Reducing the Risks to Health Care Workers From Blood and Body Fluid Exposure in a Small Rural Hospital in Thabo-Mofutsanyana, South Africa Litsitso Nkoko, B Adv Nursing, OHNP; Jerry Spiegel, PhD, MSc; Asta Rau, PhD; Stephanie Parent, BSc; Annalee Yassi, MD, MSc, FRCPC ABSTRACT Health care workers in sub-Saharan Africa are at high risk of acquiring bloodborne diseases. A training program was launched to build the capacity of occupational health nurses to design and implement workplace-based projects. The study assessed the knowledge, attitudes, and practices of health care workers regarding blood and body fluid exposures in a small district hospital in a rural area of the Free State in South Africa. Under the guidance of two experienced mentors, an occupational health nurse designed a knowledge, attitudes, and practices questionnaire and distributed it to 101 health care workers at risk throughout the hospital; 88% of questionnaires were returned in sealed envelopes. Limited knowledge and ineffective practices were documented. For example, only 54.3% of the respondents reported that needles should never be recapped. A significant correlation (p < .001) was found between limited knowledge and recent blood and body fluid exposure. The study results provided the occupational health nurse with data to address the knowledge, attitudes, and practices deficits by implementing an injury prevention educational intervention. Such training initiatives can decrease the burden of occupational disease among health care workers in rural low-resourced areas. [Workplace Health Saf 2014;62(9):382-388.]
S
ub-Saharan Africa has a high prevalence of bloodborne infectious diseases, such as human immunodeficiency virus (HIV) and hepatitis B and C
ABOUT THE AUTHORS
Ms. Nkoko is Occupational Health Nurse Practitioner, Thebe District Hospital, Harrismith, South Africa. Drs. Spiegel and Yassi are Professors, and Ms. Parent is Research Assistant, School of Population and Public Health, University of British Columbia, Vancouver, British Columbia. Dr. Rau is Senior Researcher, Centre for Health Systems Research & Development, University of the Free State, Bloemfontein, South Africa. Submitted: January 6, 2014; Accepted: July 3, 2014; Posted online: September 5, 2014 Supported by the Global Health Research Initiative (GHRI), a research funding partnership of the Canadian Institutes of Health Research, the Canadian International Development Agency, and the International Development Research Centre. The authors have disclosed no potential conflicts, financial or otherwise. The authors thank the staff, students, and colleagues from the Centre for Health Systems Research and Development at the University of Free State, the University of British Columbia, Vancouver Coastal Heath, South Africa’s Department of Health, National Institute of Occupational Health of South Africa, the World Health Organization, and the International Labour Organization who contributed to the training program; the Free State Department of Health and the management of Thebe District Hospital in Thabo Mofutsanyana in the Eastern Free State for supporting the training; and the health care workers who completed surveys. Correspondence: Annalee Yassi, MD, MSc, FRCPC, School of Population and Public Health, University of British Columbia, 4th Floor, 2206 East Mall, Vancouver, BC V6T 1Z3, Canada. E-mail: [email protected] doi:10.3928/21650799-20140815-03
382
virus (Ehlers, 2006; Lehmann, Dieleman, & Martineau, 2008). In 2010, 4.6 million South Africans were tested for HIV and an overwhelming 17% were HIV positive (Bodibe, 2011). Hepatitis B causes an estimated 14,000 deaths annually in South Africa, and 40% of hepatitis B cases are attributed to occupational exposure in health care (Crush & Pendleton, 2011; World Health Organization [WHO], 2002). Thus, the health care environment in these settings poses a high occupational risk of infection (Ehlers, 2006; Nsubuga & Jaakkola, 2005; Zungu, Sengane, & Setswe, 2008), with health care workers exposed to infected blood and body fluid via needlestick injuries (Shisana, Hall, Maluleke, Chauveau, & Schwabe, 2004; Zungu et al., 2008). WHO recommendations for health care worker safety include universal precautions (including no needle recapping), hepatitis B immunization, personal protective equipment, and post-exposure management (WHO, 2006). South Africa’s policies on blood and body fluid exposure prevention include eliminating hazards (including preventing and effectively managing blood and body fluid spills), using safety devices with engineered controls, applying administrative controls, employing procedural and clinical practice controls including effective disposal of contaminated sharp and biomedical waste,
Copyright © American Association of Occupational Health Nurses, Inc. Downloaded from whs.sagepub.com at Purdue University Libraries on July 21, 2015
providing and mandating the use of appropriate personal protective clothing, and conducting ongoing product surveillance regarding the prescribed use of safety measures (Ziady, 2010). Many local, national, and international efforts have been initiated to implement these guidelines and ensure compliance (e.g., a pilot project aimed at preventing occupational HIV and hepatitis B infection launched by the WHO in partnership with the International Council of Nurses) (Wilburn & Eijkemans, 2004). Nonetheless, occupational exposure to blood and body fluids is still common in Africa (Burnett, Kramvis, Dochez, & Meheus, 2012; Fernandes et al., 2013; Mbaisi, Wanzala, & Omolo, 2013). Although poorly studied, the high prevalence of occupational blood and body fluid exposure is especially true in rural and remote areas of Africa, where unsafe injection practices and lack of risk prevention knowledge are common (Delobelle et al., 2009). The challenges in providing essential occupational health services in rural and remote areas of Africa, especially in low- and middle-income countries, have been highlighted in the literature (Dussault & Franceschini, 2006; Lehmann et al., 2008; Rebman et al., 2007). Inadequate infrastructure and lack of support for occupational health practices are especially problematic in such settings (Lavoie et al. 2010; Rebman et al., 2007; Sagoe-Moses, Pearson, Perry, & Jagger, 2001), rendering health care workers in rural and remote areas at particularly high risk of blood and body fluid exposure. To build capacity to address this situation, the University of British Columbia in Canada joined forces with the University of the Free State in South Africa and the Free State Department of Health to offer a training program aimed at empowering local occupational health and infection control personnel to implement workplacebased interventions to protect health care workers from infectious occupational exposures (Liautaud et al., 2013). The current study, conducted in the context of that program, aimed to determine knowledge, attitudes, and practices of health care workers regarding blood and body fluids in a small district hospital in the eastern region of the Free State province of South Africa. Ninety-five percent of individuals living in this district are black and speak Sesotho and Zulu. This area of South Africa has serious socioeconomic challenges, with high rates of homelessness and an unemployment rate estimated to be 35% (Republic of South Africa, 2013). In this article, the researchers describe the results of the study conducted by one occupational health nurse who participated in the Workplace HIV/Tuberculosis (TB) Certificate Program training, and reflect on how this experience may build occupational health capacity in other low-resourced rural settings. METHODS The study was designed and implemented by an occupational health nurse with remote guidance from two mentors, one from South Africa and one from Canada. Mentors worked with the occupational health nurse to
TABLE 1
Profile of Respondents by Occupation and Department Occupation
Number
%
Professional nurse
22
29.7
Enrolled nurse assistant
16
21.6
General worker
10
13.5
Enrolled nurse
8
10.8
Physician
5
6.8
Laundry worker
4
5.4
Dentist
3
4.1
Dental assistant
2
2.7
Occupational therapist
2
2.7
Physiotherapist
1
1.4
Missing
1
1.4
74
100
Casualty
20
27.0
Women’s & pediatric ward
13
17.6
Maternity
12
16.2
Men’s ward
11
14.9
Dental
5
6.8
Laundry
4
5.4
Rehabilitation
4
5.4
Total Department
Theatre Total
5
6.8
74
100
design a questionnaire about knowledge, attitudes, and practices related to blood and body fluid. Demographic questions were taken from an existing survey used in the Free State. Questions specific to the occupational health nurse’s research were designed by the nurse herself and refined in collaboration with her project mentors. The finalized questionnaires, in envelopes, were distributed to supervisors of high-risk hospital departments, including casualty (emergency department where all patients are seen, treated, and discharged, admitted, or referred to the regional hospital), dental, laundry, women’s and pediatric wards, men’s ward (medical, surgical, orthopedic, and psychiatric male patients are admitted), maternity, rehabilitation, and theatre (operating room) (Table 1). Supervisors distributed the questionnaires to health care workers in each department (Table 1). The questionnaires were self-administered, anonymous, and voluntary. Health care workers returned the questionnaires to their supervisors in sealed envelopes and the occupational health nurse collected the questionnaires from the supervisors. The study was approved by an Ethical Review Board at the University of the Free State.
