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ORIGINAL ARTICLE
Year : 2022 | Volume
: 10
| Issue : 3 | Page : 243-252
Awareness and knowledge of postoperative surgical site infections in patients from Saudi Arabia: A multi-regional cross-sectional study
Alaa Mohammed Alsahli1, Abdullah Ahmed Alqarzaie2, Ali Mohammed Alasmari1, Mohammed M AlOtaibi3, Abdulrahman Majed Aljuraisi1, Abdulaziz Abdulrahman Khojah4, Nadia Abdullah M. Alzahrani5, Faten Alaqeel6
1 College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, National Guards Health Affairs, Riyadh, Saudi Arabia
2 College of Medicine, Imam Abdulrahman Bin Faisal University, Dammam, Saudi Arabia
3 College of Medicine, Taif University, Al Khobar, Saudi Arabia
4 College of Medicine, Prince Sattam Bin Abdulaziz University
5 College of Medicine, Tabuk University, Al Khobar, Saudi Arabia
6 Department of Surgery, Imam Abdulrahman Bin Faisal University, King Fahd Hospital of the University, Al Khobar, Saudi Arabia
Correspondence Address:
Alaa Mohammed Alsahli
College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, Riyadh
Saudi Arabia
Source of Support: None, Conflict of Interest: None
CheckDOI: 10.4103/sjmms.sjmms_421_21
Background: Knowledge regarding surgical site infections (SSIs) can help reduce hospital stay, morbidity, and mortality associated with SSI.
Objectives: This study aimed to determine the knowledge and awareness of SSI among patients undergoing surgeries across Saudi Arabia.
Methods: This multi-center cross-sectional study included adult patients (aged >18 years) who underwent surgery at six centers located across the five regions of Saudi Arabia. A 36-item questionnaire was used to elicit data regarding demographics, patient's health status, procedures, and hospitalization history and awareness and knowledge about SSIs.
Results: A total of 375 patients were included (equally for all five regions of Saudi Arabia). Most patients were male (55.7%) and aged 18–34 years (44%). Most respondents (49.1%) had poor awareness; being illiterate and from the Northern region were significant factors (P = 0.001). Patients with no history of surgery (P = 0.001) or SSI (P = 0.003) also had poor awareness levels. In terms of knowledge, 45.8% and 35.2% of the participants had fair and poor knowledge, respectively, with the level of knowledge being significantly associated with region (P = 0.001). Patients those aged >65 years had poor knowledge (P = 0.033), while of males had good knowledge (P = 0.02). Patients with no history of surgery had poor knowledge of SSIs (P = 0.003). Only 32.8% of the patients recalled having been educated by healthcare workers. About 42% learned of SSIs from sources outside the hospital, with internet/social media platforms accounting for 48.4% of such sources.
Conclusion: A significant proportion of the patients included in this study had poor awareness and knowledge of SSIs. The study highlights the need for strengthening the preoperative patient education in Saudi Arabia to reduce the likeliness of SSIs.
Keywords: Awareness, knowledge, postoperative, surgical intervention, surgical site infections
Surgical site infections (SSIs) are infections that occur within 30 days of a surgery, affecting either the incision or deep tissue at the operation site, and thus often require surgical intervention for management.[1],[2] Despite advances in surgical techniques, the rates of SSI remain considerably high, with a recent meta-analyses estimating the worldwide incidence of SSIs to be 11% after general surgeries and 7% after appendectomies.[3],[4],[5] SSI rates differ across countries depending on various factors.[3],[6],[7] In Saudi Arabia, SSIs have been reported to be 2.5%, 3.4%, and 12.9% following orthopedic surgeries, foot and ankle surgeries, and trauma laparotomies, respectively.[8],[9],[10]
SSI is a considerable disease and healthcare burden, as it increases hospitalizations, costs, and mortality rates.[11] For example, in the United States, SSI increases the average hospital length of stay by 9.7 days and the average cost of each patient by $20,000, resulting in an annual additional cost of $3.3 billion.[2] In low-and middle-income countries, SSI can pose a serious economic burden.[12] Therefore, there is need to lower the rates of SSIs worldwide.
One of the effective strategies for SSI prevention is increasing patient engagement.[13] A recent scoping review has highlighted a gap in patient participation to reduce SSIs; however, most studies in the literature are from high-income countries.[14] To develop effective engagement strategies, it is important to understand the current knowledge and awareness of patients. In Saudi Arabia, no such studies are currently available. Therefore, this study was conducted with the objective of measuring the knowledge and awareness of SSI among patients undergoing surgeries across Saudi Arabia. Through a multi-centered approach, the findings of this study would aid in the development of SSI preventative strategies in Saudi Arabia.
MethodsStudy design, setting, and participantsThis multi-center cross-sectional study included adult patients (aged >18 years) who underwent surgery at the following six centers located across the five regions of Saudi Arabia: King Abdulaziz Medical City, Riyadh, and Al Kharj Armed Forces Hospital, Al Kharj (both from the Central region); King Fahd Hospital of the University, Al-Khobar (Eastern region); King Abdulaziz Specialist Hospital, Taif (Western region); King Salman Armed Forces Hospital, Tabuk (Northern region); and Asir Central Hospital, Abha (Southern region). The chosen hospitals serve as the main government health-care centers in their respective regions and have a high volume of surgical procedures.
