
who provide direct care (not including physicians) in each of the selected study units
served as the participants for this investigation. This included nurses, physician
assistants, and paramedics. Orderlies and nursing assistants were excluded from the
sample; although they provide direct care, they are not licensed and therefore do not
perform the same procedures as professional staff.

Questionnaires were distributed in staff mail boxes. Participation was solicited
and the purpose of the survey was explained to staff at change of shifi or during other
regularly scheduled meeting times by the investigator and/or Department Managers. A
cover letter accompanied each questionnaire explaining the purpose of the study and
providing instructions for completing and returning the survey. Participants were
informed that by completing the survey they were consenting to participate in the study.
The cover letter (See Appendix A) also explained that the study was being conducted in
cooperation with but independently of the hospital and that no one associated with the
hospital would have access to individual-level data, that their participation was voluntary,
and that all information would remain anonymous. Participants were asked to complete
the survey on their own and were provided with a stamped, addressed envelope in which

to return the survey. Follow-up letters were distributed 2 weeks following the original

46

distribution of questionnaires to all participants, urging those who have not yet returned
their consent form to consider participating in the study.

Of the 328 surveys which were distributed, 160 were returned by November 15th,
1995 (this includes 8 pilot surveys which were included in the final sample). This
represents a response rate of 49.0%. This final sample size met the requirement of 150
subjects needed to achieve statistical power of .80 in order to detect R2 as small as .10. A
significance level of p<.05 was adopted for all analyses. Rates of response were fairly
consistent across five units. Four of the units had response rates ranging from 42.0-
48.0%. Labor and delivery had the highest rate of response, with 69.0% of eligible staff '
participating. Sample sizes for the different analyses varied due to incomplete surveys

and are clarified for all reported analyses.

5 l C] . .

The final sample of 160 respondents included 141 registered nurses, 2 licensed
practical nurses, 5 nurse practitioners, 5 paramedics, 1 physician assistant, and 3 nursing
administrators. The unit breakout of the sample was as follows: 1) 23.8% of the sample
was from the NICU; 2) 20.6% of the sample was from the regular nursery; 3) 21.3% of
the sample was from emergency department; 4) 19.3% of the sample was fi'om labor and
delivery; and 5) 15.0% of the sample was from the women’s pavilion.

In this study the average age of the sample was 40.1 (§D=7.26). Almost all of the
respondents were female (91.0%). Approximately half of the respondents reported

highest degree obtained (related to their medical profession) as an Associate Degree

47

(48.0%); 41.0% reported having obtained a Baccalaureate; 8.0% a Diploma; and 3.0% a
Masters.

Analyses were done to investigate whether or not there were any demographic and
employment differences between the respondents on the different units. There were no
significant between-group differences in the age of respondents and the highest degree
obtained. There were significant between-group differences in the sex of respondents
(x2=l7.2, p<.05) and current position (x2=47.5, p<.05). Over a quarter of the
respondents (26.5%) in the emergency department were male, while less than 7.0% of
respondents in the other four units were male. In the regular nursery, labor and delivery,
and women’s pavilion, over 93.0% of the respondents were nurses. In the NICU, 81.1%
of respondents were nurses and 13.5% of respondents were nurse practitioners. In the
emergency department, 82.4% of respondents were nurses and 14.7% of respondents

were paramedics.

Measums

Successive drafts of the survey instrument were developed in collaboration with
department managers and members of the hospital’s Nursing Research Committee. In
order to avoid the complexities of analyzing data with both random (procedures) and
fixed (professionals) effects, the assessment of compliance with universal precautions
was developed to force a more balanced design for this study. Based on input from
nursing and medical staff, five broad categories of procedures commonly performed in
the study units were identified: 1) patient assessment; 2) IV/puncture procedures; 3)

airway/ respiratory procedures; 4) wound care/treatment; and 5) body fluid procedures.

 

 

J} r
5:05

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48

Department managers from each unit were asked to identify commonly performed
procedures within each of these 5 categories. Two to three procedures were chosen from
each of the 5 categories to construct a list of 10-13 procedures for each of the 5 study
units. Whenever possible, procedures that were common across units were chosen.
When this was not possible, procedures were matched on the general level and type of
precaution use required. These procedures were used to construct the measures of
compliance with universal precautions, behavioral intentions, and behavioral skills.
Thus, 5 different versions of the instrument were generated for each study unit with unit-
specific measures of behavioral compliance, behavioral intentions, and behavioral skills
reflecting medical procedures commonly performed by staff in that unit.

Eight nurses were asked to pilot test the different versions of the measure by
completing and providing feedback on the questionnaire. Pilot respondents were asked:
1) if the procedures were defined in a way that would be uniformly understood by other
health care workers they work with; 2) if the questions were technically accurate; 3) if the
questions were objectionable, diffith or demanding; and 4) if the responses provided
were appropriate for each question. Results of the pilot test were used to finalize the
measure. Because the changes made on the basis of the pilot questionnaire were minor,
the 8 pilot participants were included in the final sample, however, pilot data were
excluded for any items which were significantly revised in finalizing the measure.

One of the versions of the final instrument (for Labor and Delivery) is presented
in Appendix B. Unless otherwise specified, the items in this questionnaire were
developed specifically for use in this study, although several of the items used to

construct various scales have been borrowed or modified from instruments used in

 

49

previous research. Multi-item scales were developed following rational considerations
regarding the primary constructs for this study. For each multi-item scale, an item mean
score was computed for all respondents who had completed at least 67% of the scale
items (sum of nonmissing item scores/number of nonmissing items). Table 2 outlines the
measures contained in the self—reported questionnaire and the corresponding
questionnaire item numbers.

A reliability analysis was conducted for each multi-item scale, yielding a measure
of internal consistency for each scale. For scales which include items that must be
assessed for multiple situations or for discrete behaviors, such as perceived barriers to the
use of universal precautions, items may not be expected to be internally consistent.
Nonetheless, an index of internal consistency was computed for the perceived barrier
scales because there are not available data for computing other more appropriate indices
of reliability (e.g. test-retest). In addition, item-responses which were tied to unit-specific
procedures (and therefore represented different questions for different units) would not be
expected to be internally consistent. The measures affected by this latter principle
includes behavioral compliance, behavioral intentions, and behavioral skills. For these
measures, unit-specific indices of internal consistency were calculated and the range of

reliabilities are presented.

C l. E l .
The first section of this self-report instrument contained 2 measures of self-

reported compliance with universal precautions. The first measure was designed to assess

 

: .. Respondents

50

 

 

Table 2
te r f th lf- e ort u tionn ir
Measure Item Numbers
Section 1 - Compliance Behaviors
Compliance with Universal Precautions - Last Time Procedure
Performed 1 (a-l)
Compliance with Universal Precautions - Last 3 Months 3 (a-g) 5(a-b)
Section 2 - Perceived Barriers
Individual Barriers 7(h-m) 8 (h-k)
Environmental Barriers 7 (a-g) 8 (a-g)
Barriers to the Use of Universal Precautions 7 (a-m) 8 (a-k)
Section 3 - Knowledge
Knowledge of HIV Transmission 10 (a,c,d,g-m)
Knowledge of Universal Precautions 11 (c,g,j)
Section 4 - Motivation & Behavioral Skills
Perceived Efficacy of Universal Precautions 12 (a-d,f)
Subjective Norms for Compliance with Universal Precautions 14 (a,b,d-g)
Perceived Risk of Occupational Transmission of HIV 15 (a-c, e,f)
Perceived Behavioral Control 13,17,19
Behavioral Intentions 18 (a-l)
Perceived Self-Efficacy for Performing Medical Procedures When
Utilizing Universal Precautions 16 (a-l)

Social Desirability Scale

20 (aacrg-k)

51

were asked to indicate the most recent period in which they performed specified medical
procedures. Respondents who performed a procedure within the last year were asked to
specify which precautions they used the last time they performed this procedure.

Several steps were taken to calculate scores for compliance during the last time a
procedure was performed. Routine precautions - those precautions required during the
routine performance of that procedure - were in general determined from hospital policies
specifying which precautions are to be used for procedures under routine conditions.
Input from department managers and infection control staff was also sought to account

for departmental standards for each task and used in determining minimum required

 

precautions for each of the procedures included in this measure. The use of precautions
was calculated as all or none - the use of precautions was scored as compliant only if a
respondent, at a minimum, indicated using all of the routine precautions for that
procedure. Respondents who indicated the use of additional precautions, other than those
called for under routine use, were also scored in compliance. (In this respect, the scoring
of both compliance measures used in this study was not affected by respondents
indicating that they engaged in precautions above and beyond what would be considered
required, or routine, for that procedure.) Many respondents indicated that they had not
performed airway/respiratory procedures within the last year, therefore procedures in this
category were not included in the calculation of this measure of compliance. After
calculating compliance at the level of procedure, mean compliance scale scores were
calculated by summing across all procedures. A reliability analysis for these items by
unit ranged from alpha = -1.10 - .42. In addition to this total compliance score, mean

compliance scale scores were calculated separately for each of the procedure categories:

52
1) patient assessment (alpha=.00 - .46); 2) IV/puncture (alpha=.00 - .56); 3) airway/
respiratory (alpha=-1.71 - .44); 4) wound care/treatment (alpha= .00); and 4) body fluid
(alpha=-.22 - .09). The lack of variance on items and the mixing of negative and positive
correlations between items would appear to account for the observed reliabilities on the

compliance measures. As a result, many of these reliabilities are difficult to interpret.

Section one also included an assessment of eemnfianeemmnnimsal
preeanfiensdnnngjhelastmeememhs. Utilizing a series of skip-questions, this
measure assessed whether or not participants were involved in situations with potential
exposure to blood and body fluids and if so, assessed on a 5-point scale how often they
followed guidelines for universal precautions. In addition to assessing compliance with
precautions for barriers and needles/sharps, this measure also assessed compliance with
reporting and follow-up for exposures. Mean scale scores for compliance (during the last
3 months) were calculated by using the items assessing compliance with barrier and
needle/sharp precautions. Items assessing compliance with guidelines for reporting and
following-up with exposures were not included in the scale since only a small percentage
(17.5%) of respondents indicated having been exposed in the three month period prior to
completing the survey. “Non-applicable” responses were recoded as missing. A

reliability analysis for this 9-item scale yielded low internal consistency (alpha=.49).

E . l E .
The second section of this instrument included an assessment of mreeiyed

Wrens. These measures were designed as checklists

of various individual and environmental barriers to the use of barrier precautions,

 

53

precautions related to needles/sharps, and precautions for reporting and following-up
exposures to blood and body fluids. Participants were asked to indicate which of these
barriers made it difficult or prevented them from adhering to the guidelines for universal
precautions within the last 3 months. Again, items assessing barriers to reporting and
follow-up of exposures were not scaled because only a small percentage or participants
reported being exposed in the 3 month period prior to filling out the questionnaire. These
items were used to calculate 3 barrier scale scores. Ten items assessing perceived
individual barriers (e. g., habit or carelessness, patient did not appear to be at risk for HIV,
universal precautions are unnecessary/ineffective) were used to compute a scale of
indiyidnalharriers (alpha=.50). Fourteen items assessing perceived environmental
barriers (e.g., lack of time, protective equipment interferes with technical skills, materials
poorly constructed) were used to compute a scale of enyirenmentaflrarjners (alpha=.59).

All 24 items were used to compute a total scale assessing harnerstenrnxersaLereeamien

(alpha=.62).

Kimmie:

The third section of this instrument included two measures of HIV-related
knowledge. The scale of WW included items designed to
assess knowledge of the ways in which HIV is transmitted in health care settings.
Respondents were asked to indicate the relative probability of HIV transmission to a
health care worker in different provider-patient scenarios. These scenarios represented
both viable and nonviable routes of transmission. Item responses were recoded. For

items representing situations in which there was a potential risk of HIV transmission,

 

54

responses indicating some degree of risk were scored as correct answers. For items
representing situations in which there was no potential risk for transmission, responses
indicating no risk were scored as correct answers. After recoding, there was little or no
variance on the items representing viable routes of HIV transmission as nearly all
respondents reported “correct” responses and these items were deleted from the scale.
The final scale included 10 items, with a reliability analysis yielding satisfactory internal
consistency (alpha=.81).

Several items asking participants to agree/disagree with a series of true/false
questions related to guidelines for the use of universal precautions were included in the
questionnaire as a measure of WW. Again, there was little
variance on several of these items, with nearly all respondents indicating correct
responses. The 3 items on which there was variance dealt with the perceived need for
additional or special precautions that go beyond those called for under universal
precaution guidelines. A reliability analysis for these 3 items revealed low internal

consistency (alpha=.44).

ll' . 1E1 . 15]."

The fourth section of this instrument included several measures designed to assess
the constructs of motivation and behavioral skills. Participants were asked to respond on
a four-point scale to a series of questions designed to assess mreejyedeflieaelef

nnixersalmeamiens. These questions were designed to assess the degree to which

participants believe that universal precautions provide them with adequate protection

55

against HIV infection. A final reliability analysis for this 5-item scale revealed low
internal consistency (alpha=.6 l ).

Respondents were also asked to respond on a 4-point scale to a series of questions
designed to assess snbjeetive nonns fer cemeliance with nnr'versal precautions. These
questions were designed to assess the participants’ perceptions that significant others in
their work environment support and engage in compliance with universal precautions. A
reliability analysis for this 7-item scale yielded satisfactory internal consistency
(alpha=.73).

This section also included a measure designed to assess level of fear of becoming
infected with HIV in the health care setting. Respondents were asked to respond on a
4-point scale to a series of statements designed to assess perceryeinskefleeennanenal
transmissienefiflm. A reliability analysis for this 5 item scale revealed satisfactory
internal consistency (alpha=.71).

A measure of nemeiledmhaxieraleemrel was included in this section. This
measure was adapted from a scale used by Ajzen and Madden (1986) in their
development and testing of the theory of planned behavior (alpha=.74). These 3 items,
which were included at different points throughout this section of the questionnaire, were
intended to judge the degree to which respondents feel in control of whether or not they
use universal precautions. A reliability analysis for this 3-item scale revealed low
internal consistency (alpha=.50).

BeharderaLintemiens for complying with universal precautions were assessed by
asking respondents to indicate the degree of likelihood ( extremely likely, somewhat

likely, somewhat unlikely, extremely unlikely) that they would comply with universal

56

precautions when they perform specified medical procedures. A list of procedures
identical to those used in the assessment of compliance (last time procedure was
performed) was used to assess intentions. Respondents were asked to indicate the
likelihood that they would use specific precautions for each procedure. An approach
parallel to that used in the calculation of compliance scores was taken to calculate
intention scores. Behavioral intention scale scores were calculated as the mean of
responses for those precautions required for each of the procedures. The number of items
included in this scale ranged from 8-10, as a result of the variation in the number of
procedures between units. Required precautions matched those used in the calculation of
procedure-specific compliance scores (i.e., routine precautions). In addition, responses
for a particular procedure were included only if a respondent indicated performing that
procedure in the section assessing compliance. A reliability analysis for these items by
unit revealed indices of internal consistency ranging from alpha=.06 - .55.
The fourth section of the questionnaire also included a measure designed to

assess behavioral skills, which were operationalized as W
1.1111111'1' 11-1 1 1 -1.-‘ 1-1 .'1 __1'- 1.1- ,-'11.Thismeasureasked
respondents to agree or disagree with a series of statements reflecting a level of
confidence in performing a medical procedure while utilizing the appropriate precautions.
The list of procedures identical to those used in the assessment of compliance (last time
procedure was performed) and behavioral intentions was used to construct this measure
and responses for a particular procedure were included only if a respondent indicated

performing that procedure in the section assessing compliance. Again, the number of

57

items included in this scale ranged from 8-10. A reliability analysis for these items by
unit revealed indices of internal consistency ranging from alpha=.76 - .87.

Finally, this section included a shortened version of the Crowne & Marlow (1960)
scale of seernLnesrLahnm to assess method variance. This scale has been tested on
several different samples with alphas ranging from .73-.88 (Paulhus, 1991). A random
subset of the 33-item scale was included in the questionnaire, with items assessing either
desirable but uncommon behaviors or undesirable but common behaviors. The
reliability analysis for this 8-item scale revealed low internal consistency (alpha=.59).

The final section of the self-report instrument contained several items assessing
demographicscharacteristics (age and SCX) and emnlmanemsharactetistics (current
position, degree, year degree obtained, primary clinical area of practice) of the

participants.

 

Chapter 3

RESULTS

Wax

A complete description of the analyses that were performed to examine and test
each of the research questions and hypotheses is presented in Table 3. Descriptive
analyses were conducted for items and multi-item scales in order to examine frequencies
and measures of central tendencies. Methodological analyses were conducted to
investigate issues of methodology which impact the current study. Finally, predictive
analyses were generated to examine several research questions, including: 1) differences
in the variables by type of medical procedure; 2) relationships between reported barriers
to using precautions and compliance; and 3) several exploratory relationships among
variables. Predictive analyses were used examine the relationships among the outcome
and predictor variables and to test several variations of the model for predicting
compliance with universal precautions, using LISREL VIII to test the models for

goodness of fit.

58

59

 

Table 3
MAW
Analysis Research Questions/Hypotheses Analysis Variables Data
Category Analysis
Descriptive What are current levels of Items Assessing Descriptive
Analyses compliance with UP? Compliance with UP Statistics
What are current patterns of Items Assessing: Descriptive
knowledge and motivational Barriers to UP Statistics
constructs ? Knowledge
Motivation
Methodological Is social desirability a significant Social Desirability, Correlations
Analyses source of method variance? Outcome & Predictor
Variables
How do Ievels/pattems of Compliance - last shift Correlations
compliance vary by type of & last 3 months.
instrument used?
Predictive Are there significant differences Compliance with UP - ANOVA
Analyses in compliance by medical last shift & last three (within-
procedure? months. subjects
design)
H1: Compliance will be lower
during procedures involving a
high degree dexterity.
H2: Compliance will be higher
during procedures in which there
is a greater likelihood for
exposure.
H3: The likelihood of exposures
will be stronger predictor of
compliance than loss of dexterity.
Are environmental or individual Environmental & Multiple
barriers a stronger predictor of individual barriers; Regression
compliance? compliance with UP- Analysis
last shift and last three
months
Exploratory relationships among Outcome and predictor ANOVA
variables. variables.
Testing the IMB model as applied All outcome and Correlations
to compliance with universal predictor variables. LISREL

precautions.

60

n Mo ivation Related to niversal Pr cautions

Asse lian Knowled

This study was designed to investigate current levels of compliance with universal
precautions among health care workers who have not typically been represented in the
research during this period following OSHA’s final ruling on bloodbome pathogens.
This investigation was also interested in looking at current levels of knowledge and
motivational constructs in the context of how they relate to the assessment and prediction

of compliance with universal precautions. The results of the descriptive analyses

examining compliance are presented first, summarizing current findings regarding the use

 

of universal precautions along with perceived barriers to the use of universal precautions.
Following, is a summary of the descriptive results for items assessing knowledge and
motivational constructs in relation to HIV in health care settings and to the use of

universal precautions. Finally, results are presented which address the methodological

issues of concern in the assessment of compliance.

Ce 1' 1m“. 1E .

The percentage of participants for each of the 5 units who reported using each of

the different precaution components (i.e., gloves, gowns, needle/sharp precautions)
during the last time they performed that procedure are presented in Table 4-8. Also
p reSetlted in these tables are the percentages of respondents in each of the units who were
in compliance with use of precautions for each of the specific procedures by using at a
IniniIlium, all required, routine precautions called for during the performance .of that
p r()S-‘edure. At the procedural level, results reveal high levels of compliance with use of

re - . . 1
q Illred or routine umversal precautions. For many of the procedures, respondents

61

 

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66

indicated complete compliance with all required precautions. The use of handwashing
was nearly universal and over 90.0% of respondents reported complying with precautions
for the handling and disposal of needles and sharps. Overall, levels of glove use were
high as well, with a few exceptions. Over one quarter of respondents in the regular
nursery indicated not using gloves as required when performing suctioning. Nearly 40%
in the emergency department and women’s pavilion reported not using gloves as required
when administering IM medications; and in the NICU when performing feedings and
assisting with intubations. Thus, there appear to be procedures for which health care
workers are exercising some degree of discretion in deciding whether or not to wear
gloves. Procedures with lower levels of compliance include those that call for the use of
barrier precautions beyond the use of gloves (i.e., mask, eyewear, gowns, footwear). In
these procedures, compliance frequently drops below 50.0%, largely due to the failure to
use these additional barrier precautions.

Overutilization, or unnecessary use of precautions is another aspect of compliance
that is important, with excessive use having implications for quality of care and the use of
resources. It was intended that the self-report measure assessing compliance at the
procedural level be used to calculate overutilization, by identifying the use of precautions
not required for a specific procedure. Use of precautions beyond those required in routine
Situations, however, depends on the likelihood of exposure to blood and body fluids
anticipated by the health care worker. Determining overutilization, therefore, would
require knowledge of any special circumstances which might account for the use of

Precautions beyond those required in routine situations, a measurement aspect beyond the

scape of the self-report methodology employed in the current study. With an

67

understanding of these limitations, an examination of frequency data for patterns of
precaution use beyond routine use remains useful at a preliminary level of investigation.
An examination of the frequency data for compliance at the procedural level (See Tables
4-8), does indicate some level of use of gloves and other barrier precautions (mask,
footwear, etc.) during procedures in which these precautions are not required under
routine conditions. Further investigation will be necessary to determine if these patterns
of use are accounted for by special circumstances surrounding the situations in which
these procedures were performed which would warrant the use of additional precautions
or if they represent over use of precautions.

Overall, degree of compliance appears to vary by type of procedure. Mean
compliance scores were calculated for each of the 5 procedure categories (range=l .00 -
2.00). Mean scores were highest for wound care/treatment procedures (M=l .91,
SD=.22) and patient assessment procedures (M=l .91, S_D=.21,), followed by body fluid
procedures (M=1.85, SD=.21), IV/puncture procedures (M=l .85, SD=.24), and
airway/respitory procedures (M=l .72, SD=.36). The lower level of compliance during
the performance of IV /puncture and airway/respitory procedures is explained largely by
the failure on the part of some health care workers to wear gloves or use resuscitation
devices during these procedures.

In addition to assessing patterns of compliance during the performance of specific
Procedures, the current study assessed compliance for universal precautions during the 3
month period prior to completion of the survey instrument. Results revealed slightly

IOWEI levels of compliance than those assessed for the last time a specific procedure was

Perfonned, however, the general pattern of results was similar. The percentages of those

68

who indicated “almost always” in response to items assessing use of barrier precautions
are presented in Table 9. The use of handwashing and gloves was again nearly universal.
Compliance, however, was considerably lower in the use of other barrier precautions,
including the use of face/eyewear, gowns or aprons, and protective footwear.

Levels of compliance were relatively high for the handling and disposal of sharps
and needles, with the majority of respondents (71.4%) reporting compliance with
universal precaution guidelines that prohibit the recapping of a needle after it had been
used on a patient. Results indicate, however, that a significant proportion of the
respondents, on occasion, are recapping needles, with 14.9% reporting that they recap
needles “about 25%” of the time and 13.6% reporting recapping from “SO-75%” of the
time. The majority of respondents (90.3%), however, are reporting that they are properly
disposing of needles or sharps in a puncture proof container. Of the 41.9% who reported
resuscitation in last 3 months, 87.5% were complying with guidelines for universal
precautions by almost never resuscitating without a protective device.

Despite relatively high levels of overall compliance with universal precautions, 28
of the 160 respondents (17.5%) reported that they had experienced an accidental
needlestick or unprotected body fluid contact from a patient in the 3 months prior to
completing the survey. Due to little data in this area, this study sought to explore current
levels of compliance with the established protocol for exposure incidents. Compliance
With guidelines for reporting these exposures to occupational health services was low,
With only 9 (32.1%) of these 28 respondents indicating that they had reported this

accidental needlestick or unprotected body fluid contact from this patient to occupational

69

 

 

Table 9
i' on‘ o ‘n. a ‘ 1° 09 cl... -w' ivr al .' - a 'n int - Last
Almost Always

Items N Percent
Worn gloves when potential for exposure to blood 139 88.5
and body fluids.
Worn gloves when handling contaminated blood 138 87.9
access equipment.
Worn protective eyewear/face shield when 66 44.5
potential for body fluid splash.
Worn gown or leak proof apron when potential for 38 25.9
body fluid splash.
Worn protective footwear when body fluid soiling 23 15.8
anticipated.
Washed hands immediately when contaminated 147 94.8
with blood or body fluids.
Washed hands after removing gloves/ gown and 139 88.5

before leaving the work area.

 

70

health services for risk assessment and follow-up. Five of these 9 respondents indicated

that they had requested HIV antibody testing because of the exposure.

WW

Despite overall high levels of self-reported compliance, an important aspect of
this study remains the investigation into possible factors that may explain why some
health care workers are not using universal precautions or in other cases find it more
difficult to use universal precautions. The percentage of participants reporting perceived
barriers to the use of universal precautions for: l) the use of barrier precautions; 2) the
use of precautions for needles and sharps; and 3) precautions for the reporting and follow
up for exposures to blood and body fluids, is presented in Table 10. Aspects of the
environment such as lack of time, protective equipment not being available or accessible,
and barrier equipment interfering with technical skills were the most frequently reported
environmental barriers for the use of barrier precautions. At the individual level, over
40% of respondents were willing to admit that their own habit and carelessness serves as
a barrier to the adherence of guidelines for barrier precautions.

Environmental barriers also emerged as important perceived barriers to the
adherence of universal guidelines for the handling of needles/sharps, with over one-third
of the sample indicating inconvenient disposal, recapping for safe storage, to transport, or
to protect self/patient during the disassembly of equipment, as barriers. Lack of time and
habit or carelessness were less frequently reported perceived barriers for the handling of

needles/sharps compared to barriers for the use of barrier precautions.

71

Table 10

Bemrted Barriers to Using Universal Precautions

 

Items E Percent

Barriers to Using Barrier Precautions (n=156-160)

Lack of Time 85 54.1
Habit or Carelessness 64 40.8
Interferes with Technical Skills 63 40.1
Equipment Not Accessible 57 36.3
Materials Poorly Constructed 40 25.5
Equipment Not the Right Size 30 19.1
Interferes With Patient Relationship 22 14.1
Patient Did Not Appear to Be At Risk 20 12.7
Lack of Standards 13 8.3
Allergic Latex and Hypoallergenic Materials Not 11 7.1
Available
Patient/Family Uncomfortable 8 5.1
Knew Patient Tested Negative 7 4.5
Universal Precautions Unnecessary 7 4.5
Barrier Precautions Too Hot/Uncomfortable 4 1.9
Barriers to Using Sharp Precautions (n=156-158)
Disposal Inconvenient 52 33.1
Recap for Safe Storage 50 31.6
Recap to Transport 50 31.6
Recap to Protect During Disassembly 38 24.4
Habit or Carelessness 37 23.4
Lack of Time 14 8.9

(table continues)

72

 

 

Items fl Percent
Complexity of Equipment 5 3.2
Patient Did Not Appear to Be At Risk 3 1.9

Knew Patient Had Tested Negative 1 0.6
Universal Precautions Unnecessary 1 0.6
Lack of Standards 1 0.6
Barriers to Reporting/Following-Up Exposures (n=15)
Lack of Time 1 1 73.3
Complicated 5 33.3
Reporting Invasive 4 26.7
Unnecessary 3 20.0
Forgot 2 13.3
Fear of Disciplinary Action 2 13.3
Patient Did Not Appear to Be At Risk 2 13.3
Knew Patient Had Tested Negative 1 6.7
Fear of Testing Positive 0 0.0

 

73

Perceived barriers to adhering to guidelines for reporting and following up with
exposures are important in light of the fact that only 9 of the 28 respondents who
experienced an accidental needlestick or unprotected body fluid contact from a patient
reported these incidents to occupational health services. In this case, lack of time stands
out as the strongest perceived barrier. Over 20% of those who reported exposures

reported that the procedures were too complicated, invasive, or unnecessary.

Knowledge

Responses to items assessing knowledge of HIV transmission are presented in
Table 11. Viable routes are methods of transmission of HIV that have been officially
documented through surveillance efforts (CDC, 1992; CDC 1995). Nonviable routes
represent methods of transmission that, although they may be commonly perceived as
possible means of transmission of HIV, have never been officially verified as actual
routes of transmission. Respondents demonstrated high levels of knowledge of viable
routes of HIV transmission in the health care setting, with all of the respondents correctly
indicating that HIV can be transmitted via needlestick and from HIV-infected blood
sPlaslred on non-intact skin, in eyes, or in mucous membranes. While health care
Workers are clearly aware of the major routes of transmission from infected patient to
PTOVider, there was less agreement concerning risk for HIV infection from activities that
rePresent nonviable routes of HIV transmission. The majority of respondents indicated
that health care workers are at risk for HIV infection by being bitten, coughed, or

SneeZing upon by an HIV -infected patient or by coming into contact with a small amount

 

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74

 

 

Table l 1
L‘Hr‘ 0 ‘n a 51°..-0'09'I-’ an ' '0 nr- '1!
(n=158-160)
Items Risk
Viable Routes of HIV Transmission N Percent
A needlestick injury with a sharp used on HIV-infected 160 100.0
patient.
HIV-infected blood splashed in eyes or mucous membranes. 160 100.0
HIV -infected blood splashed on non-intact skin. 159 99.4
Nonviable Routes of HIV Transmission
While feeding HIV-infected patient, small amount of saliva 97 60.6
comes in contact with the worker’s intact skin.
While changing sheets on an HIV -infected patient’s bed, intact 125 78.1
skin comes in contact with dried blood stains.
A patient infected with HIV uncontrollably coughs or sneezes 143 89.4
on a unprotected face.
Performing mouth-to-mouth resuscitation with a protective 112 70.0
device on a patient infected with HIV.
While irrigating a wound, an HIV-infected patient’s blood and 143 89.4
body fluids splash onto intact skin.
Intact skin in contact with vomit of HIV -infected patient. 128 80.0
While inserting a urinary catheter into an HIV-infected patient, 134 83.7
a large amount of urine spills onto intact skin.
While performing an admission assessment on an HIV- 122 76.2
mfected patient, a worker touches a scab-covered wound
wlthout wearing gloves.
In the course of restraining a combative patient infected with 158 8.7
, a health care worker is bitten and the skin is broken.
A health care worker conducts daily massages with HIV - 58 36.7

mfected patient without wearing gloves (provider has no open

&r sores and never touches open cuts or sores.)

75

of saliva while feeding an HIV-infected patient. Over one-third indicated a risk from
massaging an HIV-infected patient’s skin.

The majority of respondents clearly demonstrated knowledge of the major
components of turiversal precautions. Correct responses to these items are presented in
Table 12. There is some variation in the interpretation of universal precautions along
some dimensions. Substantial percentages of respondents indicated that special
precautions are needed when treating HIV-seropositive patients, including the use of
gloves for all contact and the placement of HIV-seropositive patients in single rooms.
These results suggest that while the majority of respondents understand the fundamentals
of universal precautions, there is a sizable percentage of respondents who believe that the
current set of required precautions are not sufficient to prevent the transmission of HIV in

health care settings and that additional precautions that are not required are necessary.

MI' .

The pattern of results for responses to items assessing knowledge of universal
Precaution guidelines matches closely with those found for the assessment of perceived
Cflicacy of universal precautions, with the majority of participants agreeing with the
Concept of universal precautions in principle. The majority of respondents agreed that:

I) dmpping uncapped needles and syringes directly in a sharps box reduces their risk of
c"lltl’aczting bloodbome diseases, including HIV (98.7%); 2) that infection control
precalltions taken at this hospital are sufficient with respect to HIV transmission (89.2%);

3) that universal precautions are more effective at preventing the transmission of HIV in

76

 

Table 12

" Ht.‘ 0 ‘n, a. e r‘ . 0Wld°eo nivr a1 ' wocui r'n..=10
Agree“

Items N Percent

 

Protective eyewear worn when anticipate splash body fluids. 158 988*

If exposed to blood or body fluids, report to supervisor at 56 35.0
end of shift.

Special precautions needed when treating HIV -positive 102 65.0
patients.

Wearing gloves reduces times handwashing is necessary. 2 1.3
Every patient should be considered to be potentially HIV 152 95.0*
positive.

Health care workers must consider the procedure and type of 152 95.0"'
exposure before selecting barriers.

Gloves should be worn for all contact with HIV-positive 90 56.6
patients.
More severe infection control measures required for HIV 11 6.9
than Hepatitis B.
All needles should be placed in puncture-resistant 160 1000*
containers.

Luv-positive patients should be placed in single rooms. 81 51.6

 

* Agreement with the item represents a correct response.

 

77

health care settings than testing all patients for HIV (87.4%); and 4) the precautions they
take while working are adequate to prevent me from becoming infected with HIV
(86.8%). Responses to other items, however, again reveal a desire on the part of health
care workers for alternative or additional precautions. Over half of the participants
agreed or strongly agreed that disease-specific isolation room signs are more effective
than universal precautions in promoting barrier protection (55.0%). An even greater
percentage indicated that knowing the HIV-status of a patient is more effective in
preventing the transmission of HIV than the use of universal precautions (74.9%). Thus,

while participants confirm that universal precautions are effective in preventing the t.-

 

transmission of HIV, many of these respondents also believe that knowledge of patient’s
HIV status and action based on this knowledge (i.e., use of disease-specific isolation
precautions) would be more effective than the use of universal precautions.

Responses to items assessing subjective norms for compliance - participants’
perceptions that significant others in their work environment support and comply with
universal precautions - also varied. At the policy level, most respondents reported high
levels of support for the use of universal precautions. The majority of respondents
indicated that the administration and supervisory staff of this hospital provide necessary
equipment and training for health care workers to protect themselves from exposures
(92.5%); that health care workers in their unit are expected to comply with universal
precautions (95.6%) and that staff are encouraged to use barrier protection during patient
care (91.2%). In their day-to-day practice, however, it appears that participants perceive
less support for complying with universal precautions. Significant percentages of

respondents disagreed that coworkers are consistent in their use of universal precautions

78

(37.1%) and that coworkers remind each other to practice universal precautions (37.1%).
Over one-quarter (26.1%) of participants agreed or strongly agreed that their supervisors
are inconsistent in their use of universal precautions.

Responses to items assessing perceived risk of occupational transmission of HIV
reveal that a significant proportion of participants perceive themselves to be at real risk of
contracting HIV infection from the patients they care for. Significant percentages of
respondents disagreed or strongly disagreed with the following statements: 1) the
majority of my patients present little or no risk for transmitting HIV to myself and my

coworkers (56.4%); 2) I seldom worry that I may become infected with HIV as a result of |_

 

my job (44.1%); and 3) I consider the chance of myself becoming infected with HIV in
the health care setting to be highly unlikely (39.3%). Likewise, 40.2% of respondents
agreed or strongly agreed that they are highly susceptible to contracting HIV in the health
care setting. Smaller percentages indicated that they become anxious when performing
procedures or caring for patients because of fear that they may become HIV-infected
(15.7%). Over twenty percent (20.8%) of respondents indicated that they have little
confidence in the information about HIV and AIDS that the medical and scientific
communities present.

Despite the substantial percentages of respondents reporting perceived barriers to
the use of universal precautions, participants reported a high level of perceived behavioral
control. The majority of respondents indicated that is was “extremely likely” or “quite
likely” that if they want to use universal precautions, their working conditions would
enable them to properly use precautions (89.9%). Nearly half (45.2%) of participants

responded that they have complete control over whether or not they use universal

79

precautions. The remaining respondents indicated lesser degrees of control, however, few
indicated having very little control over whether or not they use precautions (1.3%). Over
sixty percent (61.0%) of respondents indicated that using precautions that they are

required to use all the time is easy.

U' NH 0' -.- are ‘ i' o. ‘0. 0 .o' a ‘ "‘1 0 Out-1' WW 1.
Precautions
The current study was designed to contribute knowledge to methodological issues

apparent in the research literature. Social desirability as a response bias is a serious

 

concern in this field of study due to a heavy reliance on self-report methodologies.
Therefore, a scale of social desirability was included in this study to assess method
variance - in this case the degree to which social desirability influences self-report
assessments of compliance with universal precautions and other variables thought to
predict compliance. Marlow-Crowne social desirability scale scores were computed. A
score of 1.00 represents low social desirability while a score of 2.00 represents high social
desirability. The social desirability scale had a normal distribution (skewness=-0.l3) and
the sample mean was M=l .60 (range=l .13 to 2.00, n=160) with a standard deviation
SD=0.29.

Pearson correlations between social desirability and the assessment of compliance
and the predictor variables reveal an overall lack of significance in these relationships
(See Table 13). There was a significant negative relationship between social desirability
and the scale for individual barriers to the use of precautions (r=-.20), that is higher levels

of social desirability were associated with lower levels of reported individual barriers

80

 

 

 

Table 13
“..-“: 0. '_-. u 3' "r 9 ia r-siraili . . O tcm . c ' d' 0, V 'ule
Social Desirability
Variables N Pearson’s r
Compliance with Universal Precautions - Last Time 151 .06
Procedure Performed
Compliance with Universal Precautions - Last 3 156 .20*
Months
Individual Barriers 155 -.20* '-
Environmental Barriers 156 .01 !
Barriers to the Use of Universal Precautions 156 -.08 E.
Knowledge of HIV Transmission 160 -. 13
Knowledge of Universal Precautions 160 -.04
Perceived Efficacy of Universal Precautions 159 .04
Subjective Norms for Compliance with Universal 159 .03
Precautions
Perceived Risk of Occupational Transmission of HIV 158 .14
Perceived Behavioral Control 159 -.00
Behavioral Intentions 148 .07
Perceived Self-Efficacy for Performing Medical 158 -.03

Procedures While Using Universal Precautions
‘p<.05

 

81

to the use of universal precautions. The relationship between social desirability and the
scale for environmental barriers to the use of precautions was not significant. There was
also a significant relationship between social desirability and the more general of the two
compliance measures assessing compliance during the last 3 months (r=.20); higher levels
of social desirability were associated with higher levels of reported compliance. While
this finding might suggest that this measure is more susceptible to response bias than the
procedure-specific assessment of compliance for the last time the procedure was
performed, overall levels of compliance on the 3 month measure were actually lower than
those reported for the last time a procedure was performed. While the correlation was
significant, social desirability accounts for only a relatively small portion of the variance
in this compliance measure. In general, social desirability does not appear to be a
significant threat to the validity of the self-report assessments of compliance and the
predictor variables in the current study.

This study was also interested in developing a measure that was specific to both
procedures and precautions in an effort to develop a more valid methodology for
assessing compliance than those used in previous research. Both types of measures were
included in the current study so that results could be compared to examine if these
different approaches yield different results. The measure of compliance during the last 3
months, similar to self-report measures used in previous research, asked respondents to
indicate their overall degree of compliance in using precautions during the last 3 months
and the scenarios presented in which compliance is assessed were not specific to
procedures. The other measure used to assess compliance asked respondents to indicate

which precautions they used during a specific medical procedure during the last time they

82
performed that procedure. This measure, therefore, was specific to both task and
precaution and also limited the period of recall to the last time that procedure was
performed. Results presented earlier illustrate the same general pattern of results
obtained from the two measures, with overall levels of self-reported compliance lower on
the more general measure of compliance during the last 3 months. A two-tailed Pearson
correlation reveals that the two measures are moderately correlated with each other
(r=.22, p<.05).

Aside from differences in significance levels, the pattern of correlations between
these two measures of compliance and the predictor variables (See Table 14) were similar
with two exceptions: 1) compliance the last time procedure was performed was
significantly negatively correlated with knowledge of universal precautions while the
correlation between compliance for the last 3 months and knowledge of universal
precautions was positive but nonsignificant; and 2) compliance for the last 3 months was
significantly positively correlated with perceived efficacy of universal precautions while
the correlation between compliance the last time the procedure was performed was
negative but nonsignificant. While the general findings between the two measures were
similar, the correlation between the two measures, although significant, was moderate.
This suggests that these two measures are to some degree measuring different constructs
and should be viewed not as interchangeable, rather as distinct approaches for the

assessment of compliance.

 

 

Table 14
"so.” or , H 3‘ “.1 out '.n ‘ -. r an ' d'c o_ V-Ju ‘
Compliance - Last Compliance - Last 3
Time Procedure Months
Variables Performed
N Pearson’s r N Pearson’s r
Individual Barriers 147 -.24"‘ 153 -.36*
Environmental Barriers 148 -. 16 154 -.10
Barriers to the Use of Universal 148 -.24* 153 -.24*
Precautions
Knowledge of HIV 151 .23* 156 .13
Transmission
Knowledge of Universal 151 -.20* 156 .10
Precautions
Perceived Efficacy of Universal 150 -.00 155 .23*
Precautions
Subjective Norms for 150 .10 156 .19*
Compliance with Universal
Precautions
Perceived Risk of Occupational 149 .13 155 .07
Transmission of HIV
Perceived Behavioral Control 150 .18" 155 .16“
Behavioral Intentions 148 .63“ 145 .10
Perceived Self-Efficacy for 151 .29 154 .18“
Performing Medical Procedures
When Utilizing Universal
Precautions

 

 

‘p<.05

84
WW

Health care workers reported levels of compliance with the guidelines for barrier
precautions and the handling and disposal of needles and sharps much higher than those
substantiated in previous research. Compliance with guidelines for the reporting and
follow up of exposures to blood and body fluids, however, was relatively low. While
compliance was high overall, substantial numbers of participants reported perceived
barriers to the use of universal precautions. The relative importance of these perceived
barriers varied for barrier precautions, needle/sharp precautions, and for the reporting and
follow-up of exposures. In addition to these reported barriers, many respondents
indicated that at a practical day-to-day level, they did not experience strong subjective
norms from their coworkers or supervisors for complying with universal precautions.
Despite perceived barriers and lack of subjective norms for complying with universal
precautions, the majority of respondents did report a high degree of perceived control
over whether or not they use precautions.

The emotional component identified in prior research is also evident in the current
study, with substantial numbers of respondents indicating that they perceive themselves
to be at real risk of becoming infected with HIV in the health care setting. Relatedly,
responses to items assessing knowledge of HIV transmission, knowledge of universal
precautions, and perceived efficacy of universal precautions indicate that many
participants believe that HIV can be transmitted through nonviable routes of transmission
and that universal precautions alone are insufficient to protect them against HIV

infection. In terms of methodology, social desirability does not appear to be a significant

85

threat to the validity of the assessment of the variables included in this study with the

exception of the general assessment measure of compliance.

iv aut'

Multivariate analyses were conducted to investigate the relationships between
compliance and the other variables. First presented in this section are the results of
multivariate analyses examining differences in variables by medical procedure, the
relationships between reported barriers and compliance with universal precautions, and
exploratory analyses examining differences in compliance along several dimensions.
Next, the intercorrelations among constructs in the path models are examined. Finally,

the results of structural equation analyses testing the models are presented.

W
This study was designed to investigate the degree to which characteristics of
procedures - dexterity involved in performing a procedure and the likelihood of exposure
to blood and body fluids when performing a procedure - impact compliance with
universal precautions. Department managers and other key nursing personnel were asked
to rate each of the procedures as high dexterity or low dexterity and as high likelihood of
exposure or low likelihood of exposure. Four separate compliance scores were generated
for each participant: 1) compliance for high dexterity procedures; 2) compliance for low
dexterity procedures; 3) compliance for high exposure procedures; and 4) compliance for
low exposure procedures. A within-subjects analysis of variance (AN OVA) was

cmIlputed to test for differences in these compliance scores. The original hypotheses

86

were designed to test for differences in compliance with glove use specifically along these

procedure dimensions, however, given the limited variance in glove use, compliance for

the purpose of testing the following hypotheses was expanded to include all components

(gloves and other barrier precautions, needles/sharps).

Hypothesis 1:

Hypothesis 2:

Hypothesis 3:

Compliance will be lower during procedures involving a high
degree of dexterity compared to other procedures. There were no
significant differences in compliance during high dexterity
procedures compared to low dexterity procedures.

Compliance with be higher during procedures in which there is a
greater likelihood for exposure to patients’ blood and body fluids
compared to procedures with a lower level of risk for exposure.
There were no significant differences in compliance during high
exposure procedures compared to low exposure procedures.

The likelihood of exposure to blood and body fluids will be a
stronger predictor than loss of dexterity in predicting compliance.
The selection of procedures in this study did not adequately
account for the demands of analyzing the potential interaction
effect of dexterity and exposure on compliance - that is too few
respondents engaged in procedures which could be classified as

both high in dexterity and low in exposure.