WORKPLACE HEALTH & SAFETY • VOL. 62, NO. 9, 2014 Downloaded from whs.sagepub.com at Purdue University Libraries on July 21, 2015
383
TABLE 2
Summary of Health Care Worker Responses Question
Yes (%)
No (%)
Not Sure (%)
Did you have a needle stick/BBF exposure in the past 6 months?
11 (14.9)
63 (85.1)
Did you report your BBF?
9 (81.8)
2 (18.2)
55 (75.0)
6 (8.1)
12 (16.2)
Have you been vaccinated for hepatitis B?
62 (83.3)
8 (11.1)
4 (5.6)
Have you completed all three doses?
44 (59.5)
10 (13.5)
12 (16.2)
Needles should be recapped before disposala
27 (38.6)
38 (54.3)
5 (7.1)
If a patient is known to have HIV or hepatitis, you should change work practicesa
8 (11.1)
57 (79.2)
7 (9.7)
The use of gloves is recommended only when the risk of blood is presentb
36 (52.2)
31 (44.9)
2 (2.9)
All BBFs must be reported and evaluated by an occupational health practitionerb
51 (70.8)
8 (11.1)
13 (18.1)
Cleaners should use latex gloves when cleaningb
45 (63.4)
19 (26.8)
7 (9.7)
Do you know how to contact the OHS within your facility?
63 (85.9)
6 (8.1)
4 (5.4)
Do you know how to contact the Infection Control Service?
54 (73.0)
11 (15.0)
8 (11.0)
Do you know how to contact your OHS Committee representative?
46 (62.2)
18 (24.3)
10 (13.5)
Needlestick injuries
Attitude toward risk exposure Do you think it is important to take post-exposure prophylaxis each time you have an exposure? Hepatitis B vaccination
Knowledge of BBF exposure
OHS awareness
BBF = blood and body fluid; OHS = Occupational Health and Safety a No is the correct answer. b Yes is the corerct answer.
Data were analyzed using SPSS version 21 (SPSS, Inc., Chicago, IL) and descriptive statistics were generated. Chi-square tests were used to determine associations between variables, and odds ratios (ORs) with 95% confidence intervals (CIs) were calculated to measure the strength of the association between various factors and the occurrence of needlestick injuries or blood and body fluid exposures. A logistic regression model was tested to estimate the effect of these factors on blood and body fluid exposure controlling for interactions. A p value of less than .05 was considered statistically significant for all analyses. As part of the certificate program requirements, a monitoring report was provided by the occupational health nurse to the program team and a presentation given to hospital administration, including chief executive officers and provincial and national health authorities. RESULTS Seventy-four (88%) of the questionnaires were returned. Participants’ ages ranged from “younger than 20 years” to “older than 60 years”; the largest age group (38.6%) was between 40 and 49 years of age. Respon-
384
dents varied by occupation and department (Table 1). Table 2 provides a summary of responses. Blood and Body Fluid Exposure Risk Factors
Although most respondents (85.1%) reported no needlestick or sharps injury or blood and body fluid exposure in the previous 6 months, patterns were found related to worker characteristics and where these incidents occurred: (1) less than 6 years of experience in a department (19.1%; 9 of 47) versus those with greater seniority (0 of 20) (p = .035); (2) departments associated with higher risk of exposure (maternity, casualty, and the male ward) versus other units (p = .045); and (3) among nurses or physicians (9 of 50) versus other occupations (1 of 22) (p = .128). Blood and Body Fluid Reporting Practices
Of the exposed respondents, the majority had reported the blood and body fluid exposures to their supervisors (n = 7, 35.0%), the occupational health service (n = 30, 30.0%), an occupational health service representative (n = 3, 15.0%), or a colleague (n = 3, 15.0%).
Copyright © American Association of Occupational Health Nurses, Inc. Downloaded from whs.sagepub.com at Purdue University Libraries on July 21, 2015
TABLE 3
Factors Associated With Needlesticks or BBF Exposure Multivariate Model Total (%)
Variable
With Needlestick or BBF Univariate Exposure (%) OR
95% CI
B
OR Exp(B)
p
6.8
1.36 to 34.60a
3.38
29.27
.004a
4.6
.55 to 38.86
2.72
15.14
.021a
7.0
.81 to 59.34
Recapping knowledge “Recap” – wrong or unsure
32 (46.4)
9 (81.8)
“Don’t recap” – correct
37 (53.6)
2 (18.2)
Nurse or physician
50 (69.4)
9 (90.0)
Other work
22 (30.6)
1 (10.0)
Higher risk department 39 (58.2) (casualty, male, maternity)
8 (88.9)
Other department
1 (11.1)
Occupation
Risky department
28 (41.8) b
.106
.519
Experience in department < 5 years
38 (56.7)
6 (66.7)
≥ 5 years
29 (53.3)
3 (33.3)
1.6
.37 to 7.13
BBF = blood and body fluid; OR = odds ratio, expressed as Exp(B) value in logistic regression analysis; CI = confidence interval a p ≤ .05. b Experience in the department was considered in the logistic regression analysis as a continuous variable; ORs were calculated in relation to “> 5 years of experience,” as no exposures occurred in workers with 6 years or more.
Attitudes Toward Risk Exposure
When asked about the importance of monitoring blood and body fluid exposures, only 62.5% responded it was important to go to the occupational health clinic following an exposure; 25% did not think or were not sure if it was important to take post-exposure prophylaxis after each exposure. Hepatitis B Vaccination
Although most respondents reported having been vaccinated for hepatitis B, nearly one-third either did not complete all doses or could not remember doing so. Reasons given for not being vaccinated or not completing all doses included forgetting and not knowing about immunization services offered. Knowledge of Blood and Body Fluid Exposure
Health care workers working at this hospital do not use safety syringes, but rather are required to open the syringe and add the needle. To avoid injury, these types of needles should never be recapped, yet only approximately half of respondents reported that needles should never be recapped and only 27% of the health care workers who had incurred an exposure answered this question correctly. Of note, all nine enrolled nurse assistants who scored incorrectly on the question about recapping needles reported having incurred a blood and body fluid exposure but none of the four who answered this question correctly had experienced a blood and body fluid exposure (p < .001).
