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 Table of Contents  
ORIGINAL ARTICLE
Year : 2017  |  Volume : 20  |  Issue : 1  |  Page : 53-60

Infection control by nurses in selected hospitals in Anambra State, Nigeria


1 Department of Nursing Science, Faculty of Health Sciences and Technology, College of Health Sciences, Nnamdi Azikiwe University, Anambra State, Nigeria
2 Department of Nursing, Faculty of Clinical Sciences, College of Medicine, University of Ibadan, Ibadan, Oyo State, Nigeria

Date of Web Publication11-Jan-2017

Correspondence Address:
Dr. Eunice Ogonna Osuala
Department of Nursing Science, Faculty of Health Sciences and Technology, College of Health Sciences, Nnamdi Azikiwe University, Nnewi Campus, Anambra State
Nigeria
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DOI: 10.4103/1119-0388.198122

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  Abstract 

Background: Client safety in the health-care environment requires the reduction of microorganism transmission. Infection control practices are directed at controlling or eliminating source of infection in the health-care agency, home, or communities to reduce the occurrence and transmission of infectious diseases. Among health workers, nurses spend the greatest time in caregiving setting. Nurses' involvement in infection control measures will yield positive results in infection prevention and control in hospitals. Aim: To evaluate the knowledge, attitude, and practice of nurses in the state on infection control and barriers to practice to generate information that would guide future interventions to scale up practices. Methods: It is a cross-sectional study of descriptive design. Multistage sampling technique was adopted. The hospitals in the state were stratified according to ownership - federal, state, mission, and private. Using balloting, three categories of hospitals were randomly selected out of the four. One hospital each was selected from the three main cities in the state based on federal, state, and mission ownership, respectively. Instrument for data collection was a self-structured questionnaire, which was validated and with a reliability value of 0.82 computed on ten nurses in a pilot study. The population of nurses in the three hospitals was small (310). Using convenient sampling method, nurses on morning duty were selected. A sample of 202 nurses based on shift duty, out of the 310 nurses from the three selected hospitals constituted the study population even though only 197 out of the 202 nurse participants returned their questionnaire. Descriptive and inferential statistics using Spearman's rho correlation were applied. Results: Out of the 197 respondents, 84 (42.6%) responded that their hospital has infection control unit and 66 (34.1%) stated that they have infection control committee in their hospitals. Respondents with a knowledge score above 60% were only 20 (10.2%), but 170 (86.3%) and 120 (60.9%) had attitude and practice score above 60%, receptively. Only 5 respondents (2.5%) strongly agreed that hand washing is the key to infection control. Conclusion: There is a need to explore the discrepancy between knowledge, attitude, and practice. Facility monitoring is vital to effective infection control practices and should be the focus of intervention.

Keywords: Infection control, nosocomial-infections, nurses and practice


How to cite this article:
Osuala EO, Oluwatosin O A. Infection control by nurses in selected hospitals in Anambra State, Nigeria. Trop J Med Res 2017;20:53-60

How to cite this URL:
Osuala EO, Oluwatosin O A. Infection control by nurses in selected hospitals in Anambra State, Nigeria. Trop J Med Res [serial online] 2017 [cited 2019 Jun 25];20:53-60. Available from: http://www.tjmrjournal.org/text.asp?2017/20/1/53/198122


  Introduction Top


Healthcare-associated infections (HAIs) have been reported to be a serious problem in the health-care services as they are common causes of illness and mortality among hospitalized patients including health-care workers (HCWs).[1] HAIs have continued to be one of the most important public health problems in most countries of the world.[2] Infection can be contacted through various means such as inhalation or contact with contaminated surfaces. HAIs constitute one of the greatest challenges of modern medicine.[3] Nosocomial infections are a major problem in health-care facilities, resulting in extended duration of care, substantial morbidity and mortality, and excess costs.[4] Standard precautions are recommended to prevent transmission of infection in hospitals. However, their implementation is dependent on the knowledge and attitudes of HCWs.[5] The nurse, as a front-line caregiver should provide for the client's safety, on the basis of her own understanding of the factors which contribute to such harm. Many disciplines within the health sector have very important and valuable contributions to make in protecting the patient from infection. However, by virtue of nurses' long stay with the client, a much higher degree of responsibility in protecting the patient from infection rests upon them. The risk of transmission of pathogens when providing medical care and the reduction in the rates of the incidence of HAIs can be kept low through appropriate standardized prevention procedures.[6],[7]


