Knowledge and practice of injection safety among healthcare workers in a Nigerian secondary healthcare facility

Corresponding Author Salisu abubakar Department of Nursing Science, Bayero University Kano, Nigeria email: salisrn@yahoo.com Abstract Injection safety is important in today’s healthcare delivery particularly in settings with a high burden of blood-borne viruses. a safe injection protects the patient, the healthcare worker and the community from avoidable infections. In Nigeria, the national policy on injection safety and healthcare waste management were developed in 2007. the development of the policy was followed by series of training on safe injection and behavioural change. Despite this, burden of unsafe injections was reported in many parts of the country. this study assessed the level of knowledge and practice of injection safety among healthcare workers in a secondary healthcare facility in north-western Nigeria. the study targeted all the healthcare workers employed in the hospital. a self-administered questionnaire was distributed to all the available healthcare workers.


Introduction
the safety of injection is an important issue in today's healthcare where injectable medications and vaccines are commonly used.Coupled with this is the high burden of blood-borne pathogens with potential of transmission through accidental exposure to contaminated needles and syringes. 1globally, the World Health Organization (WHO) estimated that billions of injections are administered every year within healthcare settings. 2these injections according to the WHO are commonly used for curative purposes, most of which are unnecessary and avoidable.Inappropriate injections can lead to avoidable harm particularly in developing countries where safety resources and practices cannot always be guaranteed. 3a recent estimate of the burden of blood-borne infections due to unsafe injection practices revealed that up to 46% of hepatitis B, 38% of hepatitis C and 12% of human immunodeficiency virus (HIV) infections are associated with unsafe injections. 4Furthermore, unsafe injection practices can fuel the transmission of other emerging and reemerging infectious diseases such as the ebola virus disease. 5Modelling using the fraction of unsafe injection-associated bloodborne viral infections estimated a burden of 9.18 million preventable disability-adjusted life years from 2000 to 2030. 6cording to the WHO's Safe Injection Global Network (SIGN), a safe injection is one that does not harm the recipient, does not expose the provider (HCWs) to any avoidable risks and does not result in waste that is dangerous to the community. 7Hence, safe injection practice involves the administration of rational injection by a qualified and well-trained person using a sterile device, right technique, proper disposal and management of the wastes generated.The SIGN was launched by the WHO as an alliance of global stakeholders to support and ensure the safe, logical and proper use of injections worldwide. 7One of the strategies to achieve the goal of this coalition as highlighted by SIgN is the behaviour change of healthcare workers.the healthcare workers are those individuals who deliver health services such as injection to the sick either directly as nurses and physicians or indirectly as environmental health, laboratory and other supportive staff including waste handlers. 8It is believed that behaviour change among the injection providers will improve the healthcare workers' and patient safety by preventing the reuse of injection equipment, reducing unnecessary injections, prevention of needlestick injuries and enhancement of community safety via safe sharps and other waste management. 9 Nigeria, a national policy on injection safety and healthcare waste management was formulated in 2007 to address the problem of unsafe injection practices. 10he policy supported by the United States agency for International Development (USAID) under the President's Emergency Plan For AIDS Relief (PEPFAR) project included training programmes for healthcare workers on injection safety in the context of infection prevention and control and behaviour change.11 Despite the existence of the policy document and training of the healthcare providers, high burden of injections and unsafe practices was reported in parts of Nigeria.12 In addition, an array of studies found that around half of the healthcare workers had poor or low level of injection safety knowledge.13,14 equally, a wide gap was reported between the injection safety knowledge and practice with many injection providers engaging in unsafe injection practices such as recapping of used needles and syringes.15,16 Currently, little is known about the knowledge and practice of injection safety among healthcare workers in sub-urban hospitals of north-western Nigeria.Consequently, the aim of this study was to assess the level of knowledge and practice of injection safety among the healthcare workers at Birnin kudu general Hospital in north-western Nigeria.It is hoped that findings will help inform professionals, patient groups and policymakers.the study population included all the healthcare workers employed within the hospital. Inew of the small population, all the healthcare workers of the hospital were considered so as to get a sufficient sample size and avoid potential statistical error.17 the study targeted to recruit all the 88 healthcare workers.thus, all the hospital units were visited during all the shift hours and staff not on duty were reached by their unit managers or team lead.