Awareness of Occupational Health and Safety Contacts
Respondents were asked whether they knew how to contact the Occupational Health Clinic, Infection Control Services, and their Occupational Health and Safety Committee representative. Although the majority of respondents knew how to contact the first two, a large portion (24.3%) did not know how to contact the Occupational Health and Safety Committee representative within their unit. Factors Affecting Needlestick and Blood and Body Fluid Exposure
To take into account interactions among the factors observed as being associated with needlestick injuries and blood and body fluid exposure, a logistic regression analysis was used to better inform strategies for interventions that could be pursued. The results showed that those who were not aware that needles should not be recapped before disposal (OR = 29.27, p = .004) and being a nurse or physician (OR = 15.14, p = .021) were highly predictive of who suffered exposure; practicing in a higher risk department trended toward statistical significance (p = .106) (Table 3). These insights suggest how prevention activities could be designed. Ongoing Results
Based on the study results, the occupational health nurse encouraged health and safety representatives to introduce themselves to staff and become more visible
WORKPLACE HEALTH & SAFETY • VOL. 62, NO. 9, 2014 Downloaded from whs.sagepub.com at Purdue University Libraries on July 21, 2015
385
DISCUSSION Reports that health care workers in Africa still lack knowledge about blood and body fluid prevention abound (Alemie, 2012; Kebede, Molla, & Sharma, 2012; Mbaisi et al., 2013; Reda, Fisseha, Mengistie, & Vandeweerd, 2010; Zelnick & O’Donnell, 2005), but reports from small rural hospitals on the knowledge, attitudes, and practices of health care workers in these settings are scarce. The current article aimed to address this gap. This study, conducted by a single occupational health nurse working in a rural facility as part of a Workplace HIV/TB certificate program requirement, was successful in highlighting gaps in knowledge and practice that can lead to occupational blood and body fluid exposure and prompting measures to address the findings, indicating the value of supporting such personnel. In keeping with the Workplace HIV/TB certificate program’s mandate, the project was a low-cost initiative. Because of its simplicity and ease, the current study is applicable to similar settings around the globe.
IN SUMMARY Reducing the Risks to Health Care Workers From Blood and Body Fluid Exposure in a Small Rural Hospital in Thabo-Mofutsanyana, South Africa Nkoko, L., Spiegel, J., Rau, A., Parent, S., & Yassi, A. Workplace Health and Safety 2014;62(9):382-388.
1
Knowledge and practices to protect health care workers from bloodborne diseases remain inadequate in low-resource settings.
2
Poor infection control knowledge scores (e.g., recapping needles) were significantly associated with reported blood and body fluid exposures.
3
Low-cost training programs can be designed to empower and support frontline health care workers to reduce occupational health and safety risks.
Limitations of the Study
in their departments. To address identified knowledge deficits, monthly educational programs on the prevention and reporting of needlestick injuries and blood and body fluid exposure were implemented for all staff (clinical and non-clinical). The educational sessions were offered in the morning at 7 a.m. to ensure inclusion of both day and night staff during a 1-month period. Occupational health nurses and infection control nurses conducted the educational sessions, which included management of occupational exposures to blood and body fluid, standard precautionary measures, accident and incident reporting, effective use of personal protective equipment, and best practices on segregation of waste. Following the intervention, more staff began to report injuries and exposures to the occupational health clinic, and health and safety representatives and infection control conducted monthly monitoring to assess compliance, knowledge, and skills on blood and body fluid prevention procedures. The Workplace HIV/TB Certificate Program
As described elsewhere (Liautaud et al., 2013), the Workplace HIV/TB certificate program consisted of three 3.5-day modules and the requirement to design and implement a workplace project under mentorship. The first face-to-face session took place in April 2011, Module 2 was held in September 2011, and Module 3 was held in May 2012. The participants formed eight groups to conduct research projects in their health care workplace on the theme of HIV and TB prevention. Problem- and community-based learning methods were used. Participants encountered some challenges due to their lack of research skills, particularly regarding data analysis and interpretation, and mentors assisted participants with these phases of the project.
386
The questionnaire used was not tested for reliability or validity, because limited funding and time did not permit the extra resources necessary to validate the questionnaire. However, the questionnaire was designed under the guidance of two mentors experienced with survey tool designs. As mentioned above, the occupational health nurse implemented an educational intervention to address the gaps in knowledge highlighted by the knowledge, attitudes, and practices questionnaire. Although the observed increase in reported blood and body fluid injuries to occupational health clinic staff cannot be documented due to an inadequate baseline of reported injuries, the occupational health nurse was confident that staff had a greater awareness of needlestick injury and blood and body fluid risk and had adopted safer practices. Unfortunately, no resources were available for a second knowledge, attitudes, and practices survey to test this impression, but the circumstances examined by this article are now flagged for ongoing monitoring by the facility’s workplace health and safety committee. The rural hospital discussed in this article has less than 300 employees and the knowledge, attitudes, and practices questionnaire only targeted those at high risk for blood and body fluid exposure. Thus, the sample size was small, possibly decreasing the power of the study to identify additional relationships. Importance of the Study
Needlestick injuries present alarming and all-toocommon occupational health threats to health care workers, especially in sub-Saharan countries where the HIV/ AIDS, and hepatitis B and C virus prevalence is high among hospitalized patients (Alemie, 2012; Mbaisi et al., 2013). A needlestick injury can cause fatal bloodborne infections and psychological stress for affected health care workers (Kebede et al., 2012; Yang et al., 2007; Zungu et al., 2008). The rate of hepatitis B infection is of particular concern in the event of a needlestick injury because the
Copyright © American Association of Occupational Health Nurses, Inc. Downloaded from whs.sagepub.com at Purdue University Libraries on July 21, 2015
hepatitis B virus is 100 times more infectious than HIV (Fernandes et al., 2013). Hepatitis B is vaccine-preventable, yet many studies (Burnett et al., 2011, 2012; Fernandes et al., 2013; Vardas, Ross, Sharp, McAnerney, & Sim, 2002), including the current study, reported a suboptimal hepatitis B vaccination rate among health care workers. The participants in the current study attributed their non-immunized state to “forgetting” and “lack of awareness.” In response to the current study, supervisors were encouraged to promote immunization and reporting of injuries among their staff. In view of the physical and psychological damage hepatitis B-infected health care workers may suffer, promoting workplace safety by educating health care workers about the importance of immunization is crucial. Mbaisi et al. (2013) reported that needle recapping is still widely practiced. This finding is consistent with the findings of the current study; 73% of injured health care workers did not know that needles should never be recapped. Of note, all nursing assistants who did not know that needles should never be recapped suffered needlestick injuries, and all nursing assistants who reported not recapping needles did not report suffering needlestick injuries. Similarly, the National Institute for Occupational Safety and Health (2008) reported that needle recapping is a predisposing factor for needlestick injuries, and it is therefore essential to educate health care workers to avoid this practice. Yang et al. (2007) reported that the incidence of needlestick injuries decreased significantly after educational interventions, including education about recapping. Karani, Rangiah, and Ross (2011) discovered a high number of needlestick injury reports from interns working at the Addington Hospital in South Africa. The authors attributed this high number of reports to a comprehensive orientation program and strict implementation of policies and guidelines at the hospital, showing the importance of not recapping needles. Yang et al. (2007) showed that interventions such as a comprehensive training program can improve behaviors. For the current study, although the authors did not demonstrate behavior change with a formal study, they found that although there were fewer injuries after the intervention they were reported more frequently, and fewer staff were reporting needle recapping injuries. International Collaboration
This study is the result of international collaboration between Northern and Southern (Canadian and South African) researchers. The ethics of North–South research partnerships have been widely discussed (Binka, 2005; Edejer, 1999; Volmink & Dare, 2005). Thus, it was essential to the project’s objectives and long-term vision to establish strong relationships between Northern and Southern researchers, and support existing ties between the university and clinical community. Additionally, because rural health care workers’ practices are poorly understood, care was taken to ensure inclusion of occupational health nurses from rural areas for this project.
CONCLUSION It is useful to provide education to occupational health nurses in low-resource settings, to empower them to conduct small projects to assess knowledge, attitudes, and practices of staff, and implement interventions based on the findings. Baseline data can inform the design of new programs and improve existing programs; gaps in knowledge and ineffective practices can be rectified at low cost, potentially preventing morbidity and mortality of health care workers in areas with high infectious disease burdens. International collaboration with local universities works well in supporting the provision of basic training and launching such initiatives. REFERENCES
Alemie, G. A. (2012). Exploration of healthcare workers’ perceptions on occupational risk of HIV transmission at the University of Gondar Hospital, Northwest Ethiopia. BMC Research Notes, 5, 704. Binka, F. (2005). Editorial: North–South research collaborations: A move towards a true partnership? Tropical Medicine & International Health, 10, 207-209. Bodibe, K. (2011). HCT campaign: The numbers so far living with AIDS #478. South Africa Health E-news. Retrieved from http:// www.health-e.org.za/2011/06/30/hct-campaign-the-numbers-sofar-living-with-aids-478/ Burnett, R. J., François, G., Mphahlele, M. J., Mureithi, J. G., Africa, P. N., Satekge, M. M., . . . van Sprundel, M. (2011). Hepatitis B vaccination coverage in healthcare workers in Gauteng province, South Africa. Vaccine, 29, 4293-4297. Burnett, R. J., Kramvis, A., Dochez, C., & Meheus, A. (2012). An update after 16 years of hepatitis B vaccination in South Africa. Vaccine, 30, C45-C51. Crush, J., & Pendleton, W. (2011). Brain flight: The exodus of health professionals from South Africa. International Journal of Migration, Health and Social Care, 6, 3-18. Delobelle, P., Rawlinson, J. L., Ntuli, S., Malatsi, I., Decock, R., & Depoorter, A. M. (2009). HIV/AIDS knowledge, attitudes, practices and perceptions of rural nurses in South Africa. Journal of Advanced Nursing, 65, 1061-1073. Dussault, G., & Franceschini, M. C. (2006). Not enough there, too many here: Understanding geographical imbalances in the distribution of the health workforce. Human Resources for Health, 4, 12. Edejer, T. T. T. (1999). North-South research partnerships: The ethics of carrying out research in developing countries. British Medical Journal, 319, 438. Ehlers, V. (2006). Challenges nurses face in coping with the HIV/AIDS pandemic in Africa. International Journal of Nursing Studies, 43, 657-662. Fernandes, L., Burnett, R., François, G., Mphahlele, M., Van Sprundel, M., & De Schryver, A. (2013). Need for a comprehensive, consistently applied national hepatitis B vaccination policy for healthcare workers in higher educational institutions: A case study from South Africa. Journal of Hospital Infection, 83, 226-231. Karani, H., Rangiah, S., & Ross, A. J. (2011). Occupational exposure to blood-borne or body fluid pathogens among medical interns at Addington Hospital, Durban: Original research. South African Family Practice, 53, 462-466. Kebede, G., Molla, M., & Sharma, H. R. (2012). Needle stick and sharps injuries among health care workers in Gondar City, Ethiopia. Safety Science, 50, 1093-1097. Lavoie, M., Yassi, A., Bryce, E., Fujii, R., Logronio, M., & Tennassee, M. (2010). International collaboration to protect health workers from infectious diseases in Ecuador. Pan American Journal of Public Health, 27, 396-402. Lehmann, U., Dieleman, M., & Martineau, T. (2008). Staffing remote rural areas in middle-and low-income countries: A literature review of attraction and retention. BMC Health Services Research, 8, 19. Liautaud, A., Yassi, A., Engelbrecht, M. C., O’Hara, L. M., Rau, A., Bryce, E., . . . Nophale, L. E. (2013). Building capacity to design, implement and evaluate participatory action research projects to de-
WORKPLACE HEALTH & SAFETY • VOL. 62, NO. 9, 2014 Downloaded from whs.sagepub.com at Purdue University Libraries on July 21, 2015
387
crease the burden of HIV and promote and protect the health and safety of the healthcare workforce: A South African–Canadian collaboration. Open Medicine, 7, s33. Mbaisi, E. M., Wanzala, P., & Omolo, J. (2013). Prevalence and factors associated with percutaneous injuries and splash exposures among health-care workers in a provincial hospital, Kenya, 2010. Pan African Medical Journal, 14. National Institute for Occupational Safety and Health. (2008). Exposure to stress: Occupational hazards in hospitals (Publication No. 2008136). Retrieved from http://www.cdc.gov/niosh/docs/2008-136/ pdfs/2008-136.pdf Nsubuga, F. M., & Jaakkola, M. S. (2005). Needle stick injuries among nurses in sub-Sahara Africa. Tropical Medicine & International Health, 10, 773-781. Rebman, R., Rodriguez Guzman, J., Dybka, L., Watson, R., Lavoie, M., Yassi, A., . . . Nophale, L. E. (2007). Proceedings from the 2007 State-of-the-Arts Conference Pre-conference Workshop: Protecting the Health of Healthcare Workers: A Global Perspective. Vancouver, British Columbia: National Institute for Occupational Safety and Health. Retrieved from http://stacks.cdc.gov/view/cdc/11739/ Reda, A. A., Fisseha, S., Mengistie, B., & Vandeweerd, J. (2010). Standard precautions: Occupational exposure and behavior of health care workers in Ethiopia. PloS One, 5, e14420. Republic of South Africa. (2013). The Local Government Handbook: A complete guide to municipalities in South Africa. Retrieved from http://www.municipalities.co.za/south-africa/district-municipality/10/thabo-mofutsanyana-district-municipality Sagoe-Moses, C., Pearson, R. D., Perry, J., & Jagger, J. (2001). Risks to health care workers in developing countries. The New England Journal of Medicine, 345, 538-541. Shisana, O., Hall, E., Maluleke, R., Chauveau, J., & Schwabe, C. (2004). HIV/AIDS prevalence among South African health workers. South African Medical Journal, 94, 846.
388
Vardas, E., Ross, M., Sharp, G., McAnerney, J., & Sim, J. (2002). Viral hepatitis in South African healthcare workers at increased risk of occupational exposure to blood-borne viruses. Journal of Hospital Infection, 50, 6-12. Volmink, J., & Dare, L. (2005). Addressing inequalities in research capacity in Africa. British Medical Journal, 331, 705-706. Wilburn, S., & Eijkemans, G., (2004). Preventing needlestick injuries among healthcare workers: a WHO–ICN collaboration. International Journal of Occupational and Environmental Health, 10, 451-456. World Health Organization. (2002). Word Health Report 2002: Reducing risks, promoting healthy life. Retrieved from http://www.who. int/whr/2002/en/ World Health Organization. (2006). Protecting Healthcare Workers: Preventing needlestick injuries toolkit. Retrieved from http://www. who.int/occupational_health/activities/pnitoolkit/en/ Yang, Y., Liou, S., Chen, C., Yang, C., Wang, C., Chen, C., & Wu, T. (2007). The effectiveness of a training program on reducing needlestick injuries/sharp object injuries among soon graduate vocational nursing school students in southern Taiwan. Journal of Occupational Health, 49, 424-429. Zelnick, J., & O’Donnell, M. (2005). The impact of the HIV/AIDS epidemic on hospital nurses in KwaZulu natal, South Africa: Nurses’ perspectives and implications for health policy. Journal of Public Health Policy, 26, 163-185. Ziady, L. E. (2010). Infection control: Protecting South African healthcare personnel from blood-borne infection in the twenty-first century workplace. Professional Nursing Today, 14(4), 6-10. Available at http://reference.sabinet.co.za/webx/access/electronic_journals/ mp_pnt/mp_pnt_v14_n4_a2.pdf Zungu, L. I., Sengane, M., & Setswe, K. G. (2008). Knowledge and experiences of needle prick injuries (NPI) among nursing students at a university in Gauteng, South Africa. South African Family Practice, 50, 48-48c.