  Background Top


Hospital-acquired infections otherwise known as nosocomial infections are infections acquired in the hospital or other health-care facilities that were not present or incubating at the time of the client's admission. It includes those infections that become symptomatic after the client is discharged as well as infections among medical personnel. Most nosocomial infections are transmitted by health-care personnel who fail to put into practice standard infection prevention measures such as hand-washing procedures or change of gloves between client contact. Compliance on the part of HCWs including nursing and medical students with standard precautions has been recognized as being an efficient means to prevent and control HAIs.[8] Such measures not only protect the patient but also the HCWs and the environment. Among the standard precautions advocated, hand hygiene is considered, in itself, the most important one. Other measures include adequate use of gloves, adoption of safe practices for handling needlesticks and other sharp objects. Compliance with these standard precautions has been shown to reduce the risk of HAIs.[1] However, in spite of the effectiveness of these standard precautions, what reality shows us is very low compliance with these measures;[8] poor hospital hygiene has been widely publicized including patients' concerns about safety in hospitals. This has made infection control a hot topic in clinical practice, media, and community at large. The main reason for infection control is to reduce the occurrence and transmission of infectious diseases.[9] Effective hand hygiene practices in hospitals play a key role in improving patient and provider safety and in preventing the spread of HAI.[10] Evidence has shown that proper hand washing, which is one of the infection control measures, can reduce the transmission of pathogens to patients and the spread of antimicrobial resistance.[3] In an infection control program in Geneva hospitals, evidence showed that overall hand hygiene practices when increased from 48% to 66% compliance, hospital acquired infections reduced to 9.9% from 16.9%.[11] This fact notwithstanding, the level of compliance with the use of proven personal protection measures by HCWs has not been encouraging as observed by researchers. Poor adherence to hand hygiene guideline was reported among HCWs in Bethesda, USA.[12] Another study in Ethiopia[13] reported that good hand hygiene compliance was very low (16.5%) among HCWs. A cross-sectional hospital-based study sought to assess the level of knowledge and practices regarding infection control among 293 nurses in a tertiary care hospital in Delhi revealed that the nurses had poor knowledge about standard precautions (97.9%). One hundred and eighty-nine (64.5%) nurses had inadequate knowledge about the transmission of blood-borne pathogens; more than three-fourth (77.5%) were aware of hepatitis-B vaccine; majority (72.7%) practiced washing soiled hands immediately; and more than half (58.7%) used gowns and gloves very often. Refresher training (34.5%) was the major source of information. The study highlighted major gaps between the knowledge and practices of nurses regarding standard precautions.[14] Similarly, studies from Nigeria reported poor hand hygiene compliance.[15],[16],[17] The study among dental professionals from Nigeria reported inadequate hand washing, and more than half of the respondents requested for more information on the indications and the steps of hand washing. Furthermore, poor hand hygiene, especially before snacks and meals were reported; however, doctors were more likely than nurses to wash hands before interacting with their clients.[15] In the study conducted in Nasarawa, Northern part of Nigeria, on various cadres of HCWs showed that 72.4% changed gloves after each patient, but only 3.3% had a sharp disposable system in the various workplaces. Majority (98.6%) of respondents reported that the major reason for noncompliance to universal precautions is nonavailability of the equipment.[1] Another study in two tertiary hospitals in Nigeria with a total of 290 HCWs with 76% response rate including 111 (38.3%) doctors, 147 (50.7%) nurses, and 32 (11%) laboratory scientists revealed that overall median knowledge and attitude scores toward standard precautions were above 90%, but median practice score was 50.8%.[5] Nursing personnel are at a greater risk of acquiring and transmitting pathogens as they have greater contact with patients and relatives more than any other member of the health team. Knowledge about standard precautions and practicing them is very critical in preventing nosocomial infections. This study focused on knowledge, attitude as well as behavior of nurses in Anambra State, Southeast of Nigeria toward infection control. The following objectives were addressed:

  • Identify infection control facility in the study settings
  • Evaluate nurses' knowledge of infection control measures
  • Assess nurses' attitude to infection control measures
  • Assess nurses' practice of infection control measures.



  Methods Top


It is a cross-sectional study which utilized multistage sampling technique. Anambra State was purposefully selected out of the 27 states of the federation. By stratification, three types of hospitals out of four, based on ownership (federal, state, and missionary), were selected using simple random sampling method through balloting. Private-owned hospitals were not selected. One hospital setting each was again selected out of the two federal, three state, and four mission owned facilities in the state using the same method.

There were 310 nurses in the three settings in the ratio of federal-owned hospital: 160, state-owned hospital: 110, and mission-owned hospital: 40. Data were collected only from nurses on morning shift; this was done to minimize attrition. A total of 202 nurses on morning duty, in the ratio of 97:84:21 from the three hospitals, respectively (federal, state, and mission hospitals), which were selected using simple random technique participated. Exercise lasted for 1 week.

Instrument for data collection was a self-structured questionnaire developed by researchers which consisted of both closed-ended and open-ended questions. The questionnaire consists of five sections: A, B, C, D, and E which addressed the sociodemographic characteristics of respondents, knowledge, attitude, practice of infection control as well as infection control gadgets in the facilities to support infection control practices of nurses, respectively. Statement on recommendation was open ended. Scores for knowledge attitude and practice were converted to percentages and later categorized. The instrument was reviewed by experts for face and content validity. Coefficient alpha of scores of a test-retest reliability test on ten nurses in another state was computed, and value was 0.82.

After obtaining the ethical approval of the Nnamdi Azikiwe University Teaching Hospital Ethical Committee (Ethical code: NAUTH/CS/66/Vol. 3/42) and the Anambra State Ministry of Health management, permission was taken from the head of each facility through the most senior administrative nurse. Using consecutive sampling method, nurses on morning duty were selected from the various wards and outpatient department of each hospital. The nurses were given the questionnaire, and the same was collected back on the same day or the day after. The duration for data collection was 1 week. Data obtained were managed using SPSS version 20 (IBM, USA). Descriptive analysis was computed using frequency and percentages and inferential statistics utilized Spearman's rho correlation. Descriptive analysis was used to compute data on knowledge, attitude, practice, demographic distribution, and also for facility while Spearman's rho correlation was used to determine the relationship among the respondent's knowledge, attitude, practice, and demographic characteristics. Knowledge score was computed scoring correct response as one whereas incorrect response was scored zero. Resulting score ranged from 0 to 10. Attitudinal score was computed by allotting a score of 4 for strongly agreed, agree for 3, disagree for 2, and strongly disagreed for 1 while "not decided" was graded 0 for positively skewed statements and vice versa for negatively worded statements. Minimum obtainable score for attitude was 0 and maximum was 40. For practice, minimum obtainable score was 0 and maximum 28.

Mean and standard deviation (SD) of composite score of knowledge, attitude, and practice were computed, same was converted to percentages. The percentage score was recoded as 0%-39% for poor, 40%-59% for fair, and >60% as good for knowledge, attitude, and practice. Participants' years of experience were correlated with percent knowledge, attitude, and practice score. Knowledge was correlated with practice and attitude whereas attitude was also correlated with practice. All correlations were computed using Spearman's rho correlation at 0.01 level of significance.


  Results Top


There was 97.5% response rate as 197 questionnaires out of 202 were retrieved and analyzed.

