J Community Health DOI 10.1007/s10900-014-9837-7
ORIGINAL PAPER
Knowledge and Practices of Healthcare Workers in Relation to Bloodborne Pathogens in a Tertiary Care Hospital, Western Saudi Arabia Ali O. Al-Zahrani • Fayssal Farahat • Elham N. Zolaly
Ó Springer Science+Business Media New York 2014
Abstract To assess knowledge and practices of healthcare workers (HCWs) in relation to bloodborne pathogens in a tertiary care hospital, western Saudi Arabia. Selfadministered questionnaire was distributed assessing demographic characteristics, knowledge and practices of physicians, nurses and technicians on risks of exposure and prophylaxis against human immunodeficiency virus, hepatitis B virus and hepatitis C virus infections. A total of 466 participants (151; 32.4 % physicians and 315; 67.6 % nurses/technicians) completed the questionnaire. Almost two thirds of the physicians (60.9 %) and half of the nurses/technicians (47.6 %) had history of exposure to risks of bloodborne infection. Although both physicians and nurses/technicians showed acceptable level of knowledge about risks of bloodborne infections, modest proportion knew the correct actions including reporting following exposure. Behavioral-based in-service training interventions and strict policy should be implemented to promote compliance of HCWs to the protective measures against hazards of bloodborne infection.
A. O. Al-Zahrani E. N. Zolaly Family Medicine Department, Armed Forces Hospital, Taif, Saudi Arabia F. Farahat (&) Infection Prevention and Control Department, King AbdulAziz Medical City, PO Box 9515, Jeddah, Saudi Arabia e-mail: [email protected] F. Farahat King Saud bin AbdulAziz University for Health Sciences, Jeddah, Saudi Arabia F. Farahat Community Medicine and Public Health Department, Faculty of Medicine, Menoufia University, Shebin El-Kom, Egypt
Keywords Bloodborne pathogens Healthcare workers Saudi Arabia
Introduction Healthcare workers (HCWs) are those who have regular contact with patients including clinical (e.g., physicians, nurses, technicians) and non-clinical staff (e.g., receptionists, ward clerks, social workers, housekeepers) [1]. HCWs may be exposed to the risk of infection with bloodborne pathogens (BBPs) such as hepatitis B virus (HBV), hepatitis C virus (HCV), and human immunodeficiency virus (HIV). Exposures usually occur through needlesticks or cuts from other contaminated sharp instruments or through contact of the eye, nose, or mouth with infected patient’s blood or other body fluids [2, 3]. World Health Organization (WHO) estimated that about 40 % of HBV and HCV infections and 2.5 % of HIV infections in HCWs are attributable to occupational sharps exposures [4]. More than 90 % of these infections are occurring in low-income countries, and most are preventable [2, 4]. Several studies reported risks of occupational BBPs infection for HCWs in high income countries where a range of preventive interventions have been implemented [5–7]. In contrast, the situation among HCWs in low-income countries is not well documented, and their health and safety remains a neglected issue in several countries [2]. Despite improved methods of preventing exposure, occupational exposures will continue to occur [8, 9]. Studies of HCWs have estimated the average risk of transmission after percutaneous exposure as approximately 0.3 % for HIV, 6–30 % for HBV and 3 % for HCV [10–12]. Meanwhile, studies on availability or effectiveness of educational interventions and other preventive measures following exposure are very
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lacking [11]. At present, many bloodborne viral infections cannot be prevented by pre-exposure vaccinations and an effective treatment for a complete cure is yet to be found [12]. Avoiding contact with potentially infected blood, body fluids and tissues is still the essential component of risk reduction for HCWs [13]. Data from several parts of the world reported increased risk of exposure to BBPs, lack of compliance with standard precaution measures especially among young and less experienced HCWs as well as significant unsatisfactory reporting following exposure to these highly hazardous pathogens [14–16]. The current study was conducted to assess knowledge and practices associated with exposure to BBPs (HIV, HBV and HCV) among HCWs in a tertiary care military hospital (i.e., AlHada Armed Forces hospital) in the western region of Saudi Arabia. Methodology This study was conducted in Al-Hada armed forces hospital, Taif city, western region of Saudi Arabia. This 400-bed hospital is serving military personnel and their families. A pre-designed self-administered questionnaire was distributed to HCWs (physicians, nurses and laboratory technicians) currently available on service during December 2008. The questionnaire included information on age, sex, nationality, job title and years of experience in addition to specific knowledge and practice questionnaire on each of the common BBPs (viz., HIV, Hepatitis B, Hepatitis C). There were 17 knowledge questions on HIV, 14 on HBV and 14 on HCV in addition to 10 questions on practices associated with exposure to BBPs. Questions included information on modes of transmission, risky behaviors, universal precautions and measures following exposure. A correct answer was given 2 points, do not know was given 1 point and incorrect answer was given zero. Approval of the Research and Ethics Committee in AlHada Armed Forces Hospital was obtained to conduct the study. Informed consent was obtained from each participant to voluntary participate in the study and that data will be kept confidential and will not be released except for the purpose of the study. Statistical Analysis Data analysis was performed using SPSS package version 15. Data were presented using descriptive statistics in the form of frequencies and percentages for categorical variables, and means and standard deviations for quantitative variables. Chi square test was used to compare categorical variables. Student’s t test was used to compare means of two independent groups. Univariate logistic regression analysis was conducted to assess magnitude of association
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Table 1 Characteristics of the study group (n = 466) Variables
No
%
\30 years
155
33.3
30–40 years
219
47
C40 years
92
19.7
Mean (±SD)
34.9 ± 8.2
Age
Gender Male
162
34.8
Female
304
65.2
Nationality Saudi
71
15.2
Non Saudi Job titlea
395
84.8
Physician
151
32.4
Nurse/technician
315
67.6
\5
198
42.5
C5
268
57.5
Work experience in years
a
Participants represented departments of surgery, Medicine, Pediatrics, Family Medicine and Clinical Laboratory
between independent variables (age, gender, nationality, job title and experience) and knowledge outcome (below versus above average knowledge score). Odds ratio (OR) with 95 % confidence interval (95 % CI) was calculated. Statistical significance was considered at p value \0.05.
Results The current study included 466 participants (32.4 % physicians and 67.6 % nurses and technicians). Almost half of the participants (47 %) were in the age group of 30–40 years, more than two thirds were females (65.2 %) and the majority was non-Saudi (84.8 %). More than half of the participants (57.5 %) had work experience of 5 or more years (Table 1). Almost one third of the physicians (32.5 %) and one quarter of the nurses/technicians experienced splashing of blood/body fluids in their eye or mouth at least once. Moreover, it was noticed that almost two thirds of the physicians (60.9 %) compared to (47.6 %) of the nurses/ technicians had been exposed to needle stick or sharp injury at least once. The great majority of both physicians (83.4 %) and nurses/technicians (90.8 %) reported they always wash their hands as per recommendations during clinical practice (p = 0.068). It was observed that a significantly higher percentage of the nurses/technicians (84.4 %) than physicians (74.8 %) are always wearing gloves where there is possibility of blood/body fluid
J Community Health Table 2 Exposure of the participants to hazards of viral BBPs and application of universal precaution measures according to job category Physicians N = 151 N (%)
Nurses/technicians N = 315 N (%)
v2
Table 3 Knowledge of participants on reporting and prophylaxis following exposure to viral bloodborne incidents Physicians
p value (n = 151) N (%)
Experienced blood/body fluid splashing in eye or mouth 102 (67.6)
234 (74.3)
29 (9.2)
24 (15.9)
39 (12.4)
1. Emergency department
14 (9.3)
Once 2–5 times
21 (13.9)
35 (11.1)
2. Infection control
71 (47.0)
79 (25.1)
4 (2.6)
0.51
3. Laboratory
7 (2.2)
Experienced needle stick or sharps injury involving a needle or sharp instrument that may have been used on a patient Never 59 (39.1) 165 (52.4) 43.56 0.001
4. Employees clinic
5 (3.3)
8 (2.5)
61 (40.4)
198 (62.9)
5. Manpower 0 (0.0) HCV prophylaxis should be given
40 (26.5)
101 (32.1)
1. Immediatly
59 (39.1)
159 (50.5)
2–5 times
35 (23.2)
49 (15.6)
2. Within 24 h
10 (6.6)
49 (15.6)
[5 times
17 (11.3)
3. Within 48 h
1 (0.7)
6 (1.9)
4. Within 7 day
2 (1.3)
5 (1.6)
79 (52.3)
96 (30.5)
0 (0)
Hand washing when there is risk of blood/body fluid exposure Sometimes Always
6 (4.0)
7 (2.2)
19 (12.6)
22 (7.0)
126 (83.4)
286 (90.8)
5.38
0.068
Sometime Always
7 (4.6)
15 (4.8)
31 (20.5)
34 (10.8)
113 (74.8)
8.1
0.017
266 (84.4)
Wear gown when there is risk of blood/body fluid exposure Never
12 (7.9)
11 (3.5)
Sometime Always
60 (39.7) 79 (52.3)
77 (24.4) 227 (72.1)
18.28
0.001
Wear eye goggles when there is risk of blood/body fluid exposure Never
64 (42.4)
108 (34.3)
Sometime
48 (31.8)
92 (29.2)
Always
39 (25.8)
115 (36.5)
5. No specific prophylaxis
25.23
0.001
23.33
0.001
22.85
0.001
15.71
0.003
HBV prophylaxis should be given
Wear gloves when there is risk of blood/body fluid exposure Never
p value
1 (0.3)
Once
Never
v2
During regular working hours, reporting should be to
Never
[5 times
2.32
Nurses/ technicians (n = 315) N (%)
5.56
0.06
exposure (p = 0.017). Moreover, it was found that while almost three quarters of the nurses/technicians (72.1 %) are always wearing gowns during their practice, only one half of the physicians do (p = 0.001). On the same time, it was found that 42.4 % of the physicians in addition to 34.1 % of the nurses/technicians are not wearing eye goggles where there is possibility of blood/body fluid exposure (p = 0.06) (Table 2). Almost two thirds of the nurses (62.9 %) compared to only 40.4 % of the physicians who knew that they had to report to the employee health clinic when they are exposed to hazards of infection during regular working hours (p = 0.001). On the other hand, it was remarked that a significantly higher percentage of the physicians (52.3 %) compared to nurses/technicians who knew that there are no specific prophylaxis following exposure to HCV (p = 0.001). Also, a significantly higher percentage of the
1. Immediately
17 (11.3)
64 (20.3)
2. Within 24 h
31 (20.5)
105 (33.3)
3. Within 48 h
48 (31.8)
56 (17.8)
4. Within 7 days 5. No specific prophylaxis
29 (19.2) 26 (17.2)
39 (12.4) 51 (16.2)
HIV prophylaxis should be given 1. Immediately
4 (2.6)
31 (9.8)
2. Within 24 h
10 (6.6)
35 (11.1)
3. Within 48 h
5 (3.3)
21 (6.7)
4. Within 7 days 5. No specific prophylaxis
5 (3.3)
4 (1.3)
127 (84.1)
224 (71.1)
physicians (19.2 %) than nurses/technicians (12.4 %) knew that prophylaxis after exposure to HBV would be ineffective if given after 7 days (p = 0.001). On the meantime, it was observed that higher percentage of the physicians (84.1 %) than nurses/technicians (71.1 %) knew that there are no specific prophylaxis to HIV infection (p = 0.003) (Table 3). Mean ± SD knowledge scores about the risks of HIV and HCV were significantly higher among physicians (29.27 ± 2.7 and 25.0 ± 2.3, respectively) compared to nurses/technicians (28.3 ± 3.0 and 24.3 ± 3.4, respectively) (p = 0.001 and 0.01, respectively). However, although mean ± SD knowledge score of the physicians about risks of HBV (25.0 ± 2.5) was better than nurses/ technicians (24.5 ± 2.8), the difference was not statistically significant (p = 0.06) (Fig. 1). Although Saudi are more probable to have better knowledge than non-Saudi physicians regarding HIV