Copyright © American Association of Occupational Health Nurses, Inc. Downloaded from whs.sagepub.com at Purdue University Libraries on July 21, 2015
S
ub-Saharan Africa has a high prevalence of bloodborne infectious diseases, such as human immunodeficiency virus (HIV) and hepatitis B and C
ABOUT THE AUTHORS
Ms. Nkoko is Occupational Health Nurse Practitioner, Thebe District Hospital, Harrismith, South Africa. Drs. Spiegel and Yassi are Professors, and Ms. Parent is Research Assistant, School of Population and Public Health, University of British Columbia, Vancouver, British Columbia. Dr. Rau is Senior Researcher, Centre for Health Systems Research & Development, University of the Free State, Bloemfontein, South Africa. Submitted: January 6, 2014; Accepted: July 3, 2014; Posted online: September 5, 2014 Supported by the Global Health Research Initiative (GHRI), a research funding partnership of the Canadian Institutes of Health Research, the Canadian International Development Agency, and the International Development Research Centre. The authors have disclosed no potential conflicts, financial or otherwise. The authors thank the staff, students, and colleagues from the Centre for Health Systems Research and Development at the University of Free State, the University of British Columbia, Vancouver Coastal Heath, South Africa’s Department of Health, National Institute of Occupational Health of South Africa, the World Health Organization, and the International Labour Organization who contributed to the training program; the Free State Department of Health and the management of Thebe District Hospital in Thabo Mofutsanyana in the Eastern Free State for supporting the training; and the health care workers who completed surveys. Correspondence: Annalee Yassi, MD, MSc, FRCPC, School of Population and Public Health, University of British Columbia, 4th Floor, 2206 East Mall, Vancouver, BC V6T 1Z3, Canada. E-mail: [email protected] doi:10.3928/21650799-20140815-03
382
virus (Ehlers, 2006; Lehmann, Dieleman, & Martineau, 2008). In 2010, 4.6 million South Africans were tested for HIV and an overwhelming 17% were HIV positive (Bodibe, 2011). Hepatitis B causes an estimated 14,000 deaths annually in South Africa, and 40% of hepatitis B cases are attributed to occupational exposure in health care (Crush & Pendleton, 2011; World Health Organization [WHO], 2002). Thus, the health care environment in these settings poses a high occupational risk of infection (Ehlers, 2006; Nsubuga & Jaakkola, 2005; Zungu, Sengane, & Setswe, 2008), with health care workers exposed to infected blood and body fluid via needlestick injuries (Shisana, Hall, Maluleke, Chauveau, & Schwabe, 2004; Zungu et al., 2008). WHO recommendations for health care worker safety include universal precautions (including no needle recapping), hepatitis B immunization, personal protective equipment, and post-exposure management (WHO, 2006). South Africa’s policies on blood and body fluid exposure prevention include eliminating hazards (including preventing and effectively managing blood and body fluid spills), using safety devices with engineered controls, applying administrative controls, employing procedural and clinical practice controls including effective disposal of contaminated sharp and biomedical waste,
Copyright © American Association of Occupational Health Nurses, Inc. Downloaded from whs.sagepub.com at Purdue University Libraries on July 21, 2015
providing and mandating the use of appropriate personal protective clothing, and conducting ongoing product surveillance regarding the prescribed use of safety measures (Ziady, 2010). Many local, national, and international efforts have been initiated to implement these guidelines and ensure compliance (e.g., a pilot project aimed at preventing occupational HIV and hepatitis B infection launched by the WHO in partnership with the International Council of Nurses) (Wilburn & Eijkemans, 2004). Nonetheless, occupational exposure to blood and body fluids is still common in Africa (Burnett, Kramvis, Dochez, & Meheus, 2012; Fernandes et al., 2013; Mbaisi, Wanzala, & Omolo, 2013). Although poorly studied, the high prevalence of occupational blood and body fluid exposure is especially true in rural and remote areas of Africa, where unsafe injection practices and lack of risk prevention knowledge are common (Delobelle et al., 2009). The challenges in providing essential occupational health services in rural and remote areas of Africa, especially in low- and middle-income countries, have been highlighted in the literature (Dussault & Franceschini, 2006; Lehmann et al., 2008; Rebman et al., 2007). Inadequate infrastructure and lack of support for occupational health practices are especially problematic in such settings (Lavoie et al. 2010; Rebman et al., 2007; Sagoe-Moses, Pearson, Perry, & Jagger, 2001), rendering health care workers in rural and remote areas at particularly high risk of blood and body fluid exposure. To build capacity to address this situation, the University of British Columbia in Canada joined forces with the University of the Free State in South Africa and the Free State Department of Health to offer a training program aimed at empowering local occupational health and infection control personnel to implement workplacebased interventions to protect health care workers from infectious occupational exposures (Liautaud et al., 2013). The current study, conducted in the context of that program, aimed to determine knowledge, attitudes, and practices of health care workers regarding blood and body fluids in a small district hospital in the eastern region of the Free State province of South Africa. Ninety-five percent of individuals living in this district are black and speak Sesotho and Zulu. This area of South Africa has serious socioeconomic challenges, with high rates of homelessness and an unemployment rate estimated to be 35% (Republic of South Africa, 2013). In this article, the researchers describe the results of the study conducted by one occupational health nurse who participated in the Workplace HIV/Tuberculosis (TB) Certificate Program training, and reflect on how this experience may build occupational health capacity in other low-resourced rural settings. METHODS The study was designed and implemented by an occupational health nurse with remote guidance from two mentors, one from South Africa and one from Canada. Mentors worked with the occupational health nurse to
TABLE 1
Profile of Respondents by Occupation and Department Occupation
Number
%
Professional nurse
22
29.7
Enrolled nurse assistant
16
21.6
General worker
10
13.5
Enrolled nurse
8
10.8
Physician
5
6.8
Laundry worker
4
5.4
Dentist
3
4.1
Dental assistant
2
2.7
Occupational therapist
2
2.7
Physiotherapist
1
1.4
Missing
1
1.4
74
100
Casualty
20
27.0
Women’s & pediatric ward
13
17.6
Maternity
12
16.2
Men’s ward
11
14.9
Dental
5
6.8
Laundry
4
5.4
Rehabilitation
4
5.4
Total Department
Theatre Total
5
6.8
74
100
design a questionnaire about knowledge, attitudes, and practices related to blood and body fluid. Demographic questions were taken from an existing survey used in the Free State. Questions specific to the occupational health nurse’s research were designed by the nurse herself and refined in collaboration with her project mentors. The finalized questionnaires, in envelopes, were distributed to supervisors of high-risk hospital departments, including casualty (emergency department where all patients are seen, treated, and discharged, admitted, or referred to the regional hospital), dental, laundry, women’s and pediatric wards, men’s ward (medical, surgical, orthopedic, and psychiatric male patients are admitted), maternity, rehabilitation, and theatre (operating room) (Table 1). Supervisors distributed the questionnaires to health care workers in each department (Table 1). The questionnaires were self-administered, anonymous, and voluntary. Health care workers returned the questionnaires to their supervisors in sealed envelopes and the occupational health nurse collected the questionnaires from the supervisors. The study was approved by an Ethical Review Board at the University of the Free State.