Sociodemographic data

The state of origin of participants recruited for the study was from nine different states of the Federation of Nigeria with 138 (70.1%) from Anambra State, the study site. Participants were between ages 21 and 60. Mean age ± standard deviation (SD) was 37.4 years ± 10.7. The maximum number of years of experience among the respondents' was 35 years whereas minimum was 1 year with a mean year of experience ± SD of 13.9 ± 10.9. [Figure 1] shows details of other sociodemographic characteristics of the respondents whereas [Figure 2] shows the distribution of the nurses by units.
Figure 1: Demographic variable of participants

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Figure 2: Distribution of nurses in various units. O&G: Obstetrics and gynecology, GOPD: General outpatient department, ICU: Intensive Care Unit, A&E: Accident and emergency

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Infection control facility in the hospitals

Eighty-four (42.6%) had infection control units in their hospitals whereas 66 (33.5%) respondents had infection control committee. None of the participants stated the functions of the infection control committee. Existing infection control gadgets in the hospitals were assessed. Less than half (46.7%) stated that taps always run in their units whereas 80.7% stated that sharp boxes were always available in their units. [Table 1] shows details of responses about facilities for infection control.
Table 1: Infection control facilities in the hospitals


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Knowledge, attitude, and practice of infection control measures

The mean knowledge score ± SD is 3.7 ± 1.5. Thirty-six (18.3%) considered hand washing as the most effective action for controlling the spread of infection, whereas 86 (43.7%) considered inappropriate hand washing as the most common contributory factor to nosocomial infection risk [Table 2]. Only 22 (11.2%) participants had good knowledge that is score above 60%.
Table 2: Knowledge of infection control measures


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The mean attitudinal score ± SD is 29.3 ± 5.5. Most of the respondents135 (68.5%) strongly agreed that hand washing is the key to infection control. However, negative attitude was elicited through responses to some statements, for example, none of the respondents strongly agreed that nurses with common cold should be excused from duty as infection control measure. [Table 3] shows other details of respondents' attitude to infection control. One hundred and seventy-one (86.8%) had attitudinal score above 60%.
Table 3: Attitude to infection control


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The mean practice score ± SD was 24.6 ± 5.5 [Table 4] shows details of infection control practices]. One hundred and twenty (60.9%) had a practice score of ≥60%; [Figure 3] shows other details.
Figure 3: Frequency of participants categorical percent score for knowledge, attitude, and practice

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Table 4: Practice of infection control


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There was a significant relationship between respondents' attitude and practice of infection control, r = 0.35, P = 0.000. However, there was no significant relationship between knowledge and attitude or knowledge and practice, P = 0.06 and 0.47, respectively. There was no significant difference between the distribution of score of knowledge, practice, and attitude across categories of recoded years of experience, P = 0.08 and 0.06, respectively.


  Discussion Top


HAIs can be prevented with consistent compliance to universal precautions for infection control by HCWs which include practice for handling needle sticks and other sharps, use of protective gadgets, antiseptics, and effective hand washing. Traditionally, people try to limit the transfer of germs and dirt by cleaning their hands with water before eating, feeding the infant, or even clean their hands on their clothes after a dirty hand work. This shows that even the layman sees the hand as courier for germs. Hand washing has even dominated all other precautionary measures since the emergence of Ebola and Lassa fever in West Africa. Hand hygiene is now a household name in Nigeria.

Very few barely 10% of the respondents in this study showed good knowledge of infection control. Responses to many knowledge questions were incorrect showing that there remains a gap in knowledge which needs to be filled, for example, the response to "Most common contributory factor to nosocomial infection risk is insufficient hand cleaning" was only correctly answered by less than half (45%). This finding of low knowledge of infection control is similar to the findings of the study at Delhi which reported that nurses showed poor knowledge about standard precaution.[14] However, this is at discrepancy with previous studies where nurses have demonstrated a high level of knowledge.[16],[17]

Majority of the participants were in the age group of 20-30 years, in each of the different age group category, the score pattern is the same with very few scoring above 60%. The highest frequency of those that scored 0-39 was in the 31-55 years age group. However, a greater percentage in the 1-15 years' work experience group than in the 16-30 or > 30 years work experience group scored above 60%. This shows that older participants who are also likely to be those with more years of experience scored lower in knowledge than those younger or with few years of experience. This is contrary to general assumption that experienced people are more knowledgeable and the people with longer years of experience will mentor new employees.

Infection control facility was found to be inadequate. There was neither constant water nor energy supply in some of the units. This is similar to the findings of another study in Southern Nigeria where about a third of the participants also indicated that water was not running in sinks.[16] Nonavailability of taps with sensors and automated hand dryers may be attributive to the fact that water supply and electricity supply are not regular. This basic infrastructure is vital to infection control measures. Other authors Ekwere and Okafor[17] also explained that due to lack of power supply, water is sometimes stored in plastic drums as a substitute to water supply in the Nigerian environment.

