Magnitude and associated factors of needle stick and sharps injuries among health care workers in Dessie City Hospitals, north east Ethiopia.

Background Work-related exposures to needle stick and sharps accidents are essential reason of infections with blood borne pathogens amongst health care employees and can cause extensive fitness consequences and psychological stress. The aim of this study was to determine the magnitude of needle stick and sharps injuries and associated factors among health care workers in Dessie town hospitals. Method This institution-based cross-sectional study was conducted from March 21–April 21/2015, amongst health care people in Dessie city hospitals. Data have been collected by a structured and pre-tested questionnaire. The study included 438 health care employees who had been selected through the use of a simple random sampling technique. The gathered data have been checked, coded and entered to EPI-info version 3.5.1 and exported to SPSS model 20 for analysis. Bivariate and multivariate logistic regression analyses have been executed to identify elements related with the structured variable. Results From 457 selected study participants, 438 (95.8%) responded to the questionnaire. The magnitude of needle stick and sharps injuries in the last 12 months was 124(28.3%), of which 92(74.2%) was reported by males and the rest 32(25.8%) by females. Being male [AOR: 4.25, 95%CI:(2.43,7.41)],had no safety instructions in the work area [AOR:2.27,95%CI: (1.29,3.97)],had no training on safety and health [AOR:4.92,95%CI:(2.75,8.79)],had ≤5 years work experience [AOR:9.0,95%CI:(4.88,16.60)],recapping of used needle [AOR: 2.63, 95%CI: (1.39, 4.99)] were the variables that significantly associated with needle stick and sharps injuries. Conclusion This study showed still a high magnitude of needle stick or sharps among healthcare workers. Therefore, training on work related safety and wellbeing, making safety instructions accessible and avoiding a recap of the needle after use are important to reduce the chance of such injuries among healthcare workers.


Background
Needle stick or sharps injuries are caused by different types of needles, lancet, surgical scalpel, trocar puncture needle, vacuum tube blood collection needle, broken vial preparation, razors, scissors, etc. during patient cares [1,2]. Percutaneous exposures to blood and body fluids all through infected needle stick and sharps accidents are the main occupational hazard for morbidity and mortality from infections with blood borne pathogens among health care workers [1]. Needle sticks and sharps injuries (NSSIs) cause a great awesome to the transmission of blood borne pathogens [3]. According to World Health Organization (WHO) report, presentation to sharps within the working environment contributes to 40% of contaminations with Hepatitis B Infection (HBV) and Hepatitis C Infection (HCV) and 2-3% of HIV diseases among health care workers [4]. In developed countries, contact to HBV in health care workers is common, with an amplified risk of at least 3-6 times that of the common populace [4,5]. In developing countries, this number is estimated to be 6-18 times more; about 40-60% of HBV infectivity in health care workers were attributed to the professional hazard while in developed countries the attributed portion was less than 10% [4]. Particularly, those in sub-Saharan countries, have the top incidences of occupational exposures [6]. Occupational NSSIs affect the quality of health care services other than the health care providers [1]. Health care workers experience rigorous emotional distress, fear, and anxiety which lead them to occupational and behavioral changes [7,8]. From thirty five million health care workers, three million experience NSSIs every year worldwide [9], with a top incidence of these injuries being reported from health institutions in several countries [10,11]. Studies conducted in different nations showed that the level of NSSIs among health workers was exceptionally high [12]. Approximately, 1.2 million healthcare staff are exposed to needle stick injuries every year in Europe [13]. A study in Germany university hospital showed that 31.4% of health care workers sustained at least one needle stick injury in one year [8] while in Greek the overall injury rate of health care was 2.4% per year out of the total full-time employees engaged in patient-related activities [14]. Studies in health care workers in Iran, Malaysia, Saudi Arabia showed a prevalence rate of 24.9, 74, and 39.4% respectively [12,15,16]. Similar studies in Nigeria, Uganda, and Kenya showed a one-year prevalence of needle stick/ sharps object injuries were 18.5, 32.4 and 20.2%, respectively [17][18][19].
In Ethiopia, only a few studies have been done on the prevalence of needle stick/sharps injuries [20,21] and even the findings of these studies did not address the magnitude of NSSIs well among all parts of health care workers (HCWs). So, this study was conducted to assess the magnitude and associated factors of needle stick and sharps injuries, which may have a contribution in the development of prevention strategies.