Methods
the tool used for the data collection was adapted from WHO revised tool C for assessment of safe injection practices among injection providers and phlebotomists. 18the adapted tool was designed in a form of a structured self-administered questionnaire to elicit responses that will answer the research questions. the tool was assessed for clarity, completeness, face and content validity by the investigators and subsequently by an infection control specialist.the questionnaire included demographic details including age, gender, tribe, marital status, professional cadre and years of experience.the main aspect of the questionnaire comprised of questions related to knowledge of injection safety, formal training, national policy, risks associated with unsafe injection and diseases that can potentially be transmitted.the last section of the questionnaire consisted of practices that ensure safe injection, needle recapping, needlestick injury and access to prophylaxis following accidental exposure and reasons for not reporting an exposure.respondents were asked to choose the answer they believe is correct.In assessing the knowledge and practice score, 0 -59% was considered poor, 60 -69% fair and ≥70% was considered good.
the questionnaires were distributed to all the healthcare workers directly or through their clinical supervisors.a total of 88 questionnaires were distributed and the respondents were given time to fill and return the questionnaires within two days to the study investigators.and needle.Though the majority (59, 78.7%) of the respondents had a fair knowledge of risks associated with unsafe injections, only 15 (18.7%) were found to have good knowledge.accordingly, over half 42 (52.5%)had a fair knowledge of the diseases that can be transmitted through unsafe injections.Forty percent (32) of the healthcare workers had good knowledge of the diseases that can potentially be transmitted through unsafe injection practice, while 4 (5.0%) were not aware of such infections.Seventy-five respondents (93.7%) were aware of the risk associated with unsafe recapping of a used needle (Table II).A chisquare test showed a significant relationship between the healthcare workers' years of experience and knowledge of injection safety (p = 0.001) (Table III).
On the practice of injection safety among the surveyed healthcare workers, only 11 (13.7%) reported practising hand hygiene before and or after an injection.More so, 70 (87.5%)reported poor disposal of used syringes and needles and 71 (88.7%) recap used needles prior disposal.Additionally, 30 (37.5%) reported not using a new syringe and needle for injection.there was no significant association between category of the healthcare workers and practice of infection safety (p = 0.06).
Only a few respondents 25 (31.2%) reported not experiencing a needlestick injury while on their duty (Table IV).The rate of the needlestick injury was higher among doctors 3/3 (100%) followed by CHEWs 11/12 (91.6%), nurses 31/46 (64.4%) and then laboratory staff 4/7 (57.1%).The lowest incidence of needlestick injury was among environmental/public health and dental technicians 6/12 (50.0%).However, there was no significant relationship between the needlestick injuries and cadre of the healthcare workers (p = 0.08).However, a significant association was found between   The majority (48/55, 87.3%) of the healthcare workers who had needlestick injuries reported their injuries and 44 (91.7%) of those who reported the accidental exposures were advised on blood tests and postexposure prophylaxis (PEP).The belief that patient was not known to be HIV positive, the needle was not contaminated, and being too busy were reasons given by the healthcare workers who failed to report or take any action following their needlestick injuries.

Discussion
good knowledge and practice of injection safety are important particularly in developing sub-Saharan african countries where the pool of people living with blood-borne viruses is high. 19the high prevalence of blood-borne viruses places the healthcare workers at risk of exposure to contaminated sharps.equally, the community may not be safe when used injection equipment is not segregated and properly disposed of.In Nigeria, there were a lot of efforts to promote the safety of the injection recipient, the healthcare workers and the community. 12an overwhelming majority of the current study population attended a formal training on injection safety as reported in a previous study. 20is study revealed that many of the healthcare workforce were in their early careers within the range of 1 -10 years.Despite good knowledge of a safe injection as defined by the WHO, most of the not for citation purposes Knowledge and Practice of Injection Safety Abubakar et al.
study participants had only a fair knowledge of the risks associated with unsafe injