Patients knowledge, attitudes, and

behavior toward hospital-associated

infections in Italy
Rossella Abbate, MD,
a
Gabriella Di Giuseppe, MD,
b
Paolo Marinelli, MD,
a
Italo F. Angelillo, DDS, MPH,
a
and the Collaborative Working Group
Naples and Catanzaro, Italy
Background: Hospital-associated infections are associated with morbidity, extended hospital stay, mortality, and attributable costs
to the health care sector.
Methods: A survey of 450 patients admitted to hospitals in Italy determined knowledge, attitudes, and behaviors regarding hospital-
associated infections. A face-to-face interview sought information about: patients sociodemographic characteristics; hospital ad-
missions and examinations; knowledge, understanding, attitudes, and experience of health careassociated infections; and sources
for information.
Results: Patients who were higher educated, unmarried, rst-time admitted, and who have received information about hospital-
associated infections were more likely to know denition, risk groups, and risk factors of such infections. Respondents levels of
perceived risk of contracting a hospital-associated infection were signicantly higher in those who were married, unemployed, in
medical wards, who overestimated the incidence rate, and who believed that health care professionals cannot infect patients. Pa-
tients willing to stop a health care worker who is not using gloves and mask were females, higher educated, those who believed
that health care professionals can infect patients, who overestimated the incidence rate, who have never been exposed to such
infections, who have never had received information, and who do not need information about hospital-associated infections.
Conclusions: Actions aimed at improving knowledge are crucial to the development and implementation of effective public health
preventive strategies. (Am J Infect Control 2008;36:39-47.)
It is well documented in several countries that hos-
pital-associated infections represent one of the most
common adverse events affecting patients admitted
to acute care hospitals, and these infections are associ-
ated with morbidity, extended hospital stay, mortality,
and attributable costs to the health care sector.
1,2
Assessment of patients attitudes and opinions con-
cerning the risk of the transmission of infections in
health care settings deserve attention, because the
perception of risk of acquiring these infections may
exceed or be disproportionate to the actual risks. As a
result, some people may avoid seeking health care ser-
vices or discriminate among providers on the basis of
that perceived risk, a detriment to both provider and
patient. Furthermore, public health education may be
needed to promote focused efforts in prevention and
control, especially when compliance with infection
control policies and procedures, such as the routine
use of universal precautions and handwashing, varies
and frequently is below ideal levels.
At present there has been little assessment about
patients knowledge andexperiences concerning hospi-
tal-acquired infections and in particular on procedures
for prevention and control.
3-5
One hopes that gaining
a better understanding on attitudes and opinions from
the patients perspective will cause effective changes
in public health policy and infection-control proce-
dures. Therefore, the objectives of this survey were to
concurrently document the level of knowledge, atti-
tudes, and behavior and to identify their determinants
regarding hospital-associated infections among medi-
cal and surgical patients admitted to hospitals in Italy.
MATERIAL AND METHODS
The target population for this cross-sectional survey,
carried out during the period between June and Octo-
ber 2006, was a random sample of patients hospital-
ized at three randomly selected nonacademic public
acute care hospitals in the area of Naples (Italy).
From the Department of Public, Clinical and Preventive Medicine,
a
Second University of Naples, Naples, Italy; and Chair of Hygiene,
b
Med-
ical School, University of Catanzaro Magna Grcia, Catanzaro, Italy.
Address correspondence to Italo F. Angelillo, DDS, MPH, Department
of Public, Clinical and Preventive Medicine, Second University of Naples,
Via Luciano Armanni, 5, 80138 Naples, Italy. E-mail: italof.angelillo@
unina2.it.
Members of the Collaborative Working Group are as follows: Andrea
De Stefano, MD (Hospital Santa Maria della Pieta`, Nola, Naples), Maur-
izio di Mauro, MD (Hospital San Giovanni Bosco, Naples), Antonio
Sciambra, MD (Hospital Evangelico Villa Betania, Naples).