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Fig. 1 Mean (±SD) knowledge scores of the physicians and nurses/ technicians about risks of HIV, HCV and HBV infections according to job category
exposure and prophylaxis, the reverse was observed on HBV (OR 0.45, 95 % CI 0.23, 0.94; OR 2.49, 95 % CI 1.21, 5.14, respectively). However, none of the studied independent variables among physicians showed statistical significant association on knowledge of any of HIV, HBV or HCV exposure (Table 4). On the other hand, among nurses/technicians, younger participants (less than 30 years old) are more probable to have lower knowledge on HBV exposure and prophylaxis than older participants ([40 years old) (OR 2.34, 95 % CI 1.11, 4.91), also, low experience nurses/technicians are more probable for lower knowledge on HIV and HCV exposure and prophylaxis (OR 1.88, 95 % CI 1.20, 2.94; OR 1.56, 95 % CI 1.00, 2.43, respectively). Other independent variables did not show statistical significant association with knowledge of HIV, HBV and HCV infections (Table 4).
Discussion Needlesticks and sharp injuries are considered as commonly occurring occupational hazards among healthcare personnel. Although some existing types of BBPs can be life threatening, new groups of pathogens previously unknown are constantly being discovered, adding to the risks of disease transmission through sharp injuries [17, 18]. Almost two thirds of the physicians and half of the nurses/technicians had been exposed to needlestick or sharp injury at least once along their clinical practice. This finding is comparable to the results of previous studies conducted in United States (US) where 52 % of the healthcare personnel had experienced one or more percutaneous injuries in their career [7, 8]. A study conducted in a tertiary care hospital in Pakistan attributed the extra exposure to hazards of percutaneous injuries among
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physicians to the stressful environment under which the physicians are practicing or to the self-careless attitude [21]. On the other hand, cumulative incidental percutaneous injuries had been investigated in a longitudinal study conducted in an academic tertiary care hospital in Lebanon showed lower rates of exposure (13 % for house officers, 8 % for attending physicians, 5 % for nurses, 4 % for technicians and 2 % for auxiliary services employees) [15]. The increased risk of exposure mandates application of protective measures to prevent the potential hazards of bloodborne infection. Knowledge scores of healthcare personnel on potential hazards of bloodborne infections in the current study were significantly higher among physicians compared to nurses/technicians. Generally, knowledge scores were highest on HIV followed by HCV. These findings coincide partially with the findings of a study conducted in Poland among nurses where the best knowledge was on HIV and the worst was on HCV [22]. The remarkably higher knowledge of the healthcare workers about HIV could be explained by the global and public concerns about HIV which is reflected on numerous health education activities in the mass media and healthcare institutions. Awareness of the study group about risks of HIV was reflected on their knowledge of the post exposure actions. Great majority of the healthcare personnel knew that there is no prophylaxis for HIV exposure. In this context, it was noticed that modest proportions of the healthcare personnel knew the correct actions regarding the prophylaxis and reporting about exposure to other bloodborne infections. Miceli et al. [23] reported that although post exposure programs are settled in the studied hospitals in Argentine, nevertheless, the presence of the program do not guarantee appropriate behavior by HCWs. They recommended continuous education to modify individual attitudes as well as the identification of strategies to improve adherence [23]. Regarding the adoption of the healthcare personnel for protective measures against the hazards of bloodborne infection, the study showed that a considerable proportion of the physicians and nurses/technicians are always following the protective measures in terms of wearing gloves and gowns in addition to washing hands, these notions were generally better than what was found in a study conducted in Malaysia where it was cited that preventive measures taken by the healthcare workers in two studied hospitals were not satisfactory especially with reference to the use of personal protective equipment and the practice of universal precautions [24]. Also the situation is obviously better than what was found among obstetricians studied in a hospital in Italy where it was found that the HCWs were not wearing any personal protective devices [25]. Moreover, the observed significantly higher percentage of nurses/clinicians who always wearing gowns during their