WORKPLACE HEALTH & SAFETY • VOL. 62, NO. 9, 2014 Downloaded from whs.sagepub.com at Purdue University Libraries on July 21, 2015
383
TABLE 2
Summary of Health Care Worker Responses Question
Yes (%)
No (%)
Not Sure (%)
Did you have a needle stick/BBF exposure in the past 6 months?
11 (14.9)
63 (85.1)
Did you report your BBF?
9 (81.8)
2 (18.2)
55 (75.0)
6 (8.1)
12 (16.2)
Have you been vaccinated for hepatitis B?
62 (83.3)
8 (11.1)
4 (5.6)
Have you completed all three doses?
44 (59.5)
10 (13.5)
12 (16.2)
Needles should be recapped before disposala
27 (38.6)
38 (54.3)
5 (7.1)
If a patient is known to have HIV or hepatitis, you should change work practicesa
8 (11.1)
57 (79.2)
7 (9.7)
The use of gloves is recommended only when the risk of blood is presentb
36 (52.2)
31 (44.9)
2 (2.9)
All BBFs must be reported and evaluated by an occupational health practitionerb
51 (70.8)
8 (11.1)
13 (18.1)
Cleaners should use latex gloves when cleaningb
45 (63.4)
19 (26.8)
7 (9.7)
Do you know how to contact the OHS within your facility?
63 (85.9)
6 (8.1)
4 (5.4)
Do you know how to contact the Infection Control Service?
54 (73.0)
11 (15.0)
8 (11.0)
Do you know how to contact your OHS Committee representative?
46 (62.2)
18 (24.3)
10 (13.5)
Needlestick injuries
Attitude toward risk exposure Do you think it is important to take post-exposure prophylaxis each time you have an exposure? Hepatitis B vaccination
Knowledge of BBF exposure
OHS awareness
BBF = blood and body fluid; OHS = Occupational Health and Safety a No is the correct answer. b Yes is the corerct answer.
Data were analyzed using SPSS version 21 (SPSS, Inc., Chicago, IL) and descriptive statistics were generated. Chi-square tests were used to determine associations between variables, and odds ratios (ORs) with 95% confidence intervals (CIs) were calculated to measure the strength of the association between various factors and the occurrence of needlestick injuries or blood and body fluid exposures. A logistic regression model was tested to estimate the effect of these factors on blood and body fluid exposure controlling for interactions. A p value of less than .05 was considered statistically significant for all analyses. As part of the certificate program requirements, a monitoring report was provided by the occupational health nurse to the program team and a presentation given to hospital administration, including chief executive officers and provincial and national health authorities. RESULTS Seventy-four (88%) of the questionnaires were returned. Participants’ ages ranged from “younger than 20 years” to “older than 60 years”; the largest age group (38.6%) was between 40 and 49 years of age. Respon-
384
dents varied by occupation and department (Table 1). Table 2 provides a summary of responses. Blood and Body Fluid Exposure Risk Factors
Although most respondents (85.1%) reported no needlestick or sharps injury or blood and body fluid exposure in the previous 6 months, patterns were found related to worker characteristics and where these incidents occurred: (1) less than 6 years of experience in a department (19.1%; 9 of 47) versus those with greater seniority (0 of 20) (p = .035); (2) departments associated with higher risk of exposure (maternity, casualty, and the male ward) versus other units (p = .045); and (3) among nurses or physicians (9 of 50) versus other occupations (1 of 22) (p = .128). Blood and Body Fluid Reporting Practices
Of the exposed respondents, the majority had reported the blood and body fluid exposures to their supervisors (n = 7, 35.0%), the occupational health service (n = 30, 30.0%), an occupational health service representative (n = 3, 15.0%), or a colleague (n = 3, 15.0%).
Copyright © American Association of Occupational Health Nurses, Inc. Downloaded from whs.sagepub.com at Purdue University Libraries on July 21, 2015
TABLE 3
Factors Associated With Needlesticks or BBF Exposure Multivariate Model Total (%)
Variable
With Needlestick or BBF Univariate Exposure (%) OR
95% CI
B
OR Exp(B)
p
6.8
1.36 to 34.60a
3.38
29.27
.004a
4.6
.55 to 38.86
2.72
15.14
.021a
7.0
.81 to 59.34
Recapping knowledge “Recap” – wrong or unsure
32 (46.4)
9 (81.8)
“Don’t recap” – correct
37 (53.6)
2 (18.2)
Nurse or physician
50 (69.4)
9 (90.0)
Other work
22 (30.6)
1 (10.0)
Higher risk department 39 (58.2) (casualty, male, maternity)
8 (88.9)
Other department
1 (11.1)
Occupation
Risky department
28 (41.8) b
.106
.519
Experience in department < 5 years
38 (56.7)
6 (66.7)
≥ 5 years
29 (53.3)
3 (33.3)
1.6
.37 to 7.13
BBF = blood and body fluid; OR = odds ratio, expressed as Exp(B) value in logistic regression analysis; CI = confidence interval a p ≤ .05. b Experience in the department was considered in the logistic regression analysis as a continuous variable; ORs were calculated in relation to “> 5 years of experience,” as no exposures occurred in workers with 6 years or more.
Attitudes Toward Risk Exposure
When asked about the importance of monitoring blood and body fluid exposures, only 62.5% responded it was important to go to the occupational health clinic following an exposure; 25% did not think or were not sure if it was important to take post-exposure prophylaxis after each exposure. Hepatitis B Vaccination
Although most respondents reported having been vaccinated for hepatitis B, nearly one-third either did not complete all doses or could not remember doing so. Reasons given for not being vaccinated or not completing all doses included forgetting and not knowing about immunization services offered. Knowledge of Blood and Body Fluid Exposure
Health care workers working at this hospital do not use safety syringes, but rather are required to open the syringe and add the needle. To avoid injury, these types of needles should never be recapped, yet only approximately half of respondents reported that needles should never be recapped and only 27% of the health care workers who had incurred an exposure answered this question correctly. Of note, all nine enrolled nurse assistants who scored incorrectly on the question about recapping needles reported having incurred a blood and body fluid exposure but none of the four who answered this question correctly had experienced a blood and body fluid exposure (p < .001).
Awareness of Occupational Health and Safety Contacts
Respondents were asked whether they knew how to contact the Occupational Health Clinic, Infection Control Services, and their Occupational Health and Safety Committee representative. Although the majority of respondents knew how to contact the first two, a large portion (24.3%) did not know how to contact the Occupational Health and Safety Committee representative within their unit. Factors Affecting Needlestick and Blood and Body Fluid Exposure
To take into account interactions among the factors observed as being associated with needlestick injuries and blood and body fluid exposure, a logistic regression analysis was used to better inform strategies for interventions that could be pursued. The results showed that those who were not aware that needles should not be recapped before disposal (OR = 29.27, p = .004) and being a nurse or physician (OR = 15.14, p = .021) were highly predictive of who suffered exposure; practicing in a higher risk department trended toward statistical significance (p = .106) (Table 3). These insights suggest how prevention activities could be designed. Ongoing Results
Based on the study results, the occupational health nurse encouraged health and safety representatives to introduce themselves to staff and become more visible
WORKPLACE HEALTH & SAFETY • VOL. 62, NO. 9, 2014 Downloaded from whs.sagepub.com at Purdue University Libraries on July 21, 2015
385
DISCUSSION Reports that health care workers in Africa still lack knowledge about blood and body fluid prevention abound (Alemie, 2012; Kebede, Molla, & Sharma, 2012; Mbaisi et al., 2013; Reda, Fisseha, Mengistie, & Vandeweerd, 2010; Zelnick & O’Donnell, 2005), but reports from small rural hospitals on the knowledge, attitudes, and practices of health care workers in these settings are scarce. The current article aimed to address this gap. This study, conducted by a single occupational health nurse working in a rural facility as part of a Workplace HIV/TB certificate program requirement, was successful in highlighting gaps in knowledge and practice that can lead to occupational blood and body fluid exposure and prompting measures to address the findings, indicating the value of supporting such personnel. In keeping with the Workplace HIV/TB certificate program’s mandate, the project was a low-cost initiative. Because of its simplicity and ease, the current study is applicable to similar settings around the globe.
