Awareness and Occupational Exposures to Needlestick Injuries among Healthcare Workers: A Quantitative Assessment in a Ghanaian Metropolis

Healthcare workers (HCWs) are at risk of getting needlestick injuries (NSIs) and associated blood-borne infections including hepatitis B virus (HBV), hepatitis C virus (HCV), and human immunodeficiency virus (HIV).^[1] Globally, three million HCWs experience percutaneous exposure to infectious diseases each year. Approximately, 40% of HBV and HCV and 2.5% of HIV/acquired immunodeficiency syndrome (AIDS) in HCWs are attributed to NSIs.^[2] With such high rates of transmission of blood-borne diseases among HCWs because of NSIs, it is prudent to devise prevention strategies to limit such incidents. Various studies have been conducted worldwide to assess the incidence of NSIs among HCWs,^[3,4] whereas more than 90% of blood-borne infections occur among HCWs in developing countries;^[2,5] reporting of such events is rarely done.^[6–8] Furthermore, different studies have shown transmission of HBV and HCV from HCWs to patients and approximately 70 infected HCWs have been identified who transmitted their infection to patients.^[9] In a more recent report from Japan, Sugimoto et al.^[10] reported a case of 41-year-old woman who became infected with acute HBV after gynecological surgery performed by a surgeon who tested positive to HBV surface antigen. Hence, transmission of infections in the likes of HBV, HCV, and HIV from a HCW to patients can happen and represent a significant scenario in health care. Hence, health workers are exposed to blood-borne pathogens that pose a threat to them as well as their patients' health.^[11]

Although, several studies have been conducted to assess the number of HCW affected by NSIs in developed countries such as the US, limited epidemiological studies regarding the risks and circumstances of needlestick and other sharps injuries among health personnel have been identified in developing countries.^[12] In addition, where such research is available, HCWs in developing countries have been shown to have a high incidence of NSIs.^[13,14] Previous research conducted among primary HCWs in Ghana showed that 21% of staff perceived that they were not at risk of exposure to blood-borne virus although potentially exposed.^[15] Although injections represent one of the most commonly practiced in medical procedures, it has been attributed to high risk of infections with blood-borne viruses, which HCWs stand at a critical point in practice to contract such infections.^[15]

The basic medical education in Ghana lasts 6 years in all the medical schools. Other basic health programs such as nursing, midwifery, and laboratory technology are run for 3–4 years, and successful completion leads to the award of a diploma or bachelor's degree depending on the type of program pursued. These programs turn out skilled health professionals who practice in various fields in the health sector.^[16] Different studies have reported a prevalence of NSI ranging from 45% to 94% among HCW.^[8,17] This high prevalence of NSIs in HCW warrants studies of the factors associated with it to devise prevention strategies and decrease the chances of acquiring infections. In Ghana, concrete knowledge about the transmission of infection in healthcare facilities because of NSI is limited. Little is known about the prevalence of NSI in Ghanaian healthcare facilities. Moreover, contributing factors to the occurrences of occupational NSI among HCWs have not yet been addressed well. Therefore, the study aimed to determine the prevalence of NSIs in HCWs in the Kumasi Metropolis, Ghana, and to enumerate the factors associated with it.

This cross-sectional study was conducted from December 2017 to April 2018, at three selected health facilities including one teaching hospital (Komfo Anokye teaching hospital [KATH]), one polyclinic (Cocoa Clinic), and the University Hospital, Kwame Nkrumah University Science and Technology (KNUST), which serves as a district hospital for the people in Oforikrom Sub-Metropolitan. These hospitals were selected from the 2010 directory of the Ghana Health Service.^[18] This database contains the official list of health facilities in Kumasi. The selected facilities provide both clinical and public health services to the residents of the sub-metro districts in which they are located.^[18]

Stratified random sampling technique was used to recruit a total of 540 HCWs including nurses, doctors, and biomedical scientists. Each of the healthcare facilities involved was considered as a stratum. Healthcare professionals were randomly selected from each stratum, where the numbers were proportionate to the population of HCWs in each hospital stratum. Sociodemographic characteristics, such as age, gender, and employment status, were obtained using a structured self-administered questionnaire.

HCWs that used needles, syringes, or other sharp medical equipment at the workplace and were working as full-time for at least 6 months were included in this study.