J Community Health Table 4 Independent variables associated with knowledge performance regarding HIV, HBV and HCV exposure among HCWs Independent variables
HIV knowledge (below versus above average score) Odds ratio (95 % CI)
HBV knowledge (below versus above average score) Odds ratio (95 % CI)
HCV knowledge (below versus above average score) Odds ratio (95 % CI)
1.46 (0.56, 3.73) 1.30 (0.62, 2.72)
1.20 (0.48, 3.00) 0.78 (0.38, 1.60)
1.10 (0.44, 2.78) 0.93 (0.45, 1.90)
1.95 (0.82, 4.63)
1.54 (0.65, 3.66)
1.99 (0.80, 4.95)
0.45 (0.23, 0.94)*
2.49 (1.21, 5.14)*
0.94 (0.47, 1.88)
Specialist versus consultant
1.08 (0.47, 2.78)
2.24 (0.98, 5.10)
1.72 (0.76, 3.89)
Resident versus consultant
1.10 (0.49, 2.47)
0.92 (0.42, 2.04)
1.26 (0.58, 2.75)
1.60 (0.78, 3.28)
0.75 (0.37, 1.53)
1.24 (0.61, 2.54)
Physicians participants Age Below 30 versus above 40 years 30–40 versus above 40 years Sex Female versus Male Nationality Non Saudi versus Saudi Job title
Experience Below 5 years versus above 5 years Nurses participants Age Below 30 versus above 40 years
1.62 (0.79, 3.34)
2.34 (1.11, 4.91)*
1.43 (0.70, 2.94)
30—40 versus above 40 years
0.88 (0.44, 1.79)
1.31 (0.63, 2.72)
0.76 (0.38, 1.56)
0.75 (0.37, 1.52)
1.14 (0.57, 2.89)
1.88 (0.90, 3.90)
0.76 (0.33, 1.77)
0.74 (0.32, 1.71)
0.72 (0.31, 1.67)
0.82 (0.35, 1.94)
1.43 (0.60, 3.41)
1.15 (0.49, 2.70)
1.88 (1.20, 2.94)*
1.48 (0.95, 2.31)
1.56 (1.00, 2.43)*
Sex Female versus Male Nationality: Non Saudi versus Saudi Job title Nurse versus technicians Experience Below 5 years versus above 5 years * Statistically significant
clinical practice was in agreement with the findings of the study conducted in Pakistan where it was cited that the practice of nurses was generally safer than physicians [21]. The preponderance of the nurses/technicians who are pursuing the protective instructions could be attributed to the strict supervisory regimen in the paramedical field rather than the physicians’ clinical practice. Furthermore, this notion was explicitly shown in knowledge of the study group about the notification after being exposed to the risk of bloodborne infection where it was found that almost two thirds of the nurses compared to only 40.4 % of the physicians who did know that they had to report to the employees’ health clinic when they are exposed to hazards of bloodborne infection during regular working hours. A study in Nepal revealed that only 21 % of those who experienced needle injuries reported the injury to the hospital authority [26]. This reluctance in correct post exposure reporting could be attributed in part to availability of clear and strict policy on safe practices and post exposure reporting guidelines/procedeures.
Findings of the current study may be difficult to be generalized throughout Saudi Arabia, as it reflects a single military hospital experience. Some of the participants may provide responses that are not exactly reflecting their behavior or practice toward BBPs. In order to improve precision of participants’ responses, the researchers ensured confidentially of data and that all information will not be used except for research purposes and none of the personnel information will be released to the hospital administration. The current study showed considerable proportion of the physicians and nurses/technicians who reported being exposed to the risks of bloodborne infection. Although the studied population had acceptable level of knowledge about risks of bloodborne exposure, this knowledge was not fully translated into action. It was found that modest proportions of the studied healthcare workers were adherent to the recommended protective measures especially wearing gowns and eye goggles where there is risk of blood/body fluid exposure. Lack of compliance to
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recommendations of universal precaution measures was more prominent among physicians rather than nurses/ technicians. Similarly, more than one half of the physicians and one third of the nurses/technicians do not know for whom to report in case of exposure to bloodborne infection. This study alarms the need for deliberate collaborative efforts for implementation of effective intervention programs that include strict policy implementation and regular in-service behavioral-based training especially in the developing world.
10.
11. 12. 13.
14. Ethical standards This study has been approved by the research and ethics committee, Armed Forces hospital, Taif, Saudi Arabia and has been performed in accordance with the ethical standards laid down in the 1964 Declaration of Helsinki and its later amendments. Conflict of interest of interest.
15.
16.