Responses for strongly agreed were low in statements such as "Hand washing is the key to infection control" Nurses with common cold should be excused from duty as infection control measure, portrayed negative attitude. Even though adequate knowledge and positive attitude to infection control were deduced from responses by the participants, practice was also poor, for example, there was no documentation of hand hygiene compliance. Washing of hand whenever in contact with the skin of patient was not done always by many participants. Only a few just over 30% complied with this practice. This may be due to lack of running water in some units and inadequate gadgets for standard precaution measures in the various hospitals studied. Low compliance to hand washing in this study was similar to that of Trampuz and Widmer,[3] but unlike the findings of Nobile[18] in Italy, where 60% of nurses decontaminate their hands at start of shift and 72.5% before and after contact with patients. In a study carried out in Canada,[19] hand hygiene compliance was very high (70%-99%) in contrast to the findings of the current study with low hand hygiene compliance. This may be due to availability of necessary facilities, especially running water and dryers in Canada, a developed country. However, a good number of respondents' compliance with hand hygiene was also reported among nurses in some Nigerian studies.[10],[11] The lower level of compliance in this study may be associated with inadequate facilities and material as in the study by… in Nasarawa where major reason for noncompliance to universal precautions was nonavailability of equipment.[1] All the participants in this study were female, this is similar to findings in most nursing studies globally, males are usually in the minority.[20] This is in support of the gender bias in nursing profession. If the majority of the staff are from the state of study, this may be as a result of proximity to workplace or it could be buttressing the fact that the nonindigene issue is real in Nigeria, especially in the Southeast where one loses an appointment or is transferred on the basis of state of origin.[21] The staff distribution shows that the highest number of nurses was posted to the obstetrics and gynecology units, followed by the pediatrics unit. This may be due to the emphasis on maternal and child health by the Federal Ministry of Health, to reduce the high maternal and infant mortality and morbidity rate in Nigeria.[22]

Limitations

The work may not be generalized due to the small sample when compared with the number of nurses in all the States of the Federation. The study adopted descriptive design rather than quasi-experimental design which would have been more beneficial.


  Conclusion Top


Gap between knowledge and practice is noted in this study as in related studies.[5],[14] Nurses in this study did not demonstrate good knowledge of infection control with some "strongly agreed" that sterile procedures are to fulfill all righteousness. Practice of infection control to reduce infection in health-care settings and to promote patients' safety was also poor, yet the single most common transmission of HAIs in a health-care setting is through transiently colonized hands of HCWs who acquire it from contact with infected patients, or after handling contaminated material or equipment. This might be due to insufficient gadgets for infection control. Provision should be made for adequate infection control tools in the hospitals, for example, running taps in the wards are very vital for hand hygiene; this should take precedence over acquisition of highly technological equipment. Despite all odds, nurses should endeavor to put in place, all that will promote adoption of standard precaution measures in their workplace to promote infection control in hospitals and reduce the number of days of hospital stay and finance lost to nosocomial infection. Further studies in other regions or zones of the country are being recommended for generalization of findings.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Amoran O, Onwube O. Infection control and practice of standard precautions among healthcare workers in Northern Nigeria. J Glob Infect Dis 2013;5:156-63.  Back to cited text no. 1
    
2.
Osoba AO. Infection control. In: Sobayo EI, editors. A Manual on Infection Control; for Hospitals in Developing Countries. Ibadan: Ibadan University Press; 2005. p. xv-xviii.  Back to cited text no. 2
    
3.
Trampuz A, Widmer AF. Hand hygiene: A frequently missed lifesaving opportunity during patient care. Mayo Clin Proc 2004;79:109-16.  Back to cited text no. 3
    
4.
Hilburn J, Hammond BS, Fendler EJ, Groziak PA. Use of alcohol hand sanitizer as an infection control strategy in an acute care facility. Am J Infect Control 2003;31:109-16.  Back to cited text no. 4
    