87

B ' ' ins eitrf liance

Although several previous studies have assessed perceived self-reported barriers
to the use of universal precautions, there has been little systematic investigation into the
barriers related to levels and patterns of compliance with universal precautions. As a
result, it is currently unknown to what extent these behaviors are influenced by
environmental-level barriers relative to individual-level barriers. Regression analyses
were conducted to examine whether environmental barriers scale scores (14 items,
alpha=.59, M=1.23, SD=.16, skewness=.41, range=l .00-2.00, n=156) or individual-level
barrier scale scores (10 items, alpha=.50, M=l.l l, SD=.12, skewness=l.14, range=l .00-
2.00, n=155) are a stronger predictor of compliance. Scale scores for individual barriers
were significantly negatively correlated with the measure of compliance for the last time
the procedure was performed (r=-.24, p<.05, n=147) and compliance for the last 3 months
(r=-.35, p<.05, n=153). Respondents reporting lower levels of individual barriers were
more likely to report higher levels of compliance with universal precautions. The
correlations between environmental barriers and the two compliance measures were not
significant. In hierarchical regression analyses, individual and environmental barrier
scores were entered into the regression analyses. Beta-values for individual level barriers
were significant for compliance the last time a procedure was performed (B=-.22, t=-2.64,
p<.05) and compliance for the last 3 months (B=—.35, t=-4.53, p<.05). Beta-values for
environmental level barriers were not significant for either measure of compliance.
Overall, perceived barriers accounted for 7% of the variance (E=5.3 8, df=2,144, p<.05)
for compliance scores for the last time procedure was performed and 13% of the variance

(E=11.22, df=2,150, p<.05) for compliance scores for the last 3 months.

88

Descriptive results presented earlier suggest differing levels of importance for
environmental versus individual barriers depending on the category of precaution, with
fewer respondents reporting individual barriers such as habit or carelessness as factors
that prevent or make difficult the use of precautions for the handling and disposal of
needles and sharps. Further analyses examining the relationship between perceived self-
reported barriers and compliance were conducted to explore these differences. Scales of
perceived individual-level barriers for barrier precautions (6 items, alpha=.25, M=l .14,
$12=.16, skewness=1.09, range=1.00-2.00, n=157), perceived environmental-level
barriers for barrier precautions (7 items, alpha=.55, M=1.27, SD=.20, skewness=.63,
range=1.00-2.00, n=157), perceived individual-level barriers for needle/sharp precautions
(4 items, alpha=.39, M=l .07, SD=.13, skewness=2.06, range 1.00-2.00, n=158), and
perceived environmental—level barriers for needle/sharp precautions (7 items, alpha=.40,
M=l.l9, SD=.19, skewness=.7l, range 1.00-2.00, n=158) were computed separately from
items assessing perceived barriers. Likewise, separate scales were computed for
compliance with barrier precautions during the last 3 months (7 items, alpha=.47,
M=3.98, SD=.55, skewness=-.08, range=1.00-5.00, n=151) and compliance with
needles/sharp precautions during the last 3 months (2 items, alpha=.22, M=4.69, SD=.55,
skewness=-l .65, range=3.00-5.00, n=154).

Again, scale scores for individual barriers for barrier precautions were negatively
correlated with compliance for barrier precautions (r=-.22, p<.01, n=150) and individual
barriers scale scores for needle/ sharp precautions were negatively correlated with
compliance for needle/sharp precautions (r=-.26, p<.001, n=153). Environmental scale

scores for barrier precautions were not significantly correlated with barrier

89

compliance scale scores, however environmental scale scores for needle/sharp
precautions were negatively correlated with needles/sharp compliance scores.

A hierarchical regression analysis predicting compliance with barrier precautions
reveals findings similar to those for overall compliance, with Beta-values for individual
barriers significant ([3=-.21, 1:251, p<.05) and both sets of perceived barriers accounting
for 5% of the variance (E=3.69, df=2,l47, p<.05) for barrier compliance scores for the
last 3 months. A hierarchical regression analysis predicting compliance with needle/sharp
precautions, however, revealed a different pattern of results. In this equation, Beta-values
for both individual (B=-.20, t=-2.68, p<.05) and environmental (B=—.37, t=-5.01, p<.05)
barriers for compliance with needles/sharp precautions were significant, with
environmental barriers the stronger predictor of the two. Both predictor variables
accounted for 21% of the variance in this equation (E=19.76, $2,150, p<.05)

In summary, while greater percentages or respondents report perceived
environmental barriers relative to individual barriers, it is actually individual barriers
overall that account for a greater degree of the variance in overall compliance scores.
Further analyses, however, reveal differences in this pattern of finding dependent upon
the category of compliance behaviors and corresponding precautions. While the above
pattern holds true for compliance with barrier precautions, environmental rather than
individual barriers emerge as the stronger factor when predicting compliance with
needle/sharp precautions and both sets of predictors accounted for a significant and

substantial degree of variance in these compliance scores.

90

x t lati n hi 3

Between-unit differences. Several exploratory analyses were conducted to
identify between-unit differences on the outcome and predictor variables. An AN OVA
was conducted to test whether respondents working in the 5 different units had different
levels of compliance using the mean item scale scores for compliance the last time the
procedure was performed, the 4 procedure categories, and compliance for the last 3
months. A statistically significant AN OVA revealed between group differences among
participants in the 5 different units on all the measures of compliance with universal
precautions (See Table 15). Generally, compliance scores were highest in the regular
nursery and women’s pavilion and lowest in the emergency department.

Between-unit differences were also examined for variables assessing knowledge,
motivation, and behavioral skills. Significant results from one-way AN OVAs are
presented in Table 16. There were significant between-group differences among
participants on the 5 units on perceived barriers to using universal precautions. Health
care workers in the regular nursery reported the lowest mean number of perceived barriers
- both individual and environmental. The highest means for perceived barriers were
reported by participants in labor and delivery and NICU. There were also significant
between-group differences on the measure of subjective norms for complying with
universal precautions. Respondents in the women’s pavilion reported the highest means
for perceived subjective norms while those in the NICU reported the lowest. Finally,
significant between-unit differences were also found on the measure of perceived risk of

HIV infection. Those in labor and delivery reported the highest means for perceived risk

 

91

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93

of HIV infection in the health care setting; respondents in the emergency department
reported the lowest.

In summary, several significant between unit-differences were identified although
no uniform pattern of results emerged for the 5 units across these measures. These
findings do suggest, however, that the dynamics of some of the dimensions that were
investigated in this study differ from unit to unit. Respondents in the regular nursery
appear to perform in an environment with fewer perceived baniers and correspondingly
have high rates of compliance. Likewise respondents in the women’s pavilion have
higher rates of compliance. Those in the emergency department, however, have lower
rates of compliance. Participants in the NICU have higher levels of perceived barriers
and lower levels of subjective norms while those in labor and delivery reported high
levels of perceived barriers and high levels of subjective norms. Those in labor and
delivery had the highest levels of perceived risk of HIV infection, while interestingly,
those in the emergency department had the lowest levels of perceived risk.

Remnedemsmes. Given the number of individuals reporting exposures to
blood and body fluids, this variable was subjected to further analysis. The relationship
between reported exposures and compliance scale scores was nonsignificant, as was the
relationship between needle recapping and reported exposures. Participants who
reported exposures were not significantly different from other respondents along the
dimensions of age, sex, or current position. Although not significant, there were
differences in the proportion of respondents reporting exposures in the different units.
Only 3.0% of respondents in the regular nursery reported exposures while 29.0% of

respondents in labor and delivery reported exposures. Percentages reporting exposures

94

ranged from l7.6%-20.8% in the remaining units. These results suggest that to some
degree, the risk of exposure to blood and body fluids through an accidental exposure is
spread across all types of respondents, with some differences in percentages of
respondents reporting exposure between units.

WW. An additional question explored is whether or not
health care workers who have recently graduated, and therefore were indoctrinated from
the start of their professional careers with universal precautions as the prevailing
guidelines for infection control, would be more compliant than veteran health care
workers who were expected to alter previous behaviors and adopt universal precautions
as a new set of guidelines mid-way through their professional careers. This hypothesis
was explored by exanrining the relationship between years worked and compliance scale
scores. Recency of training was calculated as the number of years since respondents’
highest-level degree was obtained. The correlations with recency of training and
compliance with universal precautions (both measures) were nonsignificant. In this
sample, those who recently had obtained degrees were no more likely to comply with
universal precautions than those who had been practicing their professions for a number

of years.

1.1] 'll-E lllll
The current study was designed to test the utility of framing universal precautions

as AIDS-preventive behaviors in understanding the factors that predict compliance, using

a modified version of the Inforrnation-Motivation-Behavioral Skills Model of AIDS Risk-

Behavior Change (Fisher & Fisher, 1993). Three different versions of the model were

95

tested using path analysis in LISREL VIII. The first model tested was the theoretical
model proposed by Fisher and Fisher (1993). Path analysis was used to examine the
relationships between the latent variables within the IMB model as applied to this study
to determine the overall utility of this theoretical framework in understanding the factors
that predict compliance.

The second and third models examined the relationships between the observed
variables within the theoretical model. The second version of the model assessed
motivation using the conceptual framework of the Theory of Reasoned Action as
originally proposed by Fisher and Fisher (1993). The third version of the model assessed
motivation using the conceptual framework of the Theory of Planned Behavior. These
models served to test the utility of framing motivation within these two theoretical
frameworks. These models were generated following the framework of the IMB model
with perceived risk of HIV infection added to the model as a motivational variable. These
models were tested at the level of observed rather than latent variables to allow for an
examination of the specific relationships between observed variables.

Descriptive statistics for each of the variables in the model are presented in Table
17. Following, are the intercorrelations among all the variables in the path models. The
results are then presented for the test of each of the three models.

WWW. Intercorrelations among each
of the constructs in the path model were examined to assess the relationships among the
different scales. Table 18 presents the uncorrected correlation matrix for all the
constructs. Correlations were corrected for attenuation, however, as discussed earlier

there were a number of scales for which no appropriate indices for reliability were

96

 

 

Table 17

'v tai ' utc m di rVaria le

N M1 Range SD Skewness

Compliance With Universal 151 1.87 1.00-2.00 .12 -.78
Precautions- Last Time
Procedure Performed
Compliance With Universal 156 4.15 1.00-5.00 .48 -.07
Precautions - Last 3 Months
Perceived Barriers 156 1.18 1.00-2.00 .11 .23
Knowledge oleV 160 1.76 1.00-2.00 .24 .-1.06
Transmission
Knowledge of Universal 160 1.42 1.00-2.00 .34 .27
Precautions
Perceived Efficacy of Universal 159 2.93 1.00-4.00 .45 -.05
Precautions
Subjective Norms for 159 2.96 1.00-4.00 .38 .15
Compliance with Universal
Precautions
Perceived Risk of Occupational 158 2.34 1.00-4.00 .49 .27
HIV Transmission
Perceived Behavioral Control 159 5.63 1.00-7.00 .94 -.80
Behavioral Intentions 148 3.86 1.00-4.00 .16 -l.37
Perceived Efficacy for 158 3.77 1.00-4.00 .31 -l.56
Performing Medical Procedures
While Using Universal
Precautions

 

’ Low scale scores represent low degrees of variable dimensions.

97

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98

available and could therefore not be corrected for attenuation. The path analyses were
conducted in LISREL VIII using both the corrected and uncorrected correlations. These
analyses yielded similar results. Given these findings and the inability to correct the
entire correlation matrix, all final path analyses were conducted using the uncorrected
correlation matrix. Compliance the last time a procedure was the behavioral measure
chosen to examine the intercorrelations and test the path model. One-tailed tests of
significance were applied to all correlations in which the direction of the relationship was
predicted, while two-tailed tests of significance were applied to all other correlations in
which the nature of the relationship was exploratory.

Generally, the relationships between the two knowledge measures and the other
constructs were not consistent with the predicted relationships. Neither knowledge of
HIV transmission or knowledge of universal precaution guidelines were associated with
perceived efficacy for performing procedures when using universal precautions as
hypothesized. The prediction between knowledge of HIV transmission and compliance
with universal precautions was supported (r=.21), however, knowledge of universal
precaution guidelines was negatively correlated with compliance with specified
procedures (r=-.18), opposite to the predicted relationship. An examination of the
intercorrelation between the two knowledge measures reveals a negative correlation (r=-
.20). Knowledge of HIV transmission was significantly correlated with perceived risk of
HIV transmission (r=.27), however, those who had lower levels of knowledge of
universal precaution guidelines had higher levels of perceived risk (r=-.25). Finally,

those with lower levels of knowledge of universal precaution guidelines had lower levels

99

of perceived efficacy of universal precautions (r=.23) and higher levels of behavioral
intentions for compliance (r=-.17).

As hypothesized, perceived risk of occupational transmission was associated with
perceived efficacy of universal precautions (r=-.32) and subjective norms for compliance
with universal precautions (r=-.22). Many of the other predicted relationships between
the motivational constructs, however, were not supported. The relationship between
perceived risk and behavioral intentions was not supported and neither perceived risk,
perceived efficacy, or subjective nouns were significantly correlated with behavioral
intentions as predicted. Behavioral intentions was significantly correlated with
compliance with universal precautions (r=.62).

The intercorrelations between perceived behavioral control and behavioral
intentions and compliance with universal precautions were examined as part of the
model. Those who perceived a low degree of control over compliance behaviors reported
lower levels of behavioral intentions to comply with universal precautions (r=.32).
Likewise, those with lower perceived control were less likely to actually comply with
universal precautions (r=.21). Although not predicted in the model, perceived behavioral
control was significantly correlated with several other constructs in the model.
Respondents with low levels of perceived behavioral control reported lower levels of
perceived self-efficacy of universal precautions (r=.26), subjective norms for complying
with universal precautions (F32) and perceived efficacy for performing procedures when
utilizing universal precautions (r=.43).

There were additional unpredicted relationships identified. Health care workers

with lower levels of perceived efficacy reported lower levels of perceived efficacy for

100

performing procedures when utilizing universal precautions (r=.24). Likewise,
respondents with lower levels of subjective norms for complying with universal
precautions reported lower levels of perceived efficacy for performing procedures when
utilizing universal precautions (r=.l9). Health care workers reporting lower levels of
behavioral intentions for complying with universal precautions reported lower levels of
perceived efficacy for performing procedures when utilizing universal precautions
(r=.35).

Behavioral skills were operationalized as perceived efficacy for performing
procedures when utilizing universal precautions. As predicted in the model, behavioral
skills were significantly associated with compliance last time procedure was performed
(r=.29).

Although not included in the model, the relationships between perceived barriers
to the use of universal precautions and the constructs in the model were explored. There
were significant negative correlations between perceived barriers and many of the major
variables (n=141). High levels of perceived barriers were associated with low levels of
compliance with universal precautions (r=-.23), perceived efficacy of universal
precautions (r=-.26), subjective norms for complying with universal precautions (r=.21),
perceived behavioral control (r=- .44), behavioral intentions for complying with universal
precautions (r=-.28), and perceived efficacy for performing procedures when utilizing
universal precautions (r=-.41).