The authors declare that they have no conflict 17.
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ORIGINAL PAPER
Knowledge and Practices of Healthcare Workers in Relation to Bloodborne Pathogens in a Tertiary Care Hospital, Western Saudi Arabia Ali O. Al-Zahrani • Fayssal Farahat • Elham N. Zolaly
Ó Springer Science+Business Media New York 2014
Abstract To assess knowledge and practices of healthcare workers (HCWs) in relation to bloodborne pathogens in a tertiary care hospital, western Saudi Arabia. Selfadministered questionnaire was distributed assessing demographic characteristics, knowledge and practices of physicians, nurses and technicians on risks of exposure and prophylaxis against human immunodeficiency virus, hepatitis B virus and hepatitis C virus infections. A total of 466 participants (151; 32.4 % physicians and 315; 67.6 % nurses/technicians) completed the questionnaire. Almost two thirds of the physicians (60.9 %) and half of the nurses/technicians (47.6 %) had history of exposure to risks of bloodborne infection. Although both physicians and nurses/technicians showed acceptable level of knowledge about risks of bloodborne infections, modest proportion knew the correct actions including reporting following exposure. Behavioral-based in-service training interventions and strict policy should be implemented to promote compliance of HCWs to the protective measures against hazards of bloodborne infection.
A. O. Al-Zahrani E. N. Zolaly Family Medicine Department, Armed Forces Hospital, Taif, Saudi Arabia F. Farahat (&) Infection Prevention and Control Department, King AbdulAziz Medical City, PO Box 9515, Jeddah, Saudi Arabia e-mail: [email protected] F. Farahat King Saud bin AbdulAziz University for Health Sciences, Jeddah, Saudi Arabia F. Farahat Community Medicine and Public Health Department, Faculty of Medicine, Menoufia University, Shebin El-Kom, Egypt
Keywords Bloodborne pathogens Healthcare workers Saudi Arabia
Introduction Healthcare workers (HCWs) are those who have regular contact with patients including clinical (e.g., physicians, nurses, technicians) and non-clinical staff (e.g., receptionists, ward clerks, social workers, housekeepers) [1]. HCWs may be exposed to the risk of infection with bloodborne pathogens (BBPs) such as hepatitis B virus (HBV), hepatitis C virus (HCV), and human immunodeficiency virus (HIV). Exposures usually occur through needlesticks or cuts from other contaminated sharp instruments or through contact of the eye, nose, or mouth with infected patient’s blood or other body fluids [2, 3]. World Health Organization (WHO) estimated that about 40 % of HBV and HCV infections and 2.5 % of HIV infections in HCWs are attributable to occupational sharps exposures [4]. More than 90 % of these infections are occurring in low-income countries, and most are preventable [2, 4]. Several studies reported risks of occupational BBPs infection for HCWs in high income countries where a range of preventive interventions have been implemented [5–7]. In contrast, the situation among HCWs in low-income countries is not well documented, and their health and safety remains a neglected issue in several countries [2]. Despite improved methods of preventing exposure, occupational exposures will continue to occur [8, 9]. Studies of HCWs have estimated the average risk of transmission after percutaneous exposure as approximately 0.3 % for HIV, 6–30 % for HBV and 3 % for HCV [10–12]. Meanwhile, studies on availability or effectiveness of educational interventions and other preventive measures following exposure are very
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lacking [11]. At present, many bloodborne viral infections cannot be prevented by pre-exposure vaccinations and an effective treatment for a complete cure is yet to be found [12]. Avoiding contact with potentially infected blood, body fluids and tissues is still the essential component of risk reduction for HCWs [13]. Data from several parts of the world reported increased risk of exposure to BBPs, lack of compliance with standard precaution measures especially among young and less experienced HCWs as well as significant unsatisfactory reporting following exposure to these highly hazardous pathogens [14–16]. The current study was conducted to assess knowledge and practices associated with exposure to BBPs (HIV, HBV and HCV) among HCWs in a tertiary care military hospital (i.e., AlHada Armed Forces hospital) in the western region of Saudi Arabia. Methodology This study was conducted in Al-Hada armed forces hospital, Taif city, western region of Saudi Arabia. This 400-bed hospital is serving military personnel and their families. A pre-designed self-administered questionnaire was distributed to HCWs (physicians, nurses and laboratory technicians) currently available on service during December 2008. The questionnaire included information on age, sex, nationality, job title and years of experience in addition to specific knowledge and practice questionnaire on each of the common BBPs (viz., HIV, Hepatitis B, Hepatitis C). There were 17 knowledge questions on HIV, 14 on HBV and 14 on HCV in addition to 10 questions on practices associated with exposure to BBPs. Questions included information on modes of transmission, risky behaviors, universal precautions and measures following exposure. A correct answer was given 2 points, do not know was given 1 point and incorrect answer was given zero. Approval of the Research and Ethics Committee in AlHada Armed Forces Hospital was obtained to conduct the study. Informed consent was obtained from each participant to voluntary participate in the study and that data will be kept confidential and will not be released except for the purpose of the study. Statistical Analysis Data analysis was performed using SPSS package version 15. Data were presented using descriptive statistics in the form of frequencies and percentages for categorical variables, and means and standard deviations for quantitative variables. Chi square test was used to compare categorical variables. Student’s t test was used to compare means of two independent groups. Univariate logistic regression analysis was conducted to assess magnitude of association
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Table 1 Characteristics of the study group (n = 466) Variables
No
%
\30 years
155
33.3
30–40 years
219
47
C40 years
92
19.7
Mean (±SD)
34.9 ± 8.2
Age
Gender Male
162
34.8
Female
304
65.2
Nationality Saudi
71
15.2
Non Saudi Job titlea
395
84.8
Physician
151
32.4
Nurse/technician
315
67.6
\5
198
42.5
C5
268
57.5
Work experience in years
a
Participants represented departments of surgery, Medicine, Pediatrics, Family Medicine and Clinical Laboratory
between independent variables (age, gender, nationality, job title and experience) and knowledge outcome (below versus above average knowledge score). Odds ratio (OR) with 95 % confidence interval (95 % CI) was calculated. Statistical significance was considered at p value \0.05.