All technical, administrative, and hospital workers whose activities and profession did not expose them to NSIs were excluded from this study. Again, students who were temporarily assigned for training purpose were also excluded.

The questions used in this questionnaire were developed on an extensive review of related literature and modified according to an instrument used in the Survey of Hospital Coagulation Laboratory Practices, United States (CDC, 2001). The initial instrument was revised to improve clarity, brevity, and formatting after a pilot study. The first section of the questionnaire consisted of questions that elicited information on demographic characteristics such as age, facility, and job category. The second section consisted of questions pertaining to awareness and preventive practices of viral transmission via NSIs and sharp objects injuries among health workers. The third section constituted questions on the occurrences of NSIs such as the number of sharps injuries they had sustained while working in the healthcare sector, place of injury, purposes for which the sharp object was used for, and the duration of working in that health facility. The fourth section constituted questions on the availability of preventive measures, which include wearing of gloves, wearing of laboratory coat, completing sharp injury log, and completing training for safety-engineered sharps devices. Individuals recruited for the study were instructed to choose multiple answers where applicable. Subjects were asked to rate their perceived risk of acquiring HBV, HCV, or HIV infection at work place based on their practices regarding sharp objects and safety on a scale of 1–5 (1 = none and 5 = very high risk).

The questionnaires were personally distributed in paper form by the researcher to the registered HCWs employed at the three selected hospitals. A total of 600 questionnaires were administered. However, 543 questionnaires were returned (response rate of 90.5%) and 540 questionnaires were fully completed, therefore used for analysis.

The data entry and analysis were performed using Stata software package, version 12 (StataCorp). The final analysis was adjusted for missing variables. Descriptive statistics, such as frequencies and percentage, were used. Test of proportion statistical methods was used as appropriate to test the comparison between categorical variables. Regression analysis with robust error variance was used to estimate prevalence ratios (PR) as a measure of association for the relationship between independent variables (age, gender, type of facility, job category, and working experience) and NSI as the primary outcome. PR was used as a measure of association alongside odds ratios because of the high prevalence of the outcome (>10%), thus providing a better estimate of risk.^[19] A p value of less than 0.05 was considered statistically significant.

Approval for this study was obtained from the Committee on Human Research, Publication and Ethics, Kwame Nkrumah University of Science and Technology, Faculty of Allied Health Sciences (KNUST-SMS), and KATH, Kumasi, Ghana. Study participants were adequately informed of the purpose, nature, procedures, risks, and hazards of the study. Points to be emphasized on included anonymity, confidentiality, and the freedom to decline participation at any time without penalty.

As shown in Table 1, the majority (62.0%) of the study participants were within the age bracket 20–30 years and female participants represented approximately 51.0% of the study sample. A major percentage (60.7%) of the health workers included in this study were from a teaching/regional hospital, 31.5% were from districts health facilities, and 7.8% represented participants from the polyclinics. A majority (60.4%) of the study subjects has had working experiences of 5 years and below, 25.6% had worked between 5 and 10 years, 8.0% had between 11 and 15 years of working experience, and 6.1% had more than 15 years of experience in working.

As shown in Table 2, all the study participants (100.0%) were aware of NSI-associated HBV, HCV, or HIV acquisition. More than half of the participants (63.6%) were trained on the safety use of sharps devices. Higher proportion preferred safety-engineered devices (79.8%). Most of them perceived a very high risk of acquiring HBV, HCV, and/or HIV (33.7%). A greater proportion (85.9%) of them had HBV vaccination.

Table 3 shows the ranking of exposure to NSI or sharp object injury and the frequency of injuries reported by participants. Exposure by place of injury indicated that most (28.5%) injuries occur at patient's bedside (1st) followed by clinical laboratories (24.6%), and the least (1%) of injuries occurred outside patient area (last rank, 11th). As per exposure by usage of sharp item, injuries occurring when taking venous blood samples ranked first (19.9%), followed by injection or aspiration (15.6%), flashing of intravenous line or port (11.3%), and the least ranked exposure edge by purpose was cutting (2.3%). Also considering exposure by means of which injury occurs, injuries occurring during item use ranked 1st (34.0%) trailed by before item use (28.0%) and the least rank (9th) exposure was opening of disposable container (1.0%).