W. As discussed earlier, the original IMB Model was
modified for the current study to predict that behavioral skills would have a moderating

effect on the relationship between intentions and compliance. This relationship between

lOl

intentions and compliance was examined prior to testing the models. Multiple regression
was used to test for this moderating relationship. The main effects including behavioral
intentions and behavioral skills were entered at Step One and the product terms were
entered at Step Two. The product terms did not contribute significantly to the prediction
of compliance with universal precautions - that is behavioral skills did not moderate the
relationship between behavioral intentions and compliance with universal precautions.
Therefore, this moderating relationship was removed before testing the path model.

WWW. This path analysis tested the relationship
between the theoretical or latent variables in order to determine the fit of the data to the
relationships between the latent variables of knowledge, motivation, behavioral skills,
and behavior. The latent construct of motivation was measured by the observed variables
of perceived efficacy of universal precautions, subjective norms for complying with
universal precautions, and behavioral intentions for complying with universal
precautions. The latent construct of knowledge was assessed by the observed variables of
knowledge of HIV transmission and knowledge of universal precaution guidelines. The
latent construct of behavioral skills was assessed by the observed variable of perceived
efficacy for performing procedures while using universal precautions and the latent
construct of behavior was measured by the observed variable of the compliance with
universal precautions.

The initial LISREL solution for the model was found non-admissible after 20
iterations, however, further analysis of the model failed to achieve an admissible solution

after 60 iterations. Therefore, results from the preliminary model are provided. The

102

results of this analysis are presented in Figure 5. The results of the predicted hypothesis

were as follows:

Hypothesis 4:

Hypothesis 5:

Hypothesis 6:

Hypothesis 7:

Results did not support the predicted indirect effect of information
on behavior, as mediated through behavioral skills. Counter to
what was predicted, information had a direct, positive relationship
to behavior (r=.40; 1:2.66). Higher levels of HIV -related
knowledge were correlated with higher levels of compliance with
universal precautions.

Results failed to provide support for the predicted relationship
between motivation and behavior.

Results of this path analysis did support the predicted relationship
between behavioral skills and behavior (r=.30; 1:3.76). Higher
levels of perceived efficacy for performing procedures while using
universal precautions were predicted higher levels of compliance
with universal precautions.

Results did not support the prediction that information and
motivation would be statistically independent factors, and therefore
not be highly correlated (r=-.42; 1=-3.59). The correlation between
information and motivation was significant, and negative; those

with higher levels of information had lower levels of motivation.

The Chi-Square for goodness of fit with 8 degrees if freedom was equal to 86.89

(p<.05), suggesting poor model fit. The Goodness of Fit Index (GFI) was equal to .88,

while the Adjusted Goodness of Fit Index (AGFI) was equal to .57. Both of the GFI and

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104

AGFI values were less than the traditionally accepted cutoff. (GF I and AGFI values
should be at least .90 to conclude that there is good model fit.). The standardized Root
Mean Square Residual (RMR) was .15, which was slightly above the traditionally
accepted cutoff of .10 for this index. The Normed Fit Index (NFI) was .36, which again
is below the traditionally accepted cutoff of .90 for this index. Taken together, these
indices, along with the lack of support for many of the predicted relationships in the
model in terms of sign and statistical significance, indicate a significant discrepancy
between the observed and reproduced correlation matrices, suggesting poor model fit.
WWW. Results from the path analysis

(standardized path coefficients and 1 values) of this model are presented in Figure 6. The

results of the predicted hypothesis were as follows:

Hypothesis 8: Consistent with earlier results, the results for this path analysis did
not support the predicted indirect relationships between the
knowledge measures and compliance with universal precautions, as
mediated by perceived efficacy for performing procedures while
using universal precautions. Results supported a direct relationship
between knowledge of HIV transmission and compliance with
universal precautions (standardized path coefficient=.l3; t=1.91)
but not with knowledge of universal precaution guidelines.

Hypothesis 9: - Subjective norms for complying with universal precautions was
positively correlated with behavioral intentions for complying with
universal precautions (standardized path coefficient=.16; t=1.87),

however perceived efficacy for universal precautions was not.

105

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Hypothesis 1 1:

106

Perceived risk of occupational HIV infection was not correlated
with behavioral intentions, but was negatively correlated with
perceived efficacy of universal precautions (standardized path
coefficient=-.32; t=-4.01) and subjective norms for complying
universal precautions (standardized path coefficient-£22; t=-2.61).
Those with lower levels of perceived risk reported higher levels of
perceived efficacy of universal precautions and higher levels of
subjective norms for complying with universal precautions.
Results supported the predicted relationship between behavioral
intentions and compliance with universal precautions. Those with
higher levels of behavioral intentions for complying with universal
precautions reported higher levels of compliance with universal
precautions (standardized path coefficient=.56; 1=8.7l).

The results did not support the predicted relationship between
perceived efficacy for performing procedures while using universal

precautions and compliance with universal precautions.

Test of goodness of fit suggest poor model fit. The Chi-Square for goodness of fit

with 14 degrees if freedom was equal to 46.80 (p<.05), suggesting poor model fit. The

Goodness of Fit Index (GFI) was equal to .93, while the Adjusted Goodness of Fit Index

(AGFI) was equal to .82. The GFI value suggests good model fit, while the AGFI value

is less than the traditionally accepted cutoff. The standardized Root Mean Square

Residual (RMR) was .10, which is right at the traditionally accepted cutoff of .10 for this

index.

107

The Normed Fit Index (N F1) was .73, which again is below the traditionally accepted

cutoff of .90 for this index.

Bath analysis with the Ihegry Qt Blamed Behavigr. Results from the path
analysis of this model are presented in Figure 7. The results from the path model are
consistent with those presented for Figure 6 with a few exceptions: 1) the relationship
between perceived efficacy of universal precautions and behavioral intentions was
significant, with lower levels of perceived efficacy predictive of higher levels of
behavioral intentions (standardized path coefiicient=-.15;1=-1.76); 2) the predictive
relationship between subjective norms for complying with universal precautions and
behavioral intentions for complying with universal precautions was not significant in this
model; and 3) the predictive relationship between perceived efficacy for performing
procedures while using universal precautions and compliance with universal precautions
was significant (standardized path coefficient=.l 1; 1=1.71), with those reporting higher
behavioral skills for using precautions reporting higher levels of compliance.

The relationship between perceived behavioral control and compliance was
examined in this model. The following results were found:

Hypothesis 12: The model supported a significant, positive relationship between
perceived behavioral control and behavioral intentions for
complying with universal precautions (standardized path
coefficient-=34; 1=4.27), but did support a direct effect of perceived
behavioral control on compliance with universal precautions.

Again, test of goodness of fit suggest overall poor model fit. The Chi-Square for

goodness of fit with 17 degrees if freedom was equal to 80.33 (p<.05), suggesting poor

108

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109

model fit. The Goodness of Fit Index (GFI) was equal to .88, while the Adjusted
Goodness of Fit Index (AGFI) was equal to .70, both less than the traditionally accepted
cutoff. The standardized Root Mean Square Residual (RMR) was .13, which is above
the traditionally accepted cutoff of .10 for this index. The Normed Fit Index (N F1) was
.64, which again is below the traditionally accepted cutoff of .90 for this index.

Summinathfindjngs. Results of analyses testing the various path models
provide relatively little support for the proposed models for predicting compliance.
Results also did not provide support for either of the observed models tested (Theory of
Reasoned Action and Theory of Planned Behavior), as both models failed to achieve good
model fit. There was a significant difference in fit between these two models, confirmed
statistically by assessing the difference of the chi-square measures of fit for each model,
which was x2(3)=33.53, p<.05. The model conceptualizing motivation within the
framework of the Theory of Reasoned Action was better able to reproduce the elements
of the correlation matrix than the model in which motivation was framed using the
Theory of Planned Behavior.

In the current study, levels of behavioral skills did not moderate the effects of
either knowledge and motivation. Overall, knowledge did have a direct effect on
behavior, however, knowledge appears to be a multi-dimensional construct, with the two
knowledge measures in this study operating differently in the model. Likewise
motivation appears to have complex dimensions which were not accurately captured in
the models tested and the relationship between motivation and compliance is not clear in
the current findings. Finally, knowledge and motivation appear to be complexly

interrelated, rather than independent factors in predicting compliance.

Chapter 4

DISCUSSION

W211

This study was undertaken to investigate current levels of compliance with
universal precautions among health care workers and examine the specific factors thought
to influence levels of behavioral compliance with these infection-control guidelines. The
results of this study - in particular the findings related to levels of compliance use,
knowledge, and motivation - provide important findings that have relevance for future
research, intervention, and policy. In framing compliance with universal precautions as
preventative, health behaviors, this study attempted to build a connection between theory
and behavior. Although the findings from the tests of predictive models were
inconclusive and therefore conclusions are limited, these findings provide some insight
and direction for continuing research which examines these behaviors within a theoretical
framework.

The results of the study are examined and discussed in this section. A summary
and discussion of the major descriptive and multivariate findings are presented first. A
discussion of results related to the investigation of methodological issues is presented
next, followed by the results of analyses testing theoretical models for predicting

compliance with universal precautions. The methodological limitations of the research

110

111

are then presented. This section concludes with a discussion of the current study’s

implications for future research. intervention, and policy.

m li c wi 'v

Nearly a decade following the introduction of universal precautions (CDC, 1987)
and 5 years following OSHA’s final-ruling on bloodbome pathogens (Department of
Labor, 1991), this study establishes high overall rates of compliance with these infection
control guidelines among a sample of health care workers. Results reveal nearly
unanimous levels of compliance with guidelines for handwashing and glove use. Results
suggest, however, that health care workers are exercising some discretion in the use of
gloves during particular procedures, such as IM medications and other IV/puncture
procedures, feedings, and suctioning. It may be that health care workers perceive less of a
risk for HIV infection during these procedures and as a result fail to use required
precautions. Lack of compliance may also be a carryover from earlier universal
precaution guidelines in which some level of discretion in the use of gloves was allowed
during select procedures such as phlebotomy. Future research will be necessary to
examine the level of discretion that occurs in the use of gloves during these procedures
and to identify the reasons why variance in levels of glove use occurs. While these
procedures may indeed present little risk for HIV transmission in the health care setting,
addressing these gaps may be critical in ensuring high levels of compliance across all
medical interventions.

Although overall rates of compliance were high, this study did document

relatively lower rates of compliance centering around the use of barrier precautions other

112

than the use of gloves. Similar to previous studies ( Baraff & Talan, 1989; Hammond et
al., 1990; Kelen et al., 1989), breaks in compliance were generally the result of failure to
use barriers precautions such as gowns, masks, eyewear and footwear, with compliance
falling below 50% in the current study during procedures in which these additional
barriers were required. The current findings, therefore, reinforce the need to target
improvements in the use of barrier precautions beyond the use of gloves. While the
number of situations which demand additional levels of protection may be relatively
smaller than those requiring gloves only, these medical situations pose a greater risk for
transmission of HIV and heighten the need for compliance.

Compliance with guidelines that prohibit the recapping of needles after use on a
patient were high, with over 90% of respondents reporting that they had not recapped
needles at the procedural level and over 70% reporting that they had “almost never”
recapped needles in the 3 month period prior to completing the survey. These results can
be compared directly to those of an earlier study which found only 33% of Michigan
nurses complying with this guideline (Schillo & Reischl, 1993). The current self-reported
rates of compliance are also higher than others previously reported in the literature
(Gruber et al., 1989; Smyser, et al., 1990; Willy et al., 1990). Clearly, health care
workers have become knowledgeable of the proper guidelines for the handling of
needles/sharps in the period since these earlier studies and in the current sample have
altered their behavior accordingly. This remains, however, an important area to target for
further intervention. Given the prevalence of needlestick injuries in the workplace and
the risk these injuries represent for transmission of HIV and other bloodbome pathogens,

even these relatively low rates of recapping remain an unacceptable and unnecessary risk.

113

While compliance with guidelines for barrier precautions and the handling of
needles/sharps was high, health care workers in this study were much less likely to
comply with the guidelines for reporting exposure incidents. Only 9 of the 28 (32.1%)
health care workers who had experienced an accidental needlestick or unprotected body
fluid contact from a patient in the 3 month period prior to completing the survey reported
this exposure to occupational health services for risk assessment and follow-up. This
finding is consistent with the few other studies documenting compliance with exposures,
in which only 30% of needlesticks (Mangione et al., 1991) and 10% of all exposure
events were reported (Williams, Campbell, Henry, & Collier, 1994). The low rates of
compliance for reporting exposures is a critical area of concern, as responding adequately
to a situation in which there is a possibility of transmission of HIV requires adequate
documentation, and if warranted, testing, the prescription of AZT, and appropriate
counseling and follow-up.

Additional research is needed to understand why substantial proportions of health
care workers (in this study over 15%) experienced an accidental needlestick or exposure
to blood and body fluids, given the overall high rates of compliance with universal
precaution guidelines. In the current study, risk of exposure to blood and body fluids
through an accidental exposure was spread across all types of respondents, making this a
salient point of further investigation among all health care workers. Understanding the
etiology of these exposures will be necessary in determining what changes in behavior,
engineering controls, and policy are needed to reduce the number of exposures which put

health care workers at risk for occupational infection.

114

Attention then must turn to addressing the barriers for reporting these exposures
when they do occur. This study identified lack of time as the most frequently reported
perceived barrier to reporting exposures to occupational health services. One respondent
indicated that “it happens so often - it would become absolutely time consuming to
report”. Health care workers also perceive the process as being too complicated,
invasive, or unnecessary. These barriers are similar to those identified by Mangione et al.
(I 991), which included time constraints, perception that the percutaneous injury did not
represent a significant exposure, lack of knowledge about the reporting mechanism, and
concern about confidentiality and professional discrimination. Based on these results, it
appears that health care facilities would increase rates of reporting of exposures by
developing programs that are easy to access and strictly confidential. Additional efforts
at educating staff about the importance of reporting these exposures is also warranted.

0 -‘ -. :._,..-.. . .- -. :._,..- ... yu- ...“... ' - ._ , '..,

By systematically investigating perceived barriers to the use of universal
precautions, this study provides critical understanding into the reasons why some health
care workers are not complying with universal precautions during particular procedures.
Beyond barriers for reporting exposures, relatively high numbers of health care workers
reported perceived barriers for compliance with both barrier precautions and precautions
for needles/sharps. Results of this study confirm differences in the relative importance of
perceived barriers for different types of precautions. In this study, health care workers
perceive that lack of time, interference with technical skills, and carelessness prevent or

make it more difficult for them to comply with guidelines for barrier precautions. The

115

most frequently reported barriers for complying with guidelines for the handling and
disposal of needles/sharps, however, include inconvenient disposal, recapping for safe
storage, and recapping to transport. These findings demonstrate that health care workers
perceive competing interests for safety when handling needles/sharps. Health care
workers may perceive the need to protect themselves, their patients, or others based on
the design of their immediate environment or the nature of the patient care procedure.
Based on these perceptions, health care workers may decide that recapping poses less of a
danger than the alternative.