Results The current study included 466 participants (32.4 % physicians and 67.6 % nurses and technicians). Almost half of the participants (47 %) were in the age group of 30–40 years, more than two thirds were females (65.2 %) and the majority was non-Saudi (84.8 %). More than half of the participants (57.5 %) had work experience of 5 or more years (Table 1). Almost one third of the physicians (32.5 %) and one quarter of the nurses/technicians experienced splashing of blood/body fluids in their eye or mouth at least once. Moreover, it was noticed that almost two thirds of the physicians (60.9 %) compared to (47.6 %) of the nurses/ technicians had been exposed to needle stick or sharp injury at least once. The great majority of both physicians (83.4 %) and nurses/technicians (90.8 %) reported they always wash their hands as per recommendations during clinical practice (p = 0.068). It was observed that a significantly higher percentage of the nurses/technicians (84.4 %) than physicians (74.8 %) are always wearing gloves where there is possibility of blood/body fluid
J Community Health Table 2 Exposure of the participants to hazards of viral BBPs and application of universal precaution measures according to job category Physicians N = 151 N (%)
Nurses/technicians N = 315 N (%)
v2
Table 3 Knowledge of participants on reporting and prophylaxis following exposure to viral bloodborne incidents Physicians
p value (n = 151) N (%)
Experienced blood/body fluid splashing in eye or mouth 102 (67.6)
234 (74.3)
29 (9.2)
24 (15.9)
39 (12.4)
1. Emergency department
14 (9.3)
Once 2–5 times
21 (13.9)
35 (11.1)
2. Infection control
71 (47.0)
79 (25.1)
4 (2.6)
0.51
3. Laboratory
7 (2.2)
Experienced needle stick or sharps injury involving a needle or sharp instrument that may have been used on a patient Never 59 (39.1) 165 (52.4) 43.56 0.001
4. Employees clinic
5 (3.3)
8 (2.5)
61 (40.4)
198 (62.9)
5. Manpower 0 (0.0) HCV prophylaxis should be given
40 (26.5)
101 (32.1)
1. Immediatly
59 (39.1)
159 (50.5)
2–5 times
35 (23.2)
49 (15.6)
2. Within 24 h
10 (6.6)
49 (15.6)
[5 times
17 (11.3)
3. Within 48 h
1 (0.7)
6 (1.9)
4. Within 7 day
2 (1.3)
5 (1.6)
79 (52.3)
96 (30.5)
0 (0)
Hand washing when there is risk of blood/body fluid exposure Sometimes Always
6 (4.0)
7 (2.2)
19 (12.6)
22 (7.0)
126 (83.4)
286 (90.8)
5.38
0.068
Sometime Always
7 (4.6)
15 (4.8)
31 (20.5)
34 (10.8)
113 (74.8)
8.1
0.017
266 (84.4)
Wear gown when there is risk of blood/body fluid exposure Never
12 (7.9)
11 (3.5)
Sometime Always
60 (39.7) 79 (52.3)
77 (24.4) 227 (72.1)
18.28
0.001
Wear eye goggles when there is risk of blood/body fluid exposure Never
64 (42.4)
108 (34.3)
Sometime
48 (31.8)
92 (29.2)
Always
39 (25.8)
115 (36.5)
5. No specific prophylaxis
25.23
0.001
23.33
0.001
22.85
0.001
15.71
0.003
HBV prophylaxis should be given
Wear gloves when there is risk of blood/body fluid exposure Never
p value
1 (0.3)
Once
Never
v2
During regular working hours, reporting should be to
Never
[5 times
2.32
Nurses/ technicians (n = 315) N (%)
5.56
0.06
exposure (p = 0.017). Moreover, it was found that while almost three quarters of the nurses/technicians (72.1 %) are always wearing gowns during their practice, only one half of the physicians do (p = 0.001). On the same time, it was found that 42.4 % of the physicians in addition to 34.1 % of the nurses/technicians are not wearing eye goggles where there is possibility of blood/body fluid exposure (p = 0.06) (Table 2). Almost two thirds of the nurses (62.9 %) compared to only 40.4 % of the physicians who knew that they had to report to the employee health clinic when they are exposed to hazards of infection during regular working hours (p = 0.001). On the other hand, it was remarked that a significantly higher percentage of the physicians (52.3 %) compared to nurses/technicians who knew that there are no specific prophylaxis following exposure to HCV (p = 0.001). Also, a significantly higher percentage of the
1. Immediately
17 (11.3)
64 (20.3)
2. Within 24 h
31 (20.5)
105 (33.3)
3. Within 48 h
48 (31.8)
56 (17.8)
4. Within 7 days 5. No specific prophylaxis
29 (19.2) 26 (17.2)
39 (12.4) 51 (16.2)
HIV prophylaxis should be given 1. Immediately
4 (2.6)
31 (9.8)
2. Within 24 h
10 (6.6)
35 (11.1)
3. Within 48 h
5 (3.3)
21 (6.7)
4. Within 7 days 5. No specific prophylaxis
5 (3.3)
4 (1.3)
127 (84.1)
224 (71.1)
physicians (19.2 %) than nurses/technicians (12.4 %) knew that prophylaxis after exposure to HBV would be ineffective if given after 7 days (p = 0.001). On the meantime, it was observed that higher percentage of the physicians (84.1 %) than nurses/technicians (71.1 %) knew that there are no specific prophylaxis to HIV infection (p = 0.003) (Table 3). Mean ± SD knowledge scores about the risks of HIV and HCV were significantly higher among physicians (29.27 ± 2.7 and 25.0 ± 2.3, respectively) compared to nurses/technicians (28.3 ± 3.0 and 24.3 ± 3.4, respectively) (p = 0.001 and 0.01, respectively). However, although mean ± SD knowledge score of the physicians about risks of HBV (25.0 ± 2.5) was better than nurses/ technicians (24.5 ± 2.8), the difference was not statistically significant (p = 0.06) (Fig. 1). Although Saudi are more probable to have better knowledge than non-Saudi physicians regarding HIV