0196-6553/$34.00
Copyright 2008 by the Association for Professionals in Infection
Control and Epidemiology, Inc.
doi:10.1016/j.ajic.2007.01.006
39
In all medical (general medicine, cardiology, geriat-
rics, nephrology, pulmonary) and surgical wards (ENT
[ear, nose, throat], general surgery, gynaecology, oncol-
ogy surgery, orthopaedics/traumatology, neurosur-
gery), except psychiatric, a condential face-to-face
interview with each patient, after obtaining verbal in-
formed consent from participants, was administered
for data collection by two previously well-trained phy-
sicians. The interviewers provided to the participants
details on the study purpose and assurance about the
anonymity and condentiality of the interview. The
anonymous questionnaire was divided into a number
of areas that sought information about the following:
patients social and demographic characteristics; previ-
ous hospital admissions and examinations; current
knowledge, understanding, attitudes, and experience
of health careassociated infections; and sources for
information (Appendix A). The answers to all of the
knowledge questions about transmission and risk fac-
tors were arranged as yes, no, and do not know
choices. The response choices for all statements relat-
ing to general attitudes to ascertain level of agreement
or disagreement were given on a 3-point Likert-type
scale (i.e., agrees, uncertain, disagrees). Respondents
were also asked to report their own perceived risk of
hospital-associated infections on a 10-point Likert-
type scale with options ranging from 1 (impossible)
to 10 (very likely). Participants were asked in behav-
iors questions whether or not they have been exposed
to hospital-associated infections related to the level of
compliance of health care workers with standard
precautions and the answers were given on a 5-point
Likert-type scale, with options ranging from never to
always. We have asked whether the patient has been
exposed to a health care worker who did not wear
gloves when touching blood, body uids, mucous
membranes, or nonintact skin, and did not wear a
mask during procedures and patient-care activities
that may pose risk for contamination by nasal and/or
oral ora of the health care worker. Patients were
also asked their willingness to stop a health care
worker who is not using such precautions during these
activities and the main reasons for their decision.
All items in the original version of the questionnaire
were assessed to ensure practicability, validity, and
interpretation of answers in a pilot test among a con-
venient group of patients. On the basis of the com-
ments obtained, the questionnaire was revised in
item, wording, and format before distribution to the
study sample.
STATISTICAL ANALYSIS
Multiple stepwise logistic and linear regression
analyses were performed. In the models developed,
we included variables that we considered likely to be
associated with the following outcomes of interest:
knowledge (denition, risk groups, risk factors) about
hospital-associated infections (Model 1); willingness
to stop a health care worker who is not wearing gloves
when touching blood, body uids, mucous membranes
or nonintact skin, and mask during procedures and pa-
tient-care activities that may pose risk for contamina-
tion by nasal and/or oral ora of the health care
worker (Model 2); perception of risk of contracting a
hospital-associated infection (Model 3). The following
independent variables were included in all models:
gender (male50, female51), age (continuous, in years),
marital status (single/separated/divorced/widowed50,
married51), educational level (ve categories: ,5
years51, 5-7 years52, 8-12 years53, 13-17 years54,
.17 years55), occupational position (unemployed50,
employed51), rst-time hospital admitted (yes50,
no51), overall number of surgical procedures already
received (050, $151), hospital ward (surgical50, med-
ical51), length of hospital stay of the present admis-
sion (continuous, in days), information received about
hospital-associated infections (no50, yes51), health
professionals as source of information about hospital-
associated infections (no50, yes51), and need of
additional information regarding hospital-associated
infections (no50, yes51). The following variables
were also included: knowledge of the incidence rate
of hospital-associated infections (three categories:
underestimation50, correct estimation51, over-
estimation52), and belief that health care professionals
can infect patients (no50, yes51) in models 2 and 3;
knowledge of risk factors of hospital-associated infec-
tions (no50, yes51), perception of risk of contracting
a hospital-associated infection (continuous), and pa-
tients who have been exposed at least once to a health
care worker who did not wear gloves, when touching
blood, body uids, mucous membranes or nonintact
skin of all patients, and mask during procedures and
patient-care activities that may pose risk for contamina-
tion by nasal and/or oral ora of the health care worker
(no50, yes51) in model 2; and knowledge (denition,
risk groups, risk factors) about hospital-associated
infections (no50, yes51) in model 3.