Association between participants' demographics and the frequency of NSIs among health workers is shown in Table 4. Compared to respondents within the age range 20–30 years (reference), the chances of NSI/sharp objectives injury among the aged population are 3.19 and 4.20 times for 30–45 years age group and >45 years age group, respectively. Also compared with those with less than 5 years of working experience, having worked at the health facility between 5 and 10 years (PR ratio [PRR] = 2.11 [1.41–3.16], p = 0.0003), 11 and 15 years (PRR = 4.32 (2.14–8.73), p < 0.0001), and >15 years (PRR = 6.21 [2.62–14.74], p < 0.0001) were associated with increased chances of NSI.

Table 5 shows preventive practices on NSIs and sharp object injuries among respondents. Compared to HCWs who never wear gloves, those who “sometimes” (PRR = 0.88, p = 0.668) and “always” (PRR = 0.83 p = 1.000) wear gloves were less likely to be associated with events of NSI. HCWs who never wore laboratory coats were more likely to be exposed to NSIs (PRR = 1.08, p = 0.075) compared to those who wear them always, although no statistically significant difference was observed. However, HCWs who “sometimes” (PRR = 0.92, p = 0.002) wear laboratory coat and those who “occasionally” (PRR = 0.57, p = 0.0024) wear laboratory coat were significantly less likely to be exposed to NSIs in reference to those who wear it always. Recapping needles after use or not (p = 1.000), provision of safe working environment (p = 0.059), availability of sharp injury logs (p = 0.059), regularly sharing of sharps (p = 1.000), and sharp training (p = 1.000) were not significantly associated with the events of NSIs.

NSI is a general public health burden causing numerous hazards for HCWs.^[20] Biomedical scientists, doctors, nurses, and other health workers are at increased risk of NSIs because of the nature and exposure of their work to needles and sharp objects. There is however limited reliable surveillance data regarding occupational exposure to needlesticks in Ghana. This study, therefore, determined knowledge and occupational exposures to NSI and its associated risk factors among HCWs in the southern part of Ghana.

We found that all the study participants were aware of NSI and NSI-associated HBV, HCV, or HIV acquisition, which is consistent with previous reports from several cross-sectional studies.^[21,22] The highest NSI prevalence reported in this study was 47.4%. This is lower to a report from a cross-sectional survey by Vaz et al.^[23] that observed a prevalence of 78% and 64% among Jamaican medical doctors and nurses. Another cross-sectional survey among nurses working at a Turkish hospital in 2005 also reported that 79.7% of nurses experienced sharp or NSI once in their professional life.^[24] On the contrary, the prevalence observed in this study was considerably higher than the reports from a cross-sectional study conducted among health workers in an eastern Nigerian hospital.^[25] Ampomah^[26] reported a prevalence of 26.7% among night shift nurses in Ghana, which is lower to the reported prevalence in this study. It has been shown that the likelihood of experiencing NSIs significantly decreases if HCWs adhere to universal precautions.^[27]

Thus, inconsistencies on NSIs reported prevalence could be due to the different quality assurance practices adopted by the different hospitals to reduce NSIs. It also could be explained by the varying small sample size in the various studies.

Our results found that increased risks to NSIs exposure are associated with advanced age. This finding is inconsistent with reports by Ilhan et al.^[24] who observed increased age to be associated with decreased risk of hospital-associated injuries. Cho et al.^[28] also reported that high emotional exhaustion significantly increases the risk of NSI or sharps injuries. However, our finding is in keeping with reports by Gholami et al.^[29] in a cross-sectional study among HCWs who found increased age to be significantly associated with increased likelihood of NSI. The financial and social burden associated with aging could pose emotional instability in workers and can be extended to the workplaces. Furthermore, Ghana is a developing nation grappled with more economic challenges, this observation could contribute to these discrepancies between our findings and previous reports.