In addition to identifying the frequency of perceived barriers, the current study
also examined the relative importance of these barriers in predicting compliance. Results
demonstrate that while greater percentages of respondents report perceived environmental
barriers relative to individual barriers, it is actually individual barriers overall that account
for a greater degree of the variance in overall compliance scores. Further analyses,
however, reveal differences in this pattern of findings dependent upon the category of
compliance behaviors and corresponding precautions. While the above pattern holds true
for compliance with barrier precautions, environmental rather than individual barriers
emerge as the stronger factor when predicting compliance with needle/sharp precautions.

These results related to perceived baniers for guidelines for barrier precautions
and for needles/sharp precautions point to the need for multifaceted solutions. Results of
this study suggest that strategies for addressing perceived barriers to compliance with
barrier precautions should target individual-level barriers, in particular habit and
carelessness. This need is expressed in the words of one respondent who wrote,

“Twenty-five years of recapping is a hard habit to break.” Over 12% of respondents in

116

the current study indicated that a patient not appearing to be at risk for HIV was a barrier
to using barrier precautions. This finding highlights the need to address the erroneous
assumption on the part of some health care workers that they can tell by appearances
whether or not a patient is at risk for HIV, and use this as a basis for their decision to use
or not use precautions. Further investigation is needed to identify the source of this
misconception. Whether it be stereotyping of persons with HIV or gaps in knowledge,
this misconception is diametrically opposed to the concept of universal precautions and
must be addressed as part of continuing efforts to ensure compliance with these
guidelines. Research has clearly established that the majority of HIV-infected patients are
unknown to health care workers at the time precautions are needed (Marcus et al., 1990),
and that attempts to base the use of precautions on the basis of an assumption regarding a
patient’s HIV status, place health care workers in danger.

While addressing individual-level barriers appears key to increasing compliance
with barrier precautions, environmental-level barriers should not be overlooked. In
regards to barrier precautions specifically, health care facilities need to examine strategies
for making barrier precautions accessible, thereby reducing to the lowest level possible
the amount of time needed to comply with barrier precautions. Simultaneously, facilities
need to communicate to health care workers that the time spent putting on barrier
precautions will be viewed as a necessary and valued part of any medical procedure,
rather than as a detraction or obstacle to initiating a procedure. This message becomes
particularity relevant in emergency situations in which time is a critical factor in regards
to patient outcomes. Even in these situations, health care workers should not be forced

into situations in which they must sacrifice their own safety for that of their patients.

117

Framing the issue in terms of cost-benefit, with a few extra minutes to apply apprOpriate
precautions as the trade-off against the time and anxiety involved when an exposure
occurs, may assist in reducing the perception of time as a barrier to compliance.

Other strategies to address perceived barriers to barrier precautions include the
development of gloves and other materials that increase the level of tactile sensation and
reduce the degree to which barrier equipment interferes with technical skills. The
development of such materials may also be instrumental in increasing compliance with
gloves during IV/puncture procedures. In addition, the quality of materials - in particular
gloves - must be improved. In the current study, many of the respondents provided
written comments regarding the poor quality of gloves, indicating that they are prone to
frequent ripping and tearing.

Current findings suggest that the best use of resources for addressing perceived
barriers to compliance with guidelines for the handling of needles/sharps are those
methods which would reduce environmental barriers. This includes the development of
new technologies and re-engineering of the environment that would serve to decrease
overall use and exposure to needles/sharps in the health care setting as well as eliminating
competing safety interests. It is important to note, however, that these technologies still
require some degree of human compliance to operate, thereby maintaining a need to
examine the behavioral elements involved in compliance with universal precautions.

These findings represent the first inodepth, systematic investigation of the
relationships and contribution of perceived barriers to universal precautions. Consistent
With previous findings (Williams et al., 1994), the current study found that health care

workers who report more perceived obstacles are less likely to comply with guidelines.

118

In this study, respondents who indicated high levels of perceived barriers also reported
lower levels of perceived efficacy of universal precautions, subjective norms for
complying with universal precautions, perceived behavioral control, behavioral intentions
for complying with universal precautions, and perceived efficacy for performing
procedures when utilizing universal precautions. These findings suggest that addressing

these perceived baniers is key in closing the remaining gaps in compliance.

1; l l 1 l I 'v .

Although the assessment of knowledge and motivational constructs was included
in this study primarily for use in testing the predictive models, responses at the item-level
yielded important information for understanding the impact of HIV on health care
workers. Findings from the current study are fairly consistent with earlier results
presented by Schillo & Reischl (1993) which demonstrate that health care workers are
knowledgeable of the major routes of HIV transmission in health care setting, but greatly
overestimate the risk of becoming infected from nonviable transmission routes.
Comparisons to previous research, in fact, suggest that levels of knowledge on nonviable
routes have actually decreased. Schillo & Reischl (1993) report 56% of nurses indicating
a risk present when feeding a patient compared to 61% in the current study; 44% of
nurses indicating a risk present when changing sheets on a patient’s bed compared to 78%
in the current study; and 80% of nurses indicating a risk present from being coughed or
sneezed on by a patient compared to 89% in the current study.

Results from the assessment of knowledge of universal precaution guidelines also

Suggest that while the majority of respondents understand the fundamentals of universal

119

precautions, there is a sizable percentage of respondents who believe that additional
precautions are necessary to prevent HIV infection in health care settings. This sentiment
is also reflected in responses to items assessing perceived efficacy, with the majority of
respondents generally agreeing that precautions are effective in preventing HIV
transmission, but a sizable minority expressing a desire for alternative or additional
precautions. Thus, while participants are knowledgeable of the guidelines for universal
precautions and confirm that universal precautions are effective in preventing
transmission of HIV, results of the current study suggest that some respondents also
believe that knowledge of patient’s HIV status and action based on this knowledge (i.e.,
use of disease-specific isolation procedures, placing HIV-positive patients in single
rooms) would be more effective than the use of universal precautions.

The current study provides key insights into several other motivational constructs.
Nearly 4 out of 10 respondents in the current study indicated that they perceive their
patients to present a risk to them for HIV infection, that they worry about becoming
infected in the health care setting, and think it is likely that they may actually become
infected. This level of perceived risk is actually higher than previously documented
levels of perceived risk (Schillo & Reischl, 1993; van Servellen, Lewis, & Leake, 1988).
In a national survey conducted in the early 1990's, 21% of physicians and 36% of nurses
reported a high or moderate risk of health care workers being infected with HIV as a
result of caring for patient who are HIV positive (Colombotos et al., 1995). On a rational
level, it could be argued that levels of perceived risk should be decreasing over time, as
the issues related to HIV in the health care setting become incorporated into normal

routines and increasing nmnbers of health care workers have direct experience in dealing

120

with these issues. Findings from the current study suggest the opposite - that many health
care workers are operating in a climate of fear that has escalated over time.

The current study also assessed motivational constructs related to the environment
- subjective norms and perceived behavioral control for complying with universal
precautions. Study findings reveal that at the policy level, most respondents perceive
norms for compliance among administrative and supervisory staff. In day-to-day
practice, however, participants perceive less support for complying with universal
precautions. Health care workers in the current study, however, did report high levels of
perceived behavioral control over whether or not they use precautions. These findings
suggest that even though health care workers perceive gaps in subjective norms for
compliance and report perceived barriers, they do perceive that they have control over

whether or not they use precautions.

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In summary, the current study establishes high levels of compliance in a sample of
health care workers in an area of relatively low prevalence of AIDS and by identifying
perceived barriers provides insight into why a minority of health care workers are not
complying or why compliance is lower during some specific procedures. This
investigation also reveals a need to address the underreporting of exposures, the level of
fear surrounding HIV transmission, and the expressed desire for additional precautions. It
should also be noted that the current study identified significant differences in several
variables among the 5 different units. Differences were identified on the measures of

compliance, perceived barriers, subjective norms, and perceived risk, however, no

121
consistent pattern or ready explanation of these results emerges. These results suggest
that the dynamics that impact motivation and behavior differ in each of the unit
environments and point to the need for further investigation to identify these factors and

examine the mechanisms by which these factors differentially impact behavior.

12' . Elllll'll

The current study was designed to address several gaps in the methodology of
assessing and predicting compliance with universal precautions. The potential threat of
social desirability to the validity of self-report findings was addressed in this research
study. Findings reveal that overall, social desirability does not pose a significant threat to
the validity of self-report assessments of compliance with universal precautions and other
variables thought to predict compliance. Results do reveal, however, that the general
measure assessing compliance with universal precautions during the previous 3 months
may be somewhat susceptible to social desirability, as the correlation between these 2
measures was statistically significant.

This research study included 2 measures of compliance with universal
precautions, allowing for a comparison in measurement approaches. Both approaches
yielded similar patterns of findings, however, the 2 measures were only moderately
correlated, and therefore should be viewed as distinct rather than interchangeable
measures. The results of this study however do not provide clear evidence for supporting
one measurement approach over the other. The procedural measure was not correlated
with social desirability while the general measure was, however, this finding is difficult to

interpret given that reported rates of compliance were actually lower on the general

122
measure, not higher as would be expected if respondents were providing socially
desirable responses. At a broader level, the procedural measure proved advantageous in
providing information about compliance during a defined situation - in this study a
specified medical procedure. The importance of identifying compliance at the
procedural level is underscored by the differences in the current study in compliance for
the different categories of procedures. The results of this study point to several
improvements to this approach, however, that must be made before further used to assess
compliance. These improvements include generating a greater number of procedures to
provide a picture of compliance across a wider range of behavior. The addition of
procedures must account, however, for the need to match different versions of the
measure for different types of units or professionals by selecting similar categories of
procedures that require similar types of precautions.

Due to limitations of the procedural measure of compliance, the degree of
overutilization among health care workers was not resolved in the current study. It
should also be noted that the high levels of compliance documented in this study may be
partly a function of assessing compliance during routine conditions. This measure,
therefore, would also be improved by assessing the specific conditions surrounding
procedures to determine if the procedure calls for the routine use of procedures or if there
are additional circumstances that warrant the use of additional precautions. The need for
this improvement was reinforced by the frequency of comments written in on the survey
instrument to qualify specific conditions surrounding procedures and explain a particular
respondent’s use or non use of precautions. Assessing the conditions surrounding the

performance of a procedure would allow for a determination of overutilization of

123

precaution use and a more valid assessment of compliance with guidelines for universal
precautions.

To summarize, this examination of methodological issues provides findings which
can be used to advance the methodology of this research. The findings of this study
validate the use of self-report to assess compliance and other HIV-related constructs,
having ruled out social desirability as a significant sources of response bias. Despite
current limitations and needed improvements, development of the procedural-level

measure used in this study is an important step forward in the assessment of compliance.

' cus i i 'v

The current study was designed to examine compliance with universal precautions
as AIDS-preventive behaviors and examine the predictive relationships between
knowledge, motivation, behavioral skills, and behaviors, using a modified version of the
Information-Motivation-Behavioral-Skills Models of AIDS Risk Behavior Change
(Fisher & Fisher, 1993). As discussed earlier, the results of the analyses testing the
predictive models were relatively inconclusive, due in part to problems with some of the
measures. Therefore, the discussion of these results centers on the insights provided by
these findings for future research, rather than as conclusive findings.

Results of the analysis of the relationships between the latent variables in the
predictive model reveal that knowledge does have some impact on behavior, although the
results support a direct effect between the two, not the predicted indirect effect of
knowledge on behavior as mediated through behavioral skills. Results also failed to

support the predicted relationship between motivation and behavior as well as the

124

predicted relationship between behavioral skills and behavior. Counter to predictions,
information and motivation were strongly correlated with each other in the model (r=-.42)
with a negative, rather than expected positive relationship between these two variables.
An examination of results from the analyses of the observed models provides
some insight into the above relationships between the latent variables. In these observed
models, higher levels of knowledge of HIV transmission predict compliance while
knowledge of universal precautions has no relationship with compliance. The zero-order
correlation between the two knowledge measures was negative - those with higher levels
of knowledge of HIV transmission had lower levels of knowledge of universal
precautions. This pattern of findings suggest that the items that were intended to measure
knowledge of universal precaution guidelines were likely assessing a different construct.
Given the lack of variance on many of the items used to assess knowledge of universal
precaution guidelines, only those items with sufficient variance were used to construct
this scale. This resulted in a subset of items related primarily to the perceived need for
additional or alternative precautions to those called for in universal guidelines. While
indicating the need for unnecessary precuations could be argued to represent lack of
knowledge of universal precautions, it most likely has more to do with perceived risk of
HIV infection or other related attitudes. In this study, those with lower levels of
knowledge of universal precautions reported higher levels of perceived risk and lower
levels of perceived efficacy of universal precautions. These findings suggest that
respondents who perceive themselves to be at risk of contracting HIV in the health care
setting perceive that universal precautions alone are insufficient to protect them against

infection and that additional measures should be taken to ensure protection. These

125
observed relationships between this knowledge measure and motivational constructs may
assist in explaining the negative relationship between the latent variables of knowledge
and motivation.

An examination of the observed relationships among the motivational variables
provides insight into the lack of a significant relationship between the latent variables of
motivation and behavior. In this study, subjective norms is predictive of behavioral
intentions, however perceived efficacy of universal precautions and perceived risk of HIV
infection is not. Thus, while behavioral intentions clearly predict compliance with
universal precautions, the motivational constructs included in this study, were not
particularly useful in predicting behavioral intentions.

Results of the analyses of the observed models provide some support for the use
of the Theory of Reasoned Action for framing motivation over the use of the Theory of
Planned Behavior, although neither of the two models tested provide a good fit to the
data. Results of the model using the Theory of Planned Behavior to frame motivation
identify a strong relationship between perceived behavioral control and compliance as
mediated through behavioral intentions. The model, however, does not support a direct
relationship between perceived behavioral control and compliance and the addition of
perceived behavioral control does not improve the model’s predictive power.

In conclusion, the current study provides little support for the predictive models,
failing to support many of the models’ central propositions. However, given the
limitations of many of the measures included in these models, it seems likely that the
failure to confrrm many of the predicted results were due to measurement error. Marginal

reliabilities, lack of variance, and skewness associated with some the variables in the

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126

model, in particular with the outcome variable of compliance, underscore the need for
caution in drawing definitive conclusions for the modeling results. Given these
limitations, it is premature to dismiss the proposed models entirely.

If future research efforts that address measurement limitations still fail to provide
support for the predictive models included in this investigation, current findings do offer
insight for revising these models. The relationships identified in this study suggest that
knowledge of HIV transmission and behavioral skills (as measured by perceived efficacy
for performing procedures while using universal precautions) predict intentions which in
turn predict compliance. Findings also suggest that knowledge and skills also directly
influence behavior. Finally, given the role of barriers in impacting compliance, any
revised model should include an examination of the impact of barriers on the relationship
between intentions and barriers - that is once an individual has formed the intention to
comply (based on knowledge and skills), do barriers then serve to moderate the
relationship with actual behavior?