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Fig. 1 Mean (±SD) knowledge scores of the physicians and nurses/ technicians about risks of HIV, HCV and HBV infections according to job category
exposure and prophylaxis, the reverse was observed on HBV (OR 0.45, 95 % CI 0.23, 0.94; OR 2.49, 95 % CI 1.21, 5.14, respectively). However, none of the studied independent variables among physicians showed statistical significant association on knowledge of any of HIV, HBV or HCV exposure (Table 4). On the other hand, among nurses/technicians, younger participants (less than 30 years old) are more probable to have lower knowledge on HBV exposure and prophylaxis than older participants ([40 years old) (OR 2.34, 95 % CI 1.11, 4.91), also, low experience nurses/technicians are more probable for lower knowledge on HIV and HCV exposure and prophylaxis (OR 1.88, 95 % CI 1.20, 2.94; OR 1.56, 95 % CI 1.00, 2.43, respectively). Other independent variables did not show statistical significant association with knowledge of HIV, HBV and HCV infections (Table 4).
Discussion Needlesticks and sharp injuries are considered as commonly occurring occupational hazards among healthcare personnel. Although some existing types of BBPs can be life threatening, new groups of pathogens previously unknown are constantly being discovered, adding to the risks of disease transmission through sharp injuries [17, 18]. Almost two thirds of the physicians and half of the nurses/technicians had been exposed to needlestick or sharp injury at least once along their clinical practice. This finding is comparable to the results of previous studies conducted in United States (US) where 52 % of the healthcare personnel had experienced one or more percutaneous injuries in their career [7, 8]. A study conducted in a tertiary care hospital in Pakistan attributed the extra exposure to hazards of percutaneous injuries among
123
physicians to the stressful environment under which the physicians are practicing or to the self-careless attitude [21]. On the other hand, cumulative incidental percutaneous injuries had been investigated in a longitudinal study conducted in an academic tertiary care hospital in Lebanon showed lower rates of exposure (13 % for house officers, 8 % for attending physicians, 5 % for nurses, 4 % for technicians and 2 % for auxiliary services employees) [15]. The increased risk of exposure mandates application of protective measures to prevent the potential hazards of bloodborne infection. Knowledge scores of healthcare personnel on potential hazards of bloodborne infections in the current study were significantly higher among physicians compared to nurses/technicians. Generally, knowledge scores were highest on HIV followed by HCV. These findings coincide partially with the findings of a study conducted in Poland among nurses where the best knowledge was on HIV and the worst was on HCV [22]. The remarkably higher knowledge of the healthcare workers about HIV could be explained by the global and public concerns about HIV which is reflected on numerous health education activities in the mass media and healthcare institutions. Awareness of the study group about risks of HIV was reflected on their knowledge of the post exposure actions. Great majority of the healthcare personnel knew that there is no prophylaxis for HIV exposure. In this context, it was noticed that modest proportions of the healthcare personnel knew the correct actions regarding the prophylaxis and reporting about exposure to other bloodborne infections. Miceli et al. [23] reported that although post exposure programs are settled in the studied hospitals in Argentine, nevertheless, the presence of the program do not guarantee appropriate behavior by HCWs. They recommended continuous education to modify individual attitudes as well as the identification of strategies to improve adherence [23]. Regarding the adoption of the healthcare personnel for protective measures against the hazards of bloodborne infection, the study showed that a considerable proportion of the physicians and nurses/technicians are always following the protective measures in terms of wearing gloves and gowns in addition to washing hands, these notions were generally better than what was found in a study conducted in Malaysia where it was cited that preventive measures taken by the healthcare workers in two studied hospitals were not satisfactory especially with reference to the use of personal protective equipment and the practice of universal precautions [24]. Also the situation is obviously better than what was found among obstetricians studied in a hospital in Italy where it was found that the HCWs were not wearing any personal protective devices [25]. Moreover, the observed significantly higher percentage of nurses/clinicians who always wearing gowns during their