The study was approved by the institutional review board of King Abdullah International Medical Research Center, Riyadh, Saudi Arabia.
Sampling and data collection
The data collection method followed a non-randomized convenience sampling technique. The required sample was calculated using the Raosoft sample size calculator, with a 95% confidence interval and a 5% margin of error. The estimated sample size was 377 Saudi patients. Data were collected between November 2019 and March 2020 through face-to-face responses to a close-ended questionnaire. All interviewers were provided training to ensure coherency in the data collection process. The interviewers were natives of their respective regions and aware of differences in regional dialects, and thus were able to resolve any ambiguities in the questionnaire for the respondents.
Patients with cognitive impairment or who could not communicate were excluded from the study. Participants were informed of their response being voluntary and were assured of data confidentiality. All respondents provided consent for participating in this study.
Study tool
This study adopted the questionnaire developed by Albishi et al.[15] and modified it for a patient population. The questionnaire was in English and was composed of 36 questions categorized into three sections [Appendix 1]. Thefirst section questions elicited the demographic information (age, gender, nationality, region, marital status, level of education, and employment status). The second section investigated the patient's health status, procedures, and hospitalization history. The final section assessed the level of awareness (8 questions) and knowledge (6 questions) about SSIs using the scoring system described by Albishi et al.[15] (Good = ≥80%; fair = 50%–79%; or poor = <50% level of awareness and knowledge). The questionnaire was pilot tested in 50 randomly chosen patients from across the five regions, following which no additional changes were deemed necessary; these responses were not included in the full-scale study analyses. The reliability of the questionnaire was assessed using Cronbach alpha and was found to be 0.8.
Statistical analysis
Data were entered in Microsoft Excel 2016 and analyzed using SPSS version 25 (IBM Corporation, Armonk, NY, USA). Chi-square test was used to compare categorical variables and the outcome variable. Numerical variables were compared using an independent sample t-test. ANOVA test was used to obtain the difference in means of variables. P value < 0.05 was considered statistically significant.
ResultsA total of 375 patients were included: 75 from each of the five regions of Saudi Arabia. The majority of the participants were male (55.7%), aged 18–34 years (44%), and married (62.4%). In terms of education level, 47.7% had completed school, while 42.4% had a bachelor's degree. Most patients had either undergone laparoscopic (46.1%) or open (40.8%) surgeries and had been hospitalized for 0–7 days (89.6%) [Table 1].
Table 1: Demographic and surgical characteristics of the respondents (N=375)Awareness regarding surgical site infections
Most respondents (49.1%) had poor awareness, while 28.8% and 22.1% had good and fair awareness, respectively. The level of awareness was not associated with age, gender, marital status, and employment status. However, being illiterate and from the Northern region of Saudi Arabia were significantly associated with a poor level of awareness (P = 0.001); respondents from the Central region had the highest level of awareness. In addition, poor awareness levels were found in patients with no history of surgery (63.6%; P = 0.001) and SSI (P = 0.003) [Table 2] and [Figure 1]a. Finally, 70% of the participants who knew someone that had developed SSIs had a good level of awareness (P < 0.001).
Knowledge regarding surgical site infections
In terms of knowledge, most (45.8%) had fair knowledge, while 35.2% and 18.9% had poor and good knowledge, respectively. The level of knowledge was not associated with marital status but was significantly associated with the region (P = 0.001). Participants from the Eastern region of Saudi Arabia had good knowledge, while those from the Southern region had poor knowledge. In terms of age, a significantly higher proportion of those aged >65 years had poor knowledge (P = 0.033). A significantly higher proportion of males had good knowledge of SSI compared with females (P = 0.02).
In terms of surgical characteristics, the level of knowledge was not significantly associated with the type of surgery, days of hospitalization, previous admissions, and the number of previous surgeries. Participants with a history of surgery had good knowledge of SSIs (P = 0.003). Furthermore, 27.2% of the participants with a history of SSIs had poor knowledge level (P = 0.009) [Table 3] and [Figure 1]b.
Participants who knew of someone with SSIs had a good level of knowledge compared with those who did not (27.8% vs. 16.1%; P = 0.001). The association between pre-operative counseling on the possibility of SSI after surgery with the type of surgery and hospital stay was found to be statistically insignificant. Furthermore, only 12.5% of participants who believed they have sufficient knowledge of SSI were found to have good levels of knowledge compared to 36.3% who stated they did not have a sufficient knowledge level (P < 0.001).
Source of surgical site infections education
Around one-third (32.8%) of the patients reported that healthcare workers (HCWs) educated them about SSIs. Of these, 81.3% were satisfied with the amount of information provided and 83.7% were satisfied with the amount of time dedicated. About 42% learned of SSIs from sources outside the hospital, with internet/social media platforms accounted for 48.4% of such sources followed by awareness campaigns in malls (10.2%) and articles in newspapers (8.6%).