While the results of the current study do not rule out of the usefulness of the tested
models, further investigation should also look at the use of alternative theoretical
approaches in attempting to identify useful models for predicting compliance. The
relationships identified in this study appear to fit within the theoretical context of another
cognitive decision-making model - the Health Belief Model (Janz & Becker, 1984). In
this study, health care workers who perceive themselves as susceptible to occupationally-
acquired HIV infection and perceive few costs or barriers to the use of precautions were
more likely to use precautions, findings consistent with the Health Belief Model. The

role of perceived efficacy and perceived seriousness of the threat, the other two major

 

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127

constructs in this model would need to be accounted for in investigations within this
theoretical context.

It may be, however, that rational decision-making models are less appropriate for
predicting well-learned skills such as those involved in using universal precautions.
Given the current high levels of perceived risk for HIV infection, theories of fear arousal
may be more useful in predicting compliance. Research in the area of risk perception has
documented that people perceive a greater danger from a risk, such as HIV, that is both
unknown and dreaded (Slovic, 1987). Thus, cognitive distortion of risk probabilities may
explain why interventions that attempt to persuade health care workers that their risk is

low on the basis of epidemiological data have failed (Gerbert, 1988).

“11].”...

Several innovative methods were incorporated into the current investigation in an
attempt to advance the methodology of this field of research. Overall, the current
strategies proved effective in assessing compliance while elucidating areas for further
improvement. Although this research effort made some important methodological
achievements, there are several methodological limitations to this research which must be
noted. Concerns which threaten the external validity of results may limit their
generalizability. In this study, confidence in the ability to generalize findings is supported
by a response rate of 49%, which is satisfactory for an anonymous survey.
Generalizability of results of this survey, however, are limited to similar groups of health
care workers (i.e, nurses in a hospital setting, in a geographical area with relatively low

prevalence of AIDS/HIV). In addition, generalizability may be further limited if

 

128

nonresponders systematically differed from those who responded. In this study, it is
probable that individuals who are more compliant with guidelines for universal
precautions may have been more compliant in responding to the survey. If this is true, the
estimates for compliance in the current study would represent upper limits, that is actual
levels of compliance among all health care workers surveyed may actually be lower than
those reported.

Threats to internal validity in the current study include measurement error
resulting from the limitations of using self-report questionnaires. The sensitive and
controversial nature of these questions contributes to the possibility of response bias.
Generally, this study was able to rule out social desirability as a source of response bias.
Future research, however, should incorporate multiple methods for assessing compliance
and other related constructs such as observations, daily logs, videotaping, examination of
occupational exposure data, and needlestick counts. Given the current findings,
qualitative data, such as those generated by focus groups comprised of health care
workers, may also be useful in providing insight into the nature of observed relationships
and for framing a future research agenda.

Efforts were taken to reduce other sources of measurement error. Professional
review and piloting were used to develop a clear concise measure. Results of this study,
however, suggest several future efforts which can be taken to increase the validity and
reliability of the measures. The study was also limited in that it was cross-sectional in
nature, limiting the ability to make causal statements or draw strong conclusions about

causality. Future research should address this limitation by incorporating longitudinal

designs that assess and compare compliance behaviors over time. In conclusion, the

 

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129
current study served to advance the methodology of the field while pointing to several

potential areas for further improvement.

5 l I l' .
I l' . E B l

The current study has several important implications for the continued
investigation of the issues that surround health care workers and HIV. The high
compliance rates documented in the current study suggest a need to frame a new research
agenda. This agenda includes the need to identify and profile the minority of health care
workers who are not complying with guidelines for universal precautions. The current
study suggests that this group includes both new and “veteran” professionals. This
finding demonstrates that the problem of noncompliance will not correct itself with the
emergence of new professionals who have been trained only in the use of universal
precautions. Clearly, once these new professionals are in the field, they too are
susceptible to forces which result in noncompliance. Research will therefore be essential
in identifying noncompliers and strategies that are effective for changing their behavior.

Continuing research efforts are also needed to address those remaining areas in
which the majority of health care workers remain noncompliant, including the handling of
needles/sharps, the use of barrier precautions beyond the use of gloves, and the reporting
and follow-up of occupational exposures. Continued assessment along with the
evaluation of strategies for addressing these critical gaps in compliance are needed. In
addition, further research is needed to examine the critical elements which contribute to

the between-unit differences noted in the current survey. Understanding the role that

130

unit-specific procedures, supervisors, norms, and policies have on compliance and other
variables which impact compliance will be key to tailoring intervention strategies to
different types of units, settings, and professionals. Given the current climate of fear, a
new research agenda must also include an investigation of perceived risk of occupational
infection. Understanding the sources of this perceived risk and its impact appears critical
to understanding the psychology of compliance. A new research agenda should include
further exploration of theoretical contexts in which to study compliance with universal
precautions, thereby continuing the advancement of the this field of investigation from
one that has been primarily atheoretical, to one in which theory provides a solid base for

testing and explaining key relationShips among variables.

I l. 0 fiI .- II . S o '

While in-service training has been the standard for intervention, the current
findings suggest the need for innovative and active approaches to changing, reinforcing,
and maintaining compliance behaviors. Intervention strategies must be customized to
address issues that differ for procedures, settings, and individuals. Findings from the
current study, in particular those related to perceived barriers, support the need for
different strategies for addressing different types of barriers.

In addition, the degree of fear that exists among health care workers reinforces
that training programs that present information alone will not be adequate in addressing
compliance. It has been argued that nonrational factors involved in the perception of risk
actually interfere with the success of training programs based solely on knowledge about

HIV transmission (Colombotos et al., 1995). Therefore, the climate of fear identified in

131
the current study lends support for interventions that encourage staff who are being
trained in universal precautions and infection control procedures to talk about their beliefs
so they can confront their fear and misconceptions regarding HIV transmission. This
investigation suggests that redesigning interventions to target perceived risk along with

behaviors may be a critical step in ensuring truely universal levels of compliance.

1 1° . E E 1i

4 The current study provides further evidence for universal precaution guidelines as
sound infection-control policy against HIV and the other bloodbome pathogens that pose
an occupational risk to health care workers. While universal precautions are cost
effective and when used correctly are effective in preventing the transmission of HIV,
some continue to argue that achieving universal levels of compliance with these
guidelines is not an attainable goal. Results from the current demonstate, however, that
the efforts and polices implemented in the study hospital have proven extremely effective
in achieving high overall levels of compliance. While areas for improvement remain, the
current findings provide strong support for the policies in place which support the CDC’s
current guidelines for universal precautions.

There is a continued need to pay close attention to the occupational threat of HIV
infection to health care workers. After a decade of awareness of HIV, interest in the
issued related to this virus has generally declined. Efforts to assist workers in protecting
themselves from this threat, however, are more salient than ever. As both the prevalence
and incidence of HIV infection increases, increasing numbers of health care workers will

come into contact with HIV-infected individuals. Colomobotos et a1. (1995) reported

132
that nationally, 74% of physicians and 71% of nurses had provided care for at least one
HIV-infected patient. Unless infection control efforts remain effective, the cumulative
risk of HIV to health care workers will increase.

At the same time, health care is currently undergoing dramatic changes, resulting
in greater potential for workers to be distracted, discouraged, exhausted, and undertrained
(Clever & Leguyader, 1995). In addition, as we move from traditional hospital settings
to ambulatory and home settings, ever expanding numbers of individuals (students,
volunteers, and family members) will move into the role of “health care provider”. These
critical factors must be accounted for in ongoing efforts to protect all individuals from
becoming infected with HIV as the result of caring for another individual.

It should also be noted that the findings of the current study have policy
implications for infection control efforts worldwide. Having proven effective in the
United States and other developed countries, there remains a need to disseminate these
infection control policies to developing areas of the world. Assistance in implementing
universal precautions in these countries with the highest prevalence rates for HIV
infection and AIDS, is critical in stopping the unnecessary transmission of HIV in health
care settings. While acknowledging the differences in systems and levels of resources,
basic efforts at educating health care workers in these areas is an important area for
further policy development on the part of the key international agencies and
organizations.

Efforts to ensure compliance with universal precautions, both locally and globally,
remain a key strategy for preventing the spread of HIV transmission in the health care

setting. There are currently 8.5 million individuals in the US. classified as health care

133
workers (Clever & Leguyader, 1995). Protecting the safety of providers and patients
alike and ensuring quality care - care free from the risk of infection and discrimination
based on HIV status - remains a central challenge in addressing AIDS and HIV in the

health care setting.

APPENDICES

APPENDIX A

APPENDIX A

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_Whirllnlutrnullr.
_Wilirdnhnyenr.
WT #mewummmuym.
l.d #bnflbflfimhlmfilflfim.

 

Ptrffi
'50

- - ...
_ 5513223113

 

137

APPENDIX B

Eli-'1

munummmnsmmmm mmqmmmnmm
warm.ammumammmmammmwsrmmm remand
‘m'pMpnm'arhrprem-fiaw).

 

Magnum

 

YES NO

 

 

 

 

 

 

 

 

NWWMMdehMmm)

 

 

 

 

DWJW‘MWVflMIfl/«Mym

 

 

 

9m WWuuummanhmmmmmm?
Mame)
__wmmu2-3ays.
__wmuum
__wmunum
_Wilirdnhrtyenr.
Skirt #Mmmdfimmdmlfiym.
r.e Ammmuxummrmmm.

 

_M$_ EEELMEBMRE 9.

 

138

APPENDIX B

Pit—4

muoummm M nmmawon. wmdmmmmmm
mum. inaumammmmawmmwmmoomm,

W'm'pmmauarmg.

 

aura-gurus“.

 

YES NO

 

 

 

 

 

 

 

 

WWWMWdufluhmmm)

 

 

WNW‘MWMMIWGMM

 

 

 

 

 

'91.: W wumunmmwrnacmnehmmmpawu

M? Mum)

_mmu2-3ays.
__muhwe&.
__Vlihkhn-I.
“his”.
It #muwflmdfisMewflquw.
r: gauwmummrmum.

 

7mm

can
perfon

._ 5255255 9..

 

 

139

APPENDIX B

#3

munwusrm MmWNEONATALRESUSGTAflON. Mam Merriam
WMUMMWMW. Uyardidaatmawcflicpreamniam)b¢m¢irdhinarm
W3 NEOMTAL RESUSOTATION. regard 'NO" for that W premrar'm(s).

 

MMMMM

 

YES NO

 

 

 

 

 

 

 

 

mmm(mm.mdmhmemmhnm

 

www.cmcwmwwanwym

 

 

 

 

 

 

-)u W wuwhmmvabdotmhwhuymmm
EM? (Mame)
__muu24m.
__Wlirbhnweek.
__Wilirrbulnllr.
“mum.
Qaumuummrmum.

  

 

Z3

55550519

hm

 

 

 

140

APPENDIX B

“E!

 

munummunWMmmmnom mqunmmprmau
nwmmwm. Ifyadidnamarpecrficpremarmmitdidnaapplywarfiflngum

at ADULTIM'UBAHON. please rerpard 'NO'far Mpam'adarprmniarls).

 

Manon-aw

 

YES NO

 

 

 

 

 

 

 

 

WMMMMdehMmW)

 

morwuemcwmmmnouym

 

 

 

 

91.: WWWm-wmmdmhmmmmm

M? mam-u)

_vmhncr.2-3ays.
__Wihrlehwe&
_wrnrmcu-nu.
_Wihrhehyeu.
Skin #mnwummmum.
u #oumuuuurwum.

 

 

 

 

_mmm_ REEF—33305 -..

“

 

141

APPENDIX B

13.7

WMthMMmWSWGICALWS. mmquxmm
nwmmgmnmn. lfyaudidnamamedicpma)minfidnaapplywm

SURGCAL DRESSINGS. please respond 'NO 'far M pam'adarpreoam’ana).

 

MflMMSfla—u

 

YES

NO

 

 

 

 

 

 

 

 

WWMMWdWhn-memm)

 

 

mnwmmcwmmwamm

 

 

 

 

 

'91.: m Mummmmamhmmmmumr (acorn

w)

__Wihbhn2-3tys.
_WflthweeL
_Wflhhhmrllr.
__Wihuhyea.
Skin“ #muwummmuym
Li gauwuuuurmum.

 

142

APPENDIX B

"'2

mmoumm Myra-W rmm.mmqwmmm mum
WWW. JmfimmamficmanemebdidnaMmmrmmm

rapt!!! 'NO'fiar (harpam'adarpreama'ma).

 

Mulch“

 

YES NO

 

 

 

 

 

 

 

 

NeedhlSlmpPrec-Iiunmm.dw°fmefluhmmm)

 

 

mdwumwmmwamm

 

 

 

 

 

'91.] W Mummmmhddfinhwfldrmmmdfi

M7 Mgr“)

_Wihtll:u2.3ays.
__Wihuuweek.
_Wihdrehnm
_Wihhbym.
Stine hveuperhmddisprecehewflhdchyar.
l.j donaruflerdrelnrhednlpaformddism.

 

143

APPENDIX B

it!

munmmmmmmamurmmnommmqwmm
Wmmmmwpm. lfyaudidnaruseawedflemeamfiadflbeanauitdidaarmflyw

a URIMRY CATHEIERUAHON. respard 'NO'for tharpam'adarpreoarru'aus).

 

Quinlan!“

 

YES

NO

 

 

 

 

 

 

 

 

Nwmmmnm.mormhmmm)

 

 

 

 

MdWmmwmmoodIH/«MM

 

 

 

-)i.j W Whamdemamyahddfimhmymmwu

procedure? (Gamma)

_Waflnthelau2—3days.
.__W‘all'nrhehltweet.
__Walintehnm
___Wila‘ndnhayear.
Sk’p'l' ___Ihveuperfomdtlrisprecerhrew'ahdnlanyear.
Lk #mumuumurmmm.

 

 

 

 

151

9n

Ska: To
1.1

 

 

144

APPENDIX B

521.0
WMnRWMMmWMr-r mmmqmmmnw
Mwmmm. JyaudidnamarpedficpnmmbmeirdidnaMmefingfldrm
WWWW'WZMMWMM

 

 

(laminar-mi
YES NO

 

 

 

 

 

 

 

 

 

NeedleherrecaahsMncqpthiqronldmhmmw)
MquWWwihBhodd/«Mym

 

 

 

 

 

 

 

-)r.r: WWuummmamhmmmmumr
Mum)
_W'ahda:lanZ-3days.
_wumrnaamt.
__wrnha:ham
_Wlhtlchltyel.
muwuumurwum.

    

ii)
1.1

 

5m? _....._m_5;EEEIs

 

145

APPENDIX B

“Lil

wwwwusrmammanmanwmz mmq‘wmgmmmw
whenperfornrr‘ngrldspme. Jyaadr’daamaucificmcaruiarm bemuseirdr‘dnarapplyroAmmGA
DEUVERXrapmd 'm'grrrharparfiadnrgecam'mm.

 

 

magnum

 

YES NO

 

 

 

 

 

 

 

 

NeedleharpHecaaimhmMAfiponlofmedleshmnpmdm)

 

 

DiapasalofWanthWwihMad/orflodym

 

 

 

 

911 wwwummmthmmmmmmr (00am
W)
__wmmena2a em.
_Wihthhtleek.
__WII'-tlchtalnh.
_m&hltyeu.
«mwmummrmmm.