Methods
Study design, period, and study area Institution-based cross sectional quantitative study was conducted among HCWs in Dessie City Hospitals from March 21 to April 21/2015. Dessie is the capital city of South Wollo Zone and it has 10 sub city wards and 6 rural wards with a total population of 188,519 based on the 2007census. There were a total of 774 health care workers assigned to provide with health services to the community in the two governmental and three private hospitals.

Study population
All health care workers (physicians, nurses, lab technicians/technologists, cleaners, midwives, health officers, and anesthetists) that worked for 1 year and above in the two governmental and three private hospitals and that participated in screening, diagnosis, treatment, and follow-up of patients with the assistance of needle and sharps medical equipment, and handling of waste disposal were included in the study.

Exclusion criteria
Resident doctors and students were not participants of the study.

Sample size determination and sampling procedure
Four hundred fifty-seven participants were the sample size of this study which was calculated using a single population proportion formula, 22.2% [22] previous study of NSSIs from East Gojjam, 4% margin of error, 95% confidence interval, and 10% non-response rate.
Based on the assumption that the participants are homogeneous across the hospitals, but heterogeneous within job category with respect to the exposure of needle stick and sharps injuries, the 457 samples were proportionally allocated to each hospital and selected using lottery method from the lists of health care workers. The calculated sample size was proportionally distributed to the five hospitals based on the number of health care works. We used the list of health care workers from the monthly payroll of the five hospitals as a sampling frame. Then, a simple random sampling technique (lottery method) was used to select the study participants.

Operational definition
Healthcare workers are workers in hospitals (physicians, nurses, lab technicians/technologists, cleaners, midwives, health officers, and anesthetists) who do have contact with syringes, needles and other sharps materials due to their duties.
Safety instructions are written information in the workplace about safe work practices like the prohibition of recapping of needles, disposing of sharps immediately after use in designated sharp containers, engaging the temporary safety locking mechanism on sharps waste disposal box when not in use, and sealing and disposing of sharps containers when full of its three quarter.
OHS training is an awareness program about the different hazards and risks in the working environment, safe working procedure, and infection prevention and safety policy of the organization.

Data collection procedures
The questionnaire was developed based on related literature (Additional file 1) and had socio-demographic, behavioral, environmental, NSSIs variables. The questionnaire was prepared in English and translated to Amharic. Then, it was translated back to English to keep its consistency.
A pretest was done in Dessie health station on 42 health care workers, and necessary corrections were made based on the result of the pretest. Training was given for 2 days for the 2 supervisors (BSC nurses) and five data collectors (diploma nurses). Data were collected by interviewing health care workers, and the gathered data were checked each day by SA and supervisors.

Data processing and analysis
Data were checked, coded and entered to the EPI-info model 3.5.1 and exported to SPSS (Statistical Package for Social Science) model 20 for analysis. Bivariate logistic regressions were fitted to identify factors associated with needle stick and sharps injuries. Only variables reached a p-value≤0.2 in the bivariate logistic regression analysis had been included in the multivariate logistic regression model to check the confounding effects. Finally, variables that had p-value< 0.05 were considered as having significant association with needle stick and sharps injuries, and results were presented with an odds ratio (OR) and 95 % confidence interval (CI).

Work environment characteristics
Two hundred sixty-eight (61.2%) and 143 (32.6%) health care workers reported that their workplace had no safety instruction and work guidelines respectively. Similarly, 263 (60%) did not take occupational health and safety training ( Table 2).

Magnitude of needle stick and sharps injuries
From a total of 438 health care workers, 124 (28.3%) faced needle stick and sharps injuries in the last 12  (Table 4).

Behavioral and practical characteristics
Out of the total (438) HCWs, 254(58%) were concerned about needle stick/sharps injuries in their work environment and 276(63%) considered needle stick/sharps injuries were unavoidable. From 124 injured HCWs, 68(54.8%) did not report their injuries and the reasons for not reporting were lack of support from management 27 (39.7%), and not considering reporting as important 19 (27.9%). About 313 (71.5%) participants recap the needle after use and only 51 (11.6%) of the respondents did not use personal protective equipment (PPE) during their working procedure. The most commonly mentioned reason for not using PPE was discomfort when used 24 (47.1%) followed by a lack of PPE 14 (27.5%).