Before testing multivariable logistic regression
models assessing predictors of the outcomes of inter-
est, we examined correlations to assess collinearity
among the independent variables and bivariate rela-
tions between the independent variables and the de-
pendent variable. The criterion to be met before any
independent variable was considered for entry into
an initial multivariable logistic regression model was
a P-value of .25 or less obtained for each outcome var-
iable in the univariate analysis and noncollinear with
other predictors. Furthermore, the signicance level for
40 Vol. 36 No. 1 Abbate et al
variables entering the logistic regression model was set
at .2 and for removing from the model at .4. The mag-
nitude of the association between predictors of interest
and outcomes was measured by odds ratios (ORs) and
their corresponding 95% condence intervals (CIs).
When building linear regression model, we have rst
included only one possible variable at a time. Then, us-
ing the variables that were signicant at P-value #.25,
we constructed a stepwise multivariate linear regres-
sion model, and the signicance level for variables
entry the model was set at .2 and for removal at .4.
All tests were two-tailed and a P-value of .05 or less
was dened as statistically signicant. The data were
analyzed using the statistical software Stata.
6
RESULTS
Of the 475 patients approached to participate in the
study, a total of 450 agreed to be interviewed with an
overall response rate of 94.7%. The distribution of rel-
evant socio-demographic characteristics and selected
information on hospital admissions and examinations
of participants are summarized in Table 1. Overall,
57.8%of the patients interviewed were women, the av-
erage age was 51 years (range 16-87), and one-third
had some high school or higher level of education
and were rst-time admitted in a hospital ward.
Table 2 shows the distribution of patients who cor-
rectly mentioned each of the possible hospital-associ-
ated infections denition, incidence rate, risk groups,
risk factors, and preventive measures. Only one third
(35.1%) correctly dened hospital-associated infection
as an infection acquired in hospital that was not pre-
sent or incubating at the time of admission, whereas
a large percentage of survey respondents agreed that
elderly (89.6%), children (88.9%), and patients in sur-
gical wards (75.8%) were at risk of contracting hospi-
tal-associated infections. However, there were some
misconceptions with respondents that overestimated
the risk, because 43.8% believed that smokers were a
risk group. Regarding the most likely causes of hospi-
tal-associated infections, 97.1% identied poor hospi-
tal hygiene, 59.1% extrinsic host factors such as
invasive procedures or devices, and 48.4% the length
of hospital stay. Moreover, only 12% of the respon-
dents were able to indicate the incidence rate of hospi-
tal-associated infections with a vast majority (77.1%)
that overestimated the rate. To identify the independent
effect of the variables on knowledge and others out-
come of interest, we created several multivariate
models, and Table 3 presents the results from the nal
multiple logistic and linear regression analyses for
which variables with an association of P # .25 at the
univariate analysis were selected. After multivariate lo-
gistic adjustments, the results suggest that, among all
variables tested, several of these signicantly predicted
the knowledge. Indeed, patients with higher educa-
tional level (OR52.85; 95% CI 2.1-3.85), unmarried
status (OR50.48; 95% CI 0.28-0.82), rst-time hospital
admitted (OR50.38; 95% CI 0.23-0.64), and those who
have received information about hospital-associated
infections (OR54.01; 95% CI 2-8.05) were more likely
to knowdenition, risk groups, and risk factors of such
infections (Model 1 in Table 3).
More than two thirds (68.9%) of the patients per-
ceived that hospital-associated infections are serious,
88.2% that they are preventable, and 63.8% believed
that health care professionals cannot infect patients.