The results of this study found that increased risk of NSIs exposure was significantly associated with long duration of working experience. HCWs who have worked for 5–10 years, 11–15 years, and >15 years had 2.11 times, 4.32 times, and 6.21 times increased risk of NSI exposure [Table 4]. Afridi et al.,^[17] in a cross-sectional study conducted at two tertiary care hospitals in Pakistan, observed a similar finding. People with much working experience may have a higher tendency to ignore laid down procedures because of complacency. Also, one significant implication on this finding could be the significance of aging influencing NSI. In reality, years of working experience parallels aging, thus this observation. Moreover, our finding does concur with reports from a cross-sectional study conducted in Germany by Wicker et al.^[30]

The prevalence of NSI was insignificantly higher among nurses (50.1%) and highest among other groups of health workers (54.4%). This finding is comparable to reports from a cross-sectional study conducted at a teaching hospital in Nigeria, wherein nurses were found to be at higher risk of NSI.^[31] In addition, nurses were found to be the most affected job category in a study among HCWs in Saudi Arabia.^[32] Moreover, several studies have endorsed that nurses are more likely to experience NSI.^[3,17,33] The reason for this observation is that syringe needles are the most commonly used sharp objects among medical staffs in Ghana and basically nurses perform the majority of the injections and intravenous fluid administration.^[26] Moreover, nurses are the main healthcare professionals that deal with injections and sharp objects; and the number of nurses is generally higher in comparison to other occupational groups in hospitals. In addition, high patient-to-nurse ratio, heavy workload, crowded wards, rushed performance, and the lack of precautions could account for the high exposure of nurses to NSIs.^[34,35]

We found that as per exposure to NSIs, patient's bedside ranked the highest place of injury, followed by clinical laboratories and emergency room, whereas participants outside patient area recorded the least needle injuries [Table 2]. This observation is contrary to the findings from a cross-sectional survey among hospital workers in South Korea.^[28] Bekele et al.^[36] in a cross-sectional study among Ethiopians also reported emergency ward to be the department with the highest prevalence of NSI, which is contrary to our findings. Another finding from this study was that venous blood sampling and the giving of injections/ aspirations reportedly ranked first and second, respectively, under the heading of “the purpose of syringe and injury exposure.” Also, in terms of means of frequent exposure to injuries, NSIs commonly occur during the use of needle/ sharp object or before its usage. This report is inconsistent with the findings by Galougahi^[37] and the previous studies that found that injection was the most common activity that led to injuries.^[38] This implies that HCWs who report NSI are associated with inappropriate needle handling practices. It might be also because the majority of the procedures performed for the patients require syringe needles that may put HCWs under risk of injuries.

In clinical settings, safety demands the action of measurements, monitoring, and anticipating risk to enhance safe care practices.^[39] Thus, to prevent the spread of infection and injury, health workers must be well prepared to appropriately select and use personal protective equipment (PPE). The importance of using PPE such as gloves and laboratory coats have been established in several studies which agree to the use in double gloves in preventing NSI.^[40,41] This study showed that participants who never wore laboratory coat were 1.08 times more likely to be exposed to NSIs. Conversely, participants who “sometimes” wore a laboratory coat and those who “occasionally” wore laboratory coat were significantly less likely to be exposed to NSIs [Table 5]. Even though the provision of a safe working environment was not statistically associated with NSIs exposure (p > 0.05) in this study, NSI was higher among HCWs who responded to be working in a safer environment. These findings highlight the fact that HCWs are still not adhering to safety policies nor complying with exposure precautions and protocols. Notably, HCWs might be aware of standard precautions, these are not fully practiced.

Notwithstanding that our findings are comparable to several other studies, some limitations should be taken into consideration when interpreting the results in this study. The cross-sectional design of the study, the kind of self-reporting of collected data, not measuring the risk of NSI in a standard time unit, and finally, the small sample size, may not allow actual causative conclusions to be made.

Despite the high awareness of NSIs and its perceived risk of infection acquisition, prevalence of NSIs was still high among health workers in the Kumasi Metropolis with the most frequent rate found among nurses. Most NSIs occur at patients' bedside. Significant risk factors identified were not wearing a laboratory coat, age, and working experience of workers. It is imperative for stakeholders to promote enough working conditions and adherence of universal precautions to clamp down hospital injuries. Again, employers must enforce the universal precaution practices, provide regular training and education, and recruit OHS officers to monitor and ensure adherence of HCWs to safety precaution of needle usage.

Our gratitude goes to health workers at the Komfo Anokye Teaching Hospital and the Department of Molecular Medicine, KNUST, Cocoa Clinic, and the University Hospital, KNUST, Ghana.