    
     

Skir'l‘o
2

EEEEEEEEEII...

 

146

APPENDIX B

PL”

MMUkWMMmWWNM. Wdemmwyamm
perfmgtlnlrprocedare. Ifyou dr'dnarmamcjficpreanrriara) because r'rdidnarrpplyropafizmr‘ng SUCHOIWVG.
mpald ‘NO'far rharparricularprccaurim(s).

 

“mural-SI."

 

YES NO

 

Gave:

 

W

 

 

mauve-(mmyrum

 

Gown

 

mm

 

II"IJ'

 

Nwmm(um,mdmhmmm)

 

 

 

DMdWmmwmmm/GMM

 

 

 

 

")2. hhMmqpfldmmdmmmm?

—[_vas mmsrrrrmormrousr

___NO
IFNO: mmmmmummwmmorm
mummummmanydmmm:

 

 

 

 

 

 

 

 

 

 

 

1%“ '3. TC] I

 

 

147

APPENDIX B

3L2

MHMflMMpWthWmmfimm-
”dummvmudmmmmmdwm. Nearer-attire”
armaumgjfywmummmmqminmm3m.

 

 

 

 

93. thASIJMONl‘flSJnveymebodorbodyfiridsmcuedfonbhedingpdua?

——[_Norrrno.-roormsnou4r

 

 

_YES
EYES: Housemate
Mulch”
ALMWI‘ ABOUT‘ISS ABOUTSO‘ ABOUTZSi ALMQT Not
ALWAYS ovum or=rrrra orrrrra maven AM
11MB TIME TIME

 

a. Whenyonhvecmdpmeedmeein
Minuewupm'nlformto
hloodorbodymidsJowthaveyon
wornglovea?

b. Whenyonhveharanedw
m.m.wmma
«urbbodacceaamhowm
hveyonwornalavea?

 

 

c. Whenyouhavecondrnedprmin
whichtherewaspaenialforabodyw
MMMMwymmM

 

 

c. Whenyarhvecmmin
manhunt-cram”
footwear?

 

f. Whenyonbvecondaaedpneeaneain
mmmuoodorhody
“mu-momma“

;. Howonenhaveyonwaahedmmer

Mamwflmafluae
mum“?

 

 

 

 

 

 

 

 

 

 

'94

7.5

a.

148

APPENDIX B

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

a. WWI-“mam.“
denhveyonncappeddrenedbMa
two-MM)?

 

b. Anetnaingadiapoeabbnadleonhrp
mammmnbveyon
WWdhmfleum
hammw

 

 

 

 

 

 

13L"
94. humsmmmwnmam
r——[__NOIIFNO,SKIPTOQUESTIONSI
__YES
EYES: HwemmrheW.
“Ml-cram
ALMCST ABOU'I‘755 ABOUT ABOUT ALMCST Not
ALWAYS 091'!!! ”$0? 25$W NEVER Awflcabb
TIME THEM THETIME
a. “(Numbness-“apnea.
“hump-{mm
“mam“?
“)5. thSWMmMamwmmmhmfiupfiufl
[JIFNQMTOQUISWC]
_YES
EYES: MWWW.
ALHCBT ABOUT‘ISS ABOUT ABOUT ALMOST Not
ALWAYS onus sosor zsaor NEVER Applicant:
TIME THETIME THETIME

 

 

 

 

149

APPENDIX B

139.13

'96. ummsmmmwnmmmfiawmmnmm.
pain?

 

—{ nomm,sxnmoumloml

YES

IFYES:
a. wmmfiWMGWWMWMMMmW
wmhflkmmm-Q?

J

 

[Jmmwmmmn

___YES

IFYIS:
b. DilymmlflvmymforymbmcymchMywm
madmaplimdnymMormeacdmbcMWth-HV?

 

’l'
l_NonFNo.sxanm:snonn

___YES
EYES:
c. wmmqmwmmumwmm):
___3WEEIS?

6WEEKS?

GMONTHS?

___12MONTHS?

 

 

 

 

150

APPENDIX B

has!

 

 

mu

hhmwmmmwmm am. mmimmmmmm
m hwhmmuymmmmoMBmuflgmmmM

WW'IIMIASI‘SMONTBS.

 

 

97. humsm.mmwmamymummumm7

—-{___Nolmno.smmounsnou 3]

__YES

EYES: mumsm.m«mmmm1mmam
yahmMndnmmfotdnmof “panda-(gum, m. nub. protective

 

 

 

bum. etc. )1
' firm
YES NO
a. [staff-m.

 

 

c. memm.

 

d. wmummm.

 

c. mummmmwm.m.mmmmm.

 

f. WWW

 

g. Mdcbummnwm.

 

h. Worm.

 

I. mndidmmbhcaflghdskiormv.

 

j. mmmomwmnmv.

 

k. wmmumotmmmwm.

 

 

ll. Pm.mm.munvhmnmm«mum1mm
m.

 

u. Gunman-rite):

 

 

 

 

 

 

151

APPENDIX B

98. hdnLASfJMONTEJmeymmedamedleadudmthmfonpdm?

——-[ nommmnrmomm

____YES

mm: mumsmmmwmmmmimmumm
mmnumhu “immmmmispaflofm
hmpumfcanm)?

 

“mu

 

YESNO

 

a. Mdl'lm.

 

b.‘ ”mummmmm.

 

c. Mdchranmdsfwflemmm.

 

d. worm

 

e. mnmwhmmmmmdmmmminum
dons.

 

f. mmmwmuwamwunmmm.

 

g. Remtommponamedmdletoadisponlbox.

 

h. Mum.

 

I. mndflmtmnbcammkfwmv.

 

j. map-amnmmmpuvemmv.

 

k. mmummmm.

 

1. WWW):

 

 

 

 

 

 

152

 

APPENDIX B
m
99 bdrm SMONTBS MmanmmWMMWfima
mummm-up?
HJOIFNOJKIP‘IOQUESHONN]
__YES

[FYI-3: muLASFJMONTHSJthduWMeMiMWaWym

mwmwmmm

 

 

 

YES NO

 

a. Lackdl'lnc.

 

b. Wmfidwhm.

 

c. Wwofwkw

 

d. Wmmdmhmy.

 

aw

 

f. many-dauguwmvemmv.

 

3. Fwdmpoufivefmfllv.

 

h. Fwofdisc'plharymmcnfiimmfwowmm.

 

I. msmiunumwbenmmmmvmm.

 

j. Oh Me 4000:):

 

 

 

 

 

 

153

APPENDIX B

P422

 

mm

113mm mmmmmmmmmmmdmmm;

.

nmmuun'm.

I

I
I

910. mmnmmmbinydmvmmmmmmmmmmmm:

 

 

and am but perm
HIGH RISK MODERATE LOW RISK NO RISK
OF HIV RISK 0? “N 01' HIV OF HIV
WON mammal»: TRANSMISSION TRANSMBSION

 

a. mmammm
BIV.aunllmoflhepliul'snflva
minmw‘lhdclulhm
W’sincukh.

 

b. Whilcpufonningapmm,
HIV-hfecwdbloodinpwmnw
mmtnt'smn—hnashn.

 

c.Wflkchlngthmnmv-M
M'sMawmm’sm

hmhmwihdfndhbodnh.

 

d. Ammmm
Womanormmaw
mm'smm.

 

e. Ammmma
Mammammm

hmwmammmm.

 

f. BIV-Mbloodisqhfiedhdneyu
«mummdalulhm
mm.

 

g. Awmmmm
www.mm
mammmmv.

 

II. mmammmv-
MM’suoodmbodyM
qhdlmnahlhmm’sina
in.

 

i. Annihmm’smmm
hemmmvufidapdam
w'IhHIV.

 

 

j.WhileinIuI'IIgau'l-tythn
mV-MMIhpmdm
1:“ththan
m.

 

 

 

 

 

 

154

 

 

 

APPENDIX B
“22
Quinlan”
HIGH RISK MODERATE LOW RISK NO RISK
OFI-IIV RISK OF HIV OFIIIV 'OFI-IIV

TRANSMISSION TRANSMISSION

TRANSMISSION TRANSMISSION

 

k. hhmofpafomhgmm
WmmflV-WpflhlJ
Mmmmam

 

I. hhmdmflngam
mmmmv.awm
mummmasm

 

 

ll. Authmwmmdnfly
“mammmm
“WWW“.
ambummum-fl
mmmmmmmm
m).

 

 

 

 

 

ll. mmwmmmm?

 

 

Mastery“

 

 

AGREE DISAGREE

 

a. MWMRMVMMmunWMdW
m.

 

b. HWDM“WM.MMMUWWWI
handyman}.

 

 

d. Wmmahamwmmmdmmhm.

 

c. “mmmmmmmmmm

 

I. mmmmmmummmmuwd
wmmmmmmwm.

 

g. mmummmmmmmvem.

 

II. Mmemhbdonmlmqufidmmmvmmw

mmauwnm.

 

i. wwwmmmmmmm

 

 

j. mmmmvmmumhmm.

 

 

 

 

155

APPENDIX B

ӣ11

 

mm
mVBMnWimammeMd'hIhmpwflu-k. Animamapeaoflhismdy
is» mmmwmmmnmmmhmmnammm

12. Doynuageeordingeewihdnfonowqm?

 

 

Mflmmw

STRONGLY AGREE DISAGREE STRONGLY
AGREE DISAGREE

 

 

a. WMmmmmm
-mmummm
b. mmmmauwm

“Mmmmm .P_

c. MMImwflbwu-Manmn
d. vmmmmccfiwdvcam
mmdmhmmmmm
:Ipniunfotmv.

c. mwmmmmma
”humanlyxhkdmm

f. mummdamhmeefiwdvcin
mumdmmmmdm
pee-lion.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

[hfismduem Mummmauuuqmmmmumw
WWW Domdtdemdmmmmaw

 

 

13.
a. Emmwmmm,mmlykidnmmmwmmyww
Mucuivanlm:

my 1 2 3 4 5 6 7 UNLIKELY
mainly on: sum Neilu Slighly Quit: manly

156

APPENDIX B

"£2

14. Domwamwihmmhgm? mmmgm. mmmww
useafw'rierprcm, Wmmhngmdwmlduwesadsm. mmmrrepam'ng

Wwwmpddmfiwam.

)

 

00%-“!an

 

STRONGLY
AGREE

AGREE

DISAGREE

STRONGLY
DISAGREE

 

a. WWmmhMmdw
m.

 

b. Mymmumnmm
m.

 

c. Mymmmhdn‘rucofmnl
m.

 

d. mmmwmduwm
nuihhmymlflmihgmmw
“mumm.

 

c. Mymmmemmm
Mummm.

 

f. mmthmuman

 

 

g. ananmmmm
m.

 

 

 

 

 

15. Doprith’

 

 

Cadmium”

 

STRONGLY
AGREE

AGREE

DISAGREE

STRONGLY
DISAGREE

 

a. lacflumyhlnymww'thNaam
dnij.

 

b. tummnmmhmwm
m.

 

c. Immmmmamn
mmlnwulmmmmm
annualofmyjob.

 

¢1mmmhummmmms

 

c.1muanmdwummmmn
uwmmmumm.

 

 

f. mmiyofmypdanmlhhormmkfu
mmnmmmm.

 

 

 

 

 

 

 

157

APPENDIX B

ML”

16. mmmmmwmnnmdmmmmmmmmum
pctfommdimlm. MMhmmMymbeflcvcdmymmcfiecdvdywmm

(In WWW. Wmmwmmqmm. mammal!
Wq’needksmddwps. “WfimgmaWMyMWfima

M6")

 

 

(Id m In for w
VERY SOMEWHAT SOLEWHAT VERY
EFFECTIVE m m m

 

a. Howeflcctivdymympafounm

 

b. Howcfieaivdymywpufumw
u-swln'lenshgufivaulptw-fim?

 

c. Howefinivelyunywtu‘nlvm
WWW?

 

d. Howdfecdvetymywhwadhhod
wlilcu'mgmivanlpm?

 

e. Howefiecfivclymyoupafomm
mmmmmm?

 

f. MMmyonywudflwihn
fimmmm
W?

 

g. Howcfleaivdymwuchqem

 

h. Hwefiecdvdymyonpxwidepu'lm
wlilcnhguivcrnlpm?

 

 

j. ”Mummhpflm
nwmmmm?

 

k. HWMMMWW
WWW?

 

 

I. Howefleaivclymymmm
mmmw

 

 

 

 

 

 

158

APPENDIX B

PL“

17. MummmMMMImmmmmmms:
DIFFICUL‘I’ l 1 3 4 S 6 1 EASY

am Quin Slim Ncmr sum Quite Emly

18. mmdmmmmmmmmwmymwmmmammm
mpmumwm lmflmmaMWflmidflmm
unapmimhrpmomc.mpummA'.

MthMWMnmm:
l- EXTREMELY LIKELY

2-somzwuxr LIKELY

3-SOMEWHAT UNUKELY

4-EX'I'RMY UNLIKELY

NA-NOI’APPUCABIE

 

 

We Eymr

[M Shield
Dismal Wm
Mel-bl:

 

a. MAW

b. Vagillfim

c. SunIV

d. mmm

1:. WW

I. mmmm
& (ii-WWW
h. PuiCuc

i. 0mm

1'. mmm
k. mm

L Suction}

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

159

APPENDIX B

 

w
19. Bowdmddoymhnmmwnwuemm
VERY l 2 3 4 5 6 ‘7
11111.! COMPLETE
CONTROL CONTROL

20. mmmnmdmmmmum 1!“!!deme
bmhmamuigflhbfl

 

M

TRUE FALSE

 

 

I. Imfedmfulwhaldm‘lgetmyny.

 

b.1M'tMimmmpmmm-Mdmm.

 

c. MWMMMIMMMW.

d. OnaIewWthegiwnwmmmIWwomofmym.
c. Immbahquipwihummmamym.

f. [mammmmumwwmom

 

 

 

 

g.IaMysuywmm1M.

h. Immhcingubdwmafavor.

I. Whaldm‘tknowoanemldon'talanIdmmgl

j. IbumWynflMMhmm'sm.

k. MWMWMIHWWWWMMMWIMMy
mull

 

 

 

 

 

 

 

 

 

160

APPENDIX B

 

 

WV
Funny, wwwflkmfimmmwwbbmunresmSoffissmey mile-sew

 

 

22. Whyounex?_ FEMALE MALE

B. mummmwamum

__3N mm
_lm _WWW;)
_cninuaumspcuu

24. thWWMmmmMMymmW?

W __.Doacme
M ___CXIuer We data-nu):
___)lnsen

25. Wmdidymobuhflubdeyee? I9—

26. Whmmmmnmdprwe?

 

Jenner/Baby __Neonml W Cue
My

THANKYOUIORYOURPARTICIPATIW. rum .. . 'I’ORE'I‘URNYOURTICKETWITBYOUR
mmmmnmmmmwmc. WCOMI’IE‘I'IONOFTIIBS’IUDY,APRIN’ID
mammmmusmumummmmmcmmou
mummm

 

 

 

Chapter 5

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