Prevention of surgical site infections
In terms of perception on the possibility of preventing SSI, 93.3% of the respondents believed that SSI is preventable. Of these, 66.3% and 52.3% believed that keeping the wound clean and hand washing, respectively, were the most effective preventative measures. In regard to smoking cessation, 76% considered smoking increases the risk of developing SSI post-operatively.
DiscussionThis study found that 49.1% and 35.2% of the patients included in the study had poor levels of awareness and knowledge, respectively, which is similar to findings from a study conducted across three hospitals in England.[16] Interestingly, those with a history of SSI in the current study had significantly poor awareness levels, indicating a lack of learning curve from prior SSIs. The study was unable to assess if this was due to their lack of self-care or lack of knowledge provided after the initial SSI, and this needs to be assessed in future studies to provide data for focused interventions.[17] To the best of our knowledge, this is thefirst study from Saudi Arabia that has assessed the knowledge and awareness of surgical patients at risk of contracting SSIs, and the findings from this study is a call for action to further increase the awareness and knowledge of such patients through patient engagement.
Patient engagement by healthcare workers is a viable strategy for reducing SSIs.[13] However, in this study, only 32.8% of the patients recalled having been educated by HCWs, which is similar to the findings of Anderson et al.,[11] who reported that only 40% of surgical patients at risk of developing SSI recalled education by HCWs. Nonetheless, in our study, most patients who recalled having received education by HCWs were satisfied by the amount of information provided (81.3%) and time dedicated (83.7%). While the current study did not collect data regarding the exact amount of time HCWs spent educating patients regarding SSI, Anderson et al. found this to be <5 mins in 42% of the patients. A similar proportion of patients in our study and that of Anderson et al. (42.4% and 46%, respectively) learned of SSIs from sources outside the hospital. Internet/social media accounted for 48.4% of such sources in our study. This is understandable given the adoption of and access to internet in Saudi Arabia is high,[18] but also indicative of the urgent need to direct these patients reliable sources for obtaining information digitally. Participants in this study who believed they have sufficient knowledge about SSI had significantly poor level of knowledge, which may have been because of using incorrect sources. Surprisingly, only 16.8% of the participants in the current study reported being given educational material about SSI by HCWs, considerably lower than that reported in the study by Anderson et al. (60%).[11]
Being illiterate and aged >65 years were significant factors associated with poor levels of awareness and knowledge, respectively. Understandably, this indicates that the health information-seeking behavior among these populations are low and a more focused approach should be adopted to ensure the delivery of SSI preventive information to these groups. A higher proportion of males were found to have “good” knowledge compared with females. While it was beyond the scope of the current study to correlate the knowledge levels with those who contracted infections post-surgery, previously, SSI have been reported to be more common among males than females.[19]
Local economic conditions can cause regional healthcare variations.[20] This was also observed in our study, where SSI knowledge was highest among patients from the Central and Eastern regions, which are largest regions of the country and have the highest GDP. The Central region also has the highest number of healthcare facilities, and potentially, their health-promotion activities may have resulted in the higher knowledge levels noted in this study.[21],[22]
Participants who knew someone who had SSIs had a good level of knowledge and awareness compared with those who did not. A plausible explanation for this is that knowing someone having SSIs may have led to increased health information-seeking behavior; however, this is not a robust explanation, as patients with a history of SSIs were found to be significantly poor awareness levels. Therefore, further studies are required to identify factors that influence the health information-seeking behavior in surgical patients from Saudi Arabia.
LimitationsAlthough the sampled population was representative and statistically adequate, a larger sample size would have increased the power of the findings. In addition, only key government tertiary hospitals were included for each region; a similar study conducted within private hospitals would widen the scale of knowledge, and collectively, better guide policymakers in formulating patient-centered policies for reducing SSIs.
ConclusionA significant proportion of the patients included in this study had poor awareness and knowledge of SSI, and remarkably, those with a history of SSI, had a poor level of awareness and knowledge.
Ethical consideration
The study was approved by the Institutional Review Board of King Abdullah International Medical Research Center, Riyadh, Saudi Arabia (Ref no.: RC19/382/R; dated: October 19, 2019). In addition, verbal approval obtained from the general surgery section heads at each hospital. All participants provided consent for participating in this study. The study adhered to the general principles outlined in the Declaration of Helsinki, 2013.
Data availability statement
The datasets generated during and/or analyzed during the current study are not publicly available but are available from the corresponding author on reasonable request.
Peer review
This article was peer-reviewed by four independent and anonymous reviewers.
Acknowledgment
The authors would like to thank Dr. Hind Almodaimegh, King Saud bin Abdulaziz University for Health Sciences for her continued support and advice throughout this project. Also, we would like to thank Dr. Mohamed Eldigire Hamid Ahmed, King Saud bin Abdulaziz University for Health Sciences for his contribution to statistical analysis. Also, the authors would like to thank Ms. Haifa' Hisham A. Alwabel, College of Medicine, King Khalid University for her extensive contributions to data collection from the Southern province.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
References
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