More than three fourths (79.8%) perceived some risk
of contracting a hospital-associated infection, and the
mean total score resulted of 4.7, with only 2.7% having
reported feeling very much at risk by answering
10. A stepwise multivariate linear regression model
Table 1. Socio-demographic characteristics and selected
information on hospital admission and examinations of the
study population
n %
Gender
Female 260 57.8
Male 190 42.2
Age group (years) 50.8 6 18.6*
#30 93 20.7
31-40 58 12.9
41-50 58 12.9
51-60 87 19.3
61-70 80 17.8
.70 74 16.4
Marital status
Married 289 64.2
Single 86 19.1
Other 75 16.7
Educational level (years)
,5 58 12.9
5-7 73 16.2
8-12 169 37.5
13-17 124 27.6
.17 26 5.8
Occupational position
Unemployed 286 63.5
Employed 164 36.5
First-time hospital admitted
No 303 67.3
Yes 147 32.7
Number of surgical procedures already received
0 122 27.1
$1 328 72.9
Hospital ward
General surgery 120 26.7
Specialist surgery 146 32.4
General medicine 100 22.2
Specialist medicine 84 18.7
Length of hospital stay (days) 6.2 6 9.9*
*Mean 6 Standard deviation.
Abbate et al February 2008 41
was constructed aiming at understanding which varia-
bles had stronger associations with the perception of
risk of contracting a hospital-associated infection by
the patient. Respondents levels of perceived risk
were signicantly higher in those married, unem-
ployed, in medical wards, in those who overestimated
the incidence rate of hospital-associated infections,
and in those who believed that health care profes-
sionals cannot infect patients (Model 3 in Table 3).
Patients were asked whether or not they have a
history of exposure to hospital-associated infections
related to the level of compliance of health care
workers with standard precautions. Of those surveyed,
71.1% reported that they have been exposed at least
once to a health care worker who did not wear gloves
when touching blood, body uids, mucous membranes
or nonintact skin, and mask during procedures and pa-
tient-care activities that may pose risk for contamina-
tion by nasal and/or oral ora of the health care
worker, and almost all of them(90.3%) did not say any-
thing, whereas of those who have never been exposed,
30.8% reported that they would stop the health care
worker if he/she started the activity without gloves and
mask. Overall, 15.1% of the respondents stated that
they were more willing to stop a health care worker
who is not wearing gloves and mask. The results of the
multivariate logistic regression analysis indicated that
those patients willing to stop were females (OR52.39;
95% CI 1.28-4.47), higher educated (OR51.51; 95%
CI 1.11-2.07), those who believed that health care
professionals can infect patients (OR52.42; 95% CI
1.16-5.05), who overestimated the incidence rate
(OR53.12; 95%CI 1.39-7.01), who have never been ex-
posed to such infections (OR50.17; 95% CI 0.09-0.31),
who have never had received information (OR50.46;
95% CI 0.23-0.9), and who do not need information
about hospital-associated infections (OR50.39; 95%
CI 0.19-0.83) (Model 2 in Table 3). The most common
reasons reported by the respondents for not stopping a
health care worker who is not wearing gloves and mask
was the conviction that such behavior is not dangerous
for them.
When asked about the main sources of informa-
tion, by which knowledge and awareness of hospital-
associated infections was acquired, 68.7% of patients
recorded that they had indeed received some informa-
tion: the media were the most frequently mentioned
(53.6%) andonly15.1%fromhealthprofessionals; how-
ever, 86.9% of the patients required more information.
DISCUSSION
To the authors knowledge, this is the rst published
survey that depicts a mosaic of opinions outlining the
stated knowledge, attitudes, and self-reported behavior
patterns concerning hospital-associated infections
among a large random sample of patients in Italy.
Despite the novelty and signicance level of these
ndings, some methodological considerations ought
to be highlighted when interpreting our results. First,
all variables used in this analysis were gathered using
patients self-reports and self-perceptions, and the pos-
sibility exists that patients responses will give answers
intended to please the interviewer rather than reect-
ing the particular truth regarding the behavior in the
case of exposure to the risk of hospital-associated
infections. The problem with self-reporting is that par-
ticipants responses may attempt intentionally or unin-
tentionally to inate or minimize reports of behaviors.