J Community Health Table 4 Independent variables associated with knowledge performance regarding HIV, HBV and HCV exposure among HCWs Independent variables
HIV knowledge (below versus above average score) Odds ratio (95 % CI)
HBV knowledge (below versus above average score) Odds ratio (95 % CI)
HCV knowledge (below versus above average score) Odds ratio (95 % CI)
1.46 (0.56, 3.73) 1.30 (0.62, 2.72)
1.20 (0.48, 3.00) 0.78 (0.38, 1.60)
1.10 (0.44, 2.78) 0.93 (0.45, 1.90)
1.95 (0.82, 4.63)
1.54 (0.65, 3.66)
1.99 (0.80, 4.95)
0.45 (0.23, 0.94)*
2.49 (1.21, 5.14)*
0.94 (0.47, 1.88)
Specialist versus consultant
1.08 (0.47, 2.78)
2.24 (0.98, 5.10)
1.72 (0.76, 3.89)
Resident versus consultant
1.10 (0.49, 2.47)
0.92 (0.42, 2.04)
1.26 (0.58, 2.75)
1.60 (0.78, 3.28)
0.75 (0.37, 1.53)
1.24 (0.61, 2.54)
Physicians participants Age Below 30 versus above 40 years 30–40 versus above 40 years Sex Female versus Male Nationality Non Saudi versus Saudi Job title
Experience Below 5 years versus above 5 years Nurses participants Age Below 30 versus above 40 years
1.62 (0.79, 3.34)
2.34 (1.11, 4.91)*
1.43 (0.70, 2.94)
30—40 versus above 40 years
0.88 (0.44, 1.79)
1.31 (0.63, 2.72)
0.76 (0.38, 1.56)
0.75 (0.37, 1.52)
1.14 (0.57, 2.89)
1.88 (0.90, 3.90)
0.76 (0.33, 1.77)
0.74 (0.32, 1.71)
0.72 (0.31, 1.67)
0.82 (0.35, 1.94)
1.43 (0.60, 3.41)
1.15 (0.49, 2.70)
1.88 (1.20, 2.94)*
1.48 (0.95, 2.31)
1.56 (1.00, 2.43)*
Sex Female versus Male Nationality: Non Saudi versus Saudi Job title Nurse versus technicians Experience Below 5 years versus above 5 years * Statistically significant
clinical practice was in agreement with the findings of the study conducted in Pakistan where it was cited that the practice of nurses was generally safer than physicians [21]. The preponderance of the nurses/technicians who are pursuing the protective instructions could be attributed to the strict supervisory regimen in the paramedical field rather than the physicians’ clinical practice. Furthermore, this notion was explicitly shown in knowledge of the study group about the notification after being exposed to the risk of bloodborne infection where it was found that almost two thirds of the nurses compared to only 40.4 % of the physicians who did know that they had to report to the employees’ health clinic when they are exposed to hazards of bloodborne infection during regular working hours. A study in Nepal revealed that only 21 % of those who experienced needle injuries reported the injury to the hospital authority [26]. This reluctance in correct post exposure reporting could be attributed in part to availability of clear and strict policy on safe practices and post exposure reporting guidelines/procedeures.
Findings of the current study may be difficult to be generalized throughout Saudi Arabia, as it reflects a single military hospital experience. Some of the participants may provide responses that are not exactly reflecting their behavior or practice toward BBPs. In order to improve precision of participants’ responses, the researchers ensured confidentially of data and that all information will not be used except for research purposes and none of the personnel information will be released to the hospital administration. The current study showed considerable proportion of the physicians and nurses/technicians who reported being exposed to the risks of bloodborne infection. Although the studied population had acceptable level of knowledge about risks of bloodborne exposure, this knowledge was not fully translated into action. It was found that modest proportions of the studied healthcare workers were adherent to the recommended protective measures especially wearing gowns and eye goggles where there is risk of blood/body fluid exposure. Lack of compliance to
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recommendations of universal precaution measures was more prominent among physicians rather than nurses/ technicians. Similarly, more than one half of the physicians and one third of the nurses/technicians do not know for whom to report in case of exposure to bloodborne infection. This study alarms the need for deliberate collaborative efforts for implementation of effective intervention programs that include strict policy implementation and regular in-service behavioral-based training especially in the developing world.
10.
11. 12. 13.
14. Ethical standards This study has been approved by the research and ethics committee, Armed Forces hospital, Taif, Saudi Arabia and has been performed in accordance with the ethical standards laid down in the 1964 Declaration of Helsinki and its later amendments. Conflict of interest of interest.
15.
16.
The authors declare that they have no conflict 17.
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