Factors associated with needle stick and sharps injuries
To assess the relative effect of socio-demographic, environmental and behavioral factors on needle stick and sharps injury logistic regression was done.
In the bivariate logistic regression analysis, NSSI was associated significantly with sex, having safety instruction, OSH training, work experience, working hours/ week, recapping of the used needle, drinking of alcohol and chewing khat. However, finally, sex, safety instruction in their work area, OSH training, work experience and the recap of used needles remain significantly associated in the multivariate logistic regression analysis. Being

Magnitude of needle sticks and sharps injuries
The prevalence of NSSIs among healthcare workers in the last 12 months was 124(28.3%), which is relatively similar to studies conducted in Awassa and Bahir Dar [20,23]. But it is high compared to studies done in East Gojjam, Ethiopia [22], Kenya [19] & Nigeria [17]. The possible difference in the proportion of injury could be the socio-demographic/economic status, and cultural characteristics of study participants. Parts of the body with the highest frequency of NSSIs were fingers 56(45.2%). This result was similar to a study conducted in Saudi Arabia [24]. This could be linked to the fact that the fingers are involved in the handling of needles and other sharps, in recapping of the needles, suturing and setting intravenous lines.
In this study, the majority of HCWs who reported to have sustained needle stick and sharps injury were nurses 80(40.4%), and this is in agreement with a study done in Pretoria [25], and much higher than studies done in Kenya [19] and Nigeria [17]. The possible difference may be due to the ratio of nurse to people is not proportional as set by the WHO. Another explanation that may account for the high percentage of the injuries reported by nurses was the fact that most 198(45.2%) of study participants were nurses.
There are also a greater proportion of 17 (26.2%) injuries reported by cleaners compared to other health care workers. This could be due to the reason that they  are usually people from the lower socioeconomic status and lower educational background; no visible programs are available to teach them about the risks of occupational exposure to NSSIs. The most frequent 41 (33.1%) cause of NSSIs was syringe needles, which was in line with the findings of other studies [15,24,26]. This might be due to the fact that syringe needles have been used in every department of the health care facilities unlike that of other sharps which have been used only in a few departments.
The highest number 61(49.2%) of the NSSIs occurred on Monday. The possible explanation for this might be linked to high patient flow and a heavier workload on Monday. However, in Pakistan Public Sector Tertiary Care Hospitals, most injuries among healthcare workers occurred on Saturday [27]. This difference could be explained by the setup and culture difference between the two countries.
As the multivariate logistic regression analysis indicated, male are 4.25 times more likely to get exposed to NSSIs than females. Similar finding in a study undertaken in Malaysia indicated that there was a significant association between sex of the worker and the occurrence of sharps and needle stick injury among HCWs [15]. This may be since females are better in safety precautions compared to males.
Those respondents had no safety instruction in their work area were significantly at higher risk of getting NSSIs compared to those who had safety instruction. This finding was supported by the study conducted on needle stick injuries among doctors working in a tertiary care hospital of Karachi [10].
Respondents whoever had no training on OSH were significantly at higher risk of getting NSSIs compared to those whoever had training on OSH. This finding was supported by a study done on the prevalence of needle stick injuries among HCWs in a tertiary care hospital in Delhi India [5].
In this study, the HCWs who had work experience < 5 years were significantly at higher risk of getting NSSIs compared to≥5 years. The finding was supported by a study taken on in turkey; it confirmed that the risk of needle stick and sharps injuries were higher among health care workers of experience < 5 years [3]. This might be due to the fact that less attention has been given to the exposure of NSSIs in less experience HCWs. Note: * Significant at p < 0.05, ** Significant at p < 0.01, *** Significant at p < 0.001 In the study area, HCWs who recapped used needles indicated that they were 2.63 times more likely to get injured compared to their counterparts. This finding was supported by the study conducted in the southern part of Ethiopia, where half of the HCWs recapped needle after used [28]. This may be due to inappropriate needle handling practices like recapping, disposing of needles, and because of insufficient training of HCWs or their refusal to follow the correct procedures.
The study could have limitations. Since participants have been asked a 1 year exposure experience, there might be recall bias and limitations of data collection due to potential participants' fear.

Conclusions
The magnitude of needle stick or sharps accidents among HCWs in the hospitals in which the study took place was 28.3%. This showed still a high magnitude of NSSIs among healthcare workers, which might be an indication that the risk of health care workers toward blood borne infections, including HIV/AIDS and different hepatitis is getting increased. Lack of safety instructions, insufficient OSH services, like training on occupational health hazards and safety issues, an absence of a written protocol for reporting needle stick and sharps injuries may have contributed to expose health care workers to the risk of NSSIs. Therefore, Putting in a framework that encourages health care workers to wear PPE through accessing and supplying standard materials to the services delivered in the health care facility, training on OSH, making safety instruction available, and avoiding a recap of the needle after use are important to reduce the risk of such injuries among HCWs. Further investigation is required to determine the actual occurrence of needle stick and sharp injury exposure, and the type of disease they would acquire.