IN SUMMARY Reducing the Risks to Health Care Workers From Blood and Body Fluid Exposure in a Small Rural Hospital in Thabo-Mofutsanyana, South Africa Nkoko, L., Spiegel, J., Rau, A., Parent, S., & Yassi, A. Workplace Health and Safety 2014;62(9):382-388.
1
Knowledge and practices to protect health care workers from bloodborne diseases remain inadequate in low-resource settings.
2
Poor infection control knowledge scores (e.g., recapping needles) were significantly associated with reported blood and body fluid exposures.
3
Low-cost training programs can be designed to empower and support frontline health care workers to reduce occupational health and safety risks.
Limitations of the Study
in their departments. To address identified knowledge deficits, monthly educational programs on the prevention and reporting of needlestick injuries and blood and body fluid exposure were implemented for all staff (clinical and non-clinical). The educational sessions were offered in the morning at 7 a.m. to ensure inclusion of both day and night staff during a 1-month period. Occupational health nurses and infection control nurses conducted the educational sessions, which included management of occupational exposures to blood and body fluid, standard precautionary measures, accident and incident reporting, effective use of personal protective equipment, and best practices on segregation of waste. Following the intervention, more staff began to report injuries and exposures to the occupational health clinic, and health and safety representatives and infection control conducted monthly monitoring to assess compliance, knowledge, and skills on blood and body fluid prevention procedures. The Workplace HIV/TB Certificate Program
As described elsewhere (Liautaud et al., 2013), the Workplace HIV/TB certificate program consisted of three 3.5-day modules and the requirement to design and implement a workplace project under mentorship. The first face-to-face session took place in April 2011, Module 2 was held in September 2011, and Module 3 was held in May 2012. The participants formed eight groups to conduct research projects in their health care workplace on the theme of HIV and TB prevention. Problem- and community-based learning methods were used. Participants encountered some challenges due to their lack of research skills, particularly regarding data analysis and interpretation, and mentors assisted participants with these phases of the project.
386
The questionnaire used was not tested for reliability or validity, because limited funding and time did not permit the extra resources necessary to validate the questionnaire. However, the questionnaire was designed under the guidance of two mentors experienced with survey tool designs. As mentioned above, the occupational health nurse implemented an educational intervention to address the gaps in knowledge highlighted by the knowledge, attitudes, and practices questionnaire. Although the observed increase in reported blood and body fluid injuries to occupational health clinic staff cannot be documented due to an inadequate baseline of reported injuries, the occupational health nurse was confident that staff had a greater awareness of needlestick injury and blood and body fluid risk and had adopted safer practices. Unfortunately, no resources were available for a second knowledge, attitudes, and practices survey to test this impression, but the circumstances examined by this article are now flagged for ongoing monitoring by the facility’s workplace health and safety committee. The rural hospital discussed in this article has less than 300 employees and the knowledge, attitudes, and practices questionnaire only targeted those at high risk for blood and body fluid exposure. Thus, the sample size was small, possibly decreasing the power of the study to identify additional relationships. Importance of the Study
Needlestick injuries present alarming and all-toocommon occupational health threats to health care workers, especially in sub-Saharan countries where the HIV/ AIDS, and hepatitis B and C virus prevalence is high among hospitalized patients (Alemie, 2012; Mbaisi et al., 2013). A needlestick injury can cause fatal bloodborne infections and psychological stress for affected health care workers (Kebede et al., 2012; Yang et al., 2007; Zungu et al., 2008). The rate of hepatitis B infection is of particular concern in the event of a needlestick injury because the
Copyright © American Association of Occupational Health Nurses, Inc. Downloaded from whs.sagepub.com at Purdue University Libraries on July 21, 2015
hepatitis B virus is 100 times more infectious than HIV (Fernandes et al., 2013). Hepatitis B is vaccine-preventable, yet many studies (Burnett et al., 2011, 2012; Fernandes et al., 2013; Vardas, Ross, Sharp, McAnerney, & Sim, 2002), including the current study, reported a suboptimal hepatitis B vaccination rate among health care workers. The participants in the current study attributed their non-immunized state to “forgetting” and “lack of awareness.” In response to the current study, supervisors were encouraged to promote immunization and reporting of injuries among their staff. In view of the physical and psychological damage hepatitis B-infected health care workers may suffer, promoting workplace safety by educating health care workers about the importance of immunization is crucial. Mbaisi et al. (2013) reported that needle recapping is still widely practiced. This finding is consistent with the findings of the current study; 73% of injured health care workers did not know that needles should never be recapped. Of note, all nursing assistants who did not know that needles should never be recapped suffered needlestick injuries, and all nursing assistants who reported not recapping needles did not report suffering needlestick injuries. Similarly, the National Institute for Occupational Safety and Health (2008) reported that needle recapping is a predisposing factor for needlestick injuries, and it is therefore essential to educate health care workers to avoid this practice. Yang et al. (2007) reported that the incidence of needlestick injuries decreased significantly after educational interventions, including education about recapping. Karani, Rangiah, and Ross (2011) discovered a high number of needlestick injury reports from interns working at the Addington Hospital in South Africa. The authors attributed this high number of reports to a comprehensive orientation program and strict implementation of policies and guidelines at the hospital, showing the importance of not recapping needles. Yang et al. (2007) showed that interventions such as a comprehensive training program can improve behaviors. For the current study, although the authors did not demonstrate behavior change with a formal study, they found that although there were fewer injuries after the intervention they were reported more frequently, and fewer staff were reporting needle recapping injuries. International Collaboration
This study is the result of international collaboration between Northern and Southern (Canadian and South African) researchers. The ethics of North–South research partnerships have been widely discussed (Binka, 2005; Edejer, 1999; Volmink & Dare, 2005). Thus, it was essential to the project’s objectives and long-term vision to establish strong relationships between Northern and Southern researchers, and support existing ties between the university and clinical community. Additionally, because rural health care workers’ practices are poorly understood, care was taken to ensure inclusion of occupational health nurses from rural areas for this project.