5.
Dimie OI, Kemebradikumo P, Babatunde A, George C, Chistian I, Sanusi G. Knowledge, attitude and practice of standard precautions of infection control by hospital workers in two tertiary hospitals in Nigeria. J Infect Prev 2015;1:16-22.  Back to cited text no. 5
    
6.
Harbarth S, Sax H, Gastmeier P. The preventable proportion of nosocomial infections: An overview of published reports. J Hosp Infect 2003;54:258-66.  Back to cited text no. 6
    
7.
Ferguson JK. Preventing healthcare-associated infection: Risks, healthcare systems and behaviour. Intern Med J 2009;39:574-81.  Back to cited text no. 7
    
8.
Yakob E, Lamaro T, Henok A. Knowledge, attitude and practice towards infection control measures among Mizan-Aman general hospital workers, South West Ethiopia. J Community Med Health Educ 2015;5:370.  Back to cited text no. 8
    
9.
Ojulong J, Mitonga KH, Iipinge SN. Knowledge and attitudes of infection prevention and control among health sciences students at University of Namibia. Afr Health Sci 2013;13:1071-8.  Back to cited text no. 9
    
10.
Ronnebeck L. Infection Control; 2008. Available from: http://www.ontario.ca/patientsafety [Last accessed on 2014 Feb 21].  Back to cited text no. 10
    
11.
Pittet D, Hugonnet S, Harbarth S, Mourouga P, Sauvan V, Touveneau S, et al. Effectiveness of a hospital-wide programme to improve compliance with hand hygiene. Infection control programme. Lancet 2000;356:1307-12.  Back to cited text no. 11
    
12.
Llata E, Gaynes RP, Fridkin S. Measuring the scope and magnitude of hospital-associated infection in the United States: The value of prevalence surveys. Clin Infect Dis 2009;48:1434-40.  Back to cited text no. 12
    
13.
Abdella NM, Tefera MA, Erede AE, Landers TF, Malefa YD, Alene KA. Hand hygiene compliance and associated factors among health care providers in Gonder University Hospital, Gonder North West Ethiopia. BMC Public Health 2014;14:96.  Back to cited text no. 13
    
14.
Acharya AS, Khandekar J, Sharma A, Tilak HR, Kataria A. Awareness and practices of standard precautions for infection control among nurses in a tertiary care hospital. Nurs J India 2013;104:275-9.  Back to cited text no. 14
    
15.
Omogbai JJ, Azodo CC, Ehizele AO, Umoh A. Hand hygiene among dental professionals. Afr J Clin Exp Microbiol 2011;12:9-14.  Back to cited text no. 15
    
16.
Bello S, Effa EE, Okokon EO, Oduwole OA. Hand washing practice among health care providers in a teaching hospital in Southern Nigeria. Int J Infect Control 2013;9:i4.  Back to cited text no. 16
    
17.
Ekwere TA, Okafor IP. Hand hygeine knowledge and practices among health care providers in a tertiary hospital in South West Nigeria. Int J Infect Control 2013;9:i4.  Back to cited text no. 17
    
18.
Nobile CG. Knowledge, attitude and behavior of personal of ICU about prevention of HAIs. J Hosp Infect 2002;3:226-32.  Back to cited text no. 18
    
19.
Dixit D, Hagtvedt R, Reay T, Ballermann M, Forgie S. Attitudes and beliefs about hand hygiene among paediatric residents: A qualitative study. BMJ Open 2012;2. pii: E002188.  Back to cited text no. 19
    
20.
Okanlawon FA. Gender mix in nursing: Implication for training and practice. Afr J Nurs Health Issues 2010;1:19-25.  Back to cited text no. 20
    
21.
Eke U. Minimum Wage: Abia Deports Non Indigenous Workers. Available from: http://www.thenationonlineNg.net/2011/index.php/news update/18677. [Last accessed on 2014 Jun 07].  Back to cited text no. 21
    
22.
National Primary Healthcare Development Agency of Nigeria. Nigeria Midwives Service Scheme; 2011. Available from: http://www.who.int/workforcealliance/forum/2011/hrhawardscs26/en/. [Last accessed on 2015 Jul 08].  Back to cited text no. 22
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]
 
 
    Tables

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



 

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