However, it has been demonstrated that means of im-
proving the validity of self-report data include the as-
surance of condentiality and establishment of good
relationship. In our study, interviews were conducted
in a condential setting, and interviews were carried
out by interviewers trained for the task, which included
the need to establish a good relationship. Second, the
survey was conducted on admitted patients and it is
possible that they underestimated risk perception,
since they are selected among those who do not avoid
health care services. Third, since the study was cross-
sectional in design, there was no temporal separation
of the explanatory variables from the outcomes, so
that it was not possible to distinguish whether those
variables preceded the outcome or vice versa. Despite
the potential limitations, there were strong advantages
of the present study. First, because the study was not
conducted with volunteers but rather with a random
sample, we believe that our results are representative
of the patients in the area studied. Second, we were
able to utilize a very large sample and the high
Table 2. Knowledge about hospital-associated infections
of the study population
Correctly answered
n %
Denition 158 35.1
Incidence rate (5-8%) 54 12
Risk groups
Elderly 403 89.6
Children 400 88.9
Patients in surgical wards 341 75.8
Risk factors
Hospital hygiene 437 97.1
Health care worker behavior 408 90.7
Invasive procedures or devices 266 59.1
Length of hospital stay 218 48.4
Preventive measures
Hospital hygiene 313 69.6
Health care worker behavior 135 30
Patient behavior 38 8.4
42 Vol. 36 No. 1 Abbate et al
response rate excludes one major potential source of
sample bias in the results. We believe that this high re-
sponse rate was made possible through the extreme
importance of the topic surveyed. Third, we have
used the multivariable analysis that is essential for
determining which are, among a number of factors,
the most signicant predictors of an outcome. Fourth,
the combination of quantitative and qualitative data
provides a comprehensive picture of the overall knowl-
edge, attitudes, and behaviors towards hospital-associ-
ated infections.
Most patients were condent about their knowledge
of hospital-associated infections, and most recognized
the well-known risk groups and risk factors for these
infections, although it was also quite noteworthy that
there are some misconceptions about risk groups and
only one third of patients were able to provide the
correct denition. The respondents to our question-
naire exhibited similar levels of knowledge when com-
pared with those reported in a previous survey
conducted in France, because among the 65 surgical
patients, only 26.2% were able to describe a nosoco-
mial infection.
4
A higher value has been observed in
329 subjects selected from the general population in
Germany with 66.9% that claimed to know about nos-
ocomial infections.
7
When viewed from the perspec-
tive of informed decision-making, patients who have
misconceptions are clearly not in a position to play a
role in the implementation of change in public health
policy and infection control procedures, and such mis-
conceptions can also impair the quality of communica-
tion between clinicians and their patients more
generally. Indeed, it is notable that in our study the
main source of information through which awareness
Table 3. Logistic and linear regression models results
Variable OR SE 95% CI P
Model 1. Knowledge (denition, risk groups, risk factors) about hospital-associated infections
Log likelihood 5 2194.09, x
2
5 151.05 (7 df), P ,.0001
Information received about hospital-associated infections 4.01 1.43 2-8.05 ,.001
Educational level 2.85 0.44 2.1-3.85 ,.001
First-time hospital admitted 0.38 0.1 0.23-0.64 ,.001
Marital status 0.48 0.13 0.28-0.82 .007
Hospital ward 1.69 0.48 0.98-2.94 .06
Need of additional information about hospital-associated infections 1.74 0.68 0.8-3.76 .16
Gender 0.76 0.21 0.45-1.3 .32
Model 2. Willingness to stop a health care worker who is not wearing gloves and mask
Log likelihood 5 2152.91, x
2
5 76.36 (9 df), P ,.0001
Exposed at least once to a health care worker who did not wear
gloves and mask
0.17 0.05 0.09-0.31 ,.001
Knowledge of the incidence rate of hospital-associated infections:
Correct* 1.0 - - -
Overestimation 3.12 1.29 1.39-7.01 .006
Gender 2.39 0.76 1.28-4.47 .006
Educational level 1.51 0.24 1.11-2.07 .009
Need of additional information about hospital-associated infections 0.39 0.15 0.19-0.83 .014
Belief that health care professionals can infect patients 2.42 0.91 1.16-5.05 .019
Information received about hospital-associated infections 0.46 0.16 0.23-0.9 .023
Health professionals as source of information about
hospital-associated infections
0.42 0.22 0.15-1.16 .09
Surgical procedures already received 1.68 0.61 0.83-3.42 .15
Variable Coeff. SE t P
Model 3. Perception of risk of contracting a hospital-associated infection
F(7,442) 5 16.77, P ,.0001, R
2
5 21%, adjusted R
2
5 19.7%
Knowledge of the incidence rate of hospital-associated infections:
Correct* - - - -
Overestimation 1.14 0.28 4.05 ,.001
Belief that health care professionals can infect patients 21.38 0.25 25.46 ,.001
Hospital ward 20.67 0.26 22.61 .009
Marital status 0.53 0.24 2.16 .031
Occupational position 20.5 0.25 21.98 .048
Age 0.01 0.01 1.92 .055
Need of additional information about hospital-associated infections 0.64 0.34 1.87 .06
Constant 4.92
*Reference category.