CONCLUSION It is useful to provide education to occupational health nurses in low-resource settings, to empower them to conduct small projects to assess knowledge, attitudes, and practices of staff, and implement interventions based on the findings. Baseline data can inform the design of new programs and improve existing programs; gaps in knowledge and ineffective practices can be rectified at low cost, potentially preventing morbidity and mortality of health care workers in areas with high infectious disease burdens. International collaboration with local universities works well in supporting the provision of basic training and launching such initiatives. REFERENCES
Alemie, G. A. (2012). Exploration of healthcare workers’ perceptions on occupational risk of HIV transmission at the University of Gondar Hospital, Northwest Ethiopia. BMC Research Notes, 5, 704. Binka, F. (2005). Editorial: North–South research collaborations: A move towards a true partnership? Tropical Medicine & International Health, 10, 207-209. Bodibe, K. (2011). HCT campaign: The numbers so far living with AIDS #478. South Africa Health E-news. Retrieved from http:// www.health-e.org.za/2011/06/30/hct-campaign-the-numbers-sofar-living-with-aids-478/ Burnett, R. J., François, G., Mphahlele, M. J., Mureithi, J. G., Africa, P. N., Satekge, M. M., . . . van Sprundel, M. (2011). Hepatitis B vaccination coverage in healthcare workers in Gauteng province, South Africa. Vaccine, 29, 4293-4297. Burnett, R. J., Kramvis, A., Dochez, C., & Meheus, A. (2012). An update after 16 years of hepatitis B vaccination in South Africa. Vaccine, 30, C45-C51. Crush, J., & Pendleton, W. (2011). Brain flight: The exodus of health professionals from South Africa. International Journal of Migration, Health and Social Care, 6, 3-18. Delobelle, P., Rawlinson, J. L., Ntuli, S., Malatsi, I., Decock, R., & Depoorter, A. M. (2009). HIV/AIDS knowledge, attitudes, practices and perceptions of rural nurses in South Africa. Journal of Advanced Nursing, 65, 1061-1073. Dussault, G., & Franceschini, M. C. (2006). Not enough there, too many here: Understanding geographical imbalances in the distribution of the health workforce. Human Resources for Health, 4, 12. Edejer, T. T. T. (1999). North-South research partnerships: The ethics of carrying out research in developing countries. British Medical Journal, 319, 438. Ehlers, V. (2006). Challenges nurses face in coping with the HIV/AIDS pandemic in Africa. International Journal of Nursing Studies, 43, 657-662. Fernandes, L., Burnett, R., François, G., Mphahlele, M., Van Sprundel, M., & De Schryver, A. (2013). Need for a comprehensive, consistently applied national hepatitis B vaccination policy for healthcare workers in higher educational institutions: A case study from South Africa. Journal of Hospital Infection, 83, 226-231. Karani, H., Rangiah, S., & Ross, A. J. (2011). Occupational exposure to blood-borne or body fluid pathogens among medical interns at Addington Hospital, Durban: Original research. South African Family Practice, 53, 462-466. Kebede, G., Molla, M., & Sharma, H. R. (2012). Needle stick and sharps injuries among health care workers in Gondar City, Ethiopia. Safety Science, 50, 1093-1097. Lavoie, M., Yassi, A., Bryce, E., Fujii, R., Logronio, M., & Tennassee, M. (2010). International collaboration to protect health workers from infectious diseases in Ecuador. Pan American Journal of Public Health, 27, 396-402. Lehmann, U., Dieleman, M., & Martineau, T. (2008). Staffing remote rural areas in middle-and low-income countries: A literature review of attraction and retention. BMC Health Services Research, 8, 19. Liautaud, A., Yassi, A., Engelbrecht, M. C., O’Hara, L. M., Rau, A., Bryce, E., . . . Nophale, L. E. (2013). Building capacity to design, implement and evaluate participatory action research projects to de-
WORKPLACE HEALTH & SAFETY • VOL. 62, NO. 9, 2014 Downloaded from whs.sagepub.com at Purdue University Libraries on July 21, 2015
387
crease the burden of HIV and promote and protect the health and safety of the healthcare workforce: A South African–Canadian collaboration. Open Medicine, 7, s33. Mbaisi, E. M., Wanzala, P., & Omolo, J. (2013). Prevalence and factors associated with percutaneous injuries and splash exposures among health-care workers in a provincial hospital, Kenya, 2010. Pan African Medical Journal, 14. National Institute for Occupational Safety and Health. (2008). Exposure to stress: Occupational hazards in hospitals (Publication No. 2008136). Retrieved from http://www.cdc.gov/niosh/docs/2008-136/ pdfs/2008-136.pdf Nsubuga, F. M., & Jaakkola, M. S. (2005). Needle stick injuries among nurses in sub-Sahara Africa. Tropical Medicine & International Health, 10, 773-781. Rebman, R., Rodriguez Guzman, J., Dybka, L., Watson, R., Lavoie, M., Yassi, A., . . . Nophale, L. E. (2007). Proceedings from the 2007 State-of-the-Arts Conference Pre-conference Workshop: Protecting the Health of Healthcare Workers: A Global Perspective. Vancouver, British Columbia: National Institute for Occupational Safety and Health. Retrieved from http://stacks.cdc.gov/view/cdc/11739/ Reda, A. A., Fisseha, S., Mengistie, B., & Vandeweerd, J. (2010). Standard precautions: Occupational exposure and behavior of health care workers in Ethiopia. PloS One, 5, e14420. Republic of South Africa. (2013). The Local Government Handbook: A complete guide to municipalities in South Africa. Retrieved from http://www.municipalities.co.za/south-africa/district-municipality/10/thabo-mofutsanyana-district-municipality Sagoe-Moses, C., Pearson, R. D., Perry, J., & Jagger, J. (2001). Risks to health care workers in developing countries. The New England Journal of Medicine, 345, 538-541. Shisana, O., Hall, E., Maluleke, R., Chauveau, J., & Schwabe, C. (2004). HIV/AIDS prevalence among South African health workers. South African Medical Journal, 94, 846.
388
Vardas, E., Ross, M., Sharp, G., McAnerney, J., & Sim, J. (2002). Viral hepatitis in South African healthcare workers at increased risk of occupational exposure to blood-borne viruses. Journal of Hospital Infection, 50, 6-12. Volmink, J., & Dare, L. (2005). Addressing inequalities in research capacity in Africa. British Medical Journal, 331, 705-706. Wilburn, S., & Eijkemans, G., (2004). Preventing needlestick injuries among healthcare workers: a WHO–ICN collaboration. International Journal of Occupational and Environmental Health, 10, 451-456. World Health Organization. (2002). Word Health Report 2002: Reducing risks, promoting healthy life. Retrieved from http://www.who. int/whr/2002/en/ World Health Organization. (2006). Protecting Healthcare Workers: Preventing needlestick injuries toolkit. Retrieved from http://www. who.int/occupational_health/activities/pnitoolkit/en/ Yang, Y., Liou, S., Chen, C., Yang, C., Wang, C., Chen, C., & Wu, T. (2007). The effectiveness of a training program on reducing needlestick injuries/sharp object injuries among soon graduate vocational nursing school students in southern Taiwan. Journal of Occupational Health, 49, 424-429. Zelnick, J., & O’Donnell, M. (2005). The impact of the HIV/AIDS epidemic on hospital nurses in KwaZulu natal, South Africa: Nurses’ perspectives and implications for health policy. Journal of Public Health Policy, 26, 163-185. Ziady, L. E. (2010). Infection control: Protecting South African healthcare personnel from blood-borne infection in the twenty-first century workplace. Professional Nursing Today, 14(4), 6-10. Available at http://reference.sabinet.co.za/webx/access/electronic_journals/ mp_pnt/mp_pnt_v14_n4_a2.pdf Zungu, L. I., Sengane, M., & Setswe, K. G. (2008). Knowledge and experiences of needle prick injuries (NPI) among nursing students at a university in Gauteng, South Africa. South African Family Practice, 50, 48-48c.
Copyright © American Association of Occupational Health Nurses, Inc. Downloaded from whs.sagepub.com at Purdue University Libraries on July 21, 2015