Abbate et al February 2008 43
was attained was the media and not by qualied health
care representatives. We believe that although media
campaigns may have a positive impact, they appear
to have limited impact on long-term behavioral
changes, thereby necessitating the implementation of
educational and policy strategies. These ndings sug-
gest that it is crucial for infection control professionals
to disseminate information to patients in the context of
routine medical care and this is also supported by our
nding that health care workers are viewed by almost
all respondents as useful resources that can be used
to provide patient information and patient education.
With regard to attitudes and opinions expressed dur-
ing this survey, a vast majority of patients believe that
hospital-associated infections are preventable, but the
study discovered that more than three-quarters of re-
spondents (79.8%) were worried about contracting
such infections, and 2.7% said that they were very
much concerned about this. In this scenario, whereby
poor knowledge coexists with high perceived risk, one
may argue that hospital-associated infections educa-
tional programs are not needed, but also very likely
to be welcomed. Results of this study agree with those
of a previous mail survey conducted in the late 1980s
in the United States, in that 83% of those responding
believed that nosocomial infections were preventable,
and 70% were concerned about their risk of acquiring
such infections if future hospitalization was required.
3
A lower value was observed in Nigeria with 54% of the
patients attending dental clinics felt they could con-
tract an infection.
8
Data from our study suggest that, although 71.1% of
the patients self-reported having had at least one expo-
sure to hospital-associated infections related to the
compliance of health care workers with standard pre-
cautions, a large proportion did not say anything when
the worker did not wear gloves, when touching blood,
body uids, mucous membranes, or nonintact skin, and
mask during procedures and patient-care activities that
may pose risk for contamination by nasal and/or oral
ora of the health care worker. The implication of this
nding is that, despite increasedconcerns about the risk
of hospital-associated infections, exposure continues
to be frequent. Therefore, there is a special need to
reinforce information to health care workers about
personal and patients exposure and to follow standard
precautions in order to prevent such infections.
The results of the regression models, it is worth men-
tioning, revealed that patient knowledge of hospital-
associated infections signicantly inuences percep-
tion of risk. Specically, patients who overestimate
the incidence rate, perceived their own risk as signi-
cantly higher than that of those more knowledgeable.
Furthermore, it has been well established that worried
individuals were, although not signicantly, more likely
to seek more information. Such ndings suggest that
patients would both welcome and benet from tools
and strategies that would help reduce fear because it
is important in whether or not they adhere to these
procedures. It is also evident from the survey that the
perception that health care workers can transmit a
hospital-associated infection was related to precau-
tionary behaviors among respondents. Those patients
who have this perception were more likely to practice
precautionary behaviors, because they were more will-
ing to stop a health care worker who is not using gloves
and face mask during the activity.
In conclusion, our results indicate signicant oppor-
tunities for improving current levels of knowledge
about hospital-associated infections among the general
public that it is crucial to the development and imple-
mentation of effective public health preventive strate-
gies. Close monitoring of the population-specic
impacts of these interventions is required to assess
the efcacy of these efforts.
The authors would like to thank all patients who participated in the study.
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44 Vol. 36 No. 1 Abbate et al
APPENDIX A
Abbate et al February 2008 45
46 Vol. 36 No. 1 Abbate et al
Abbate et al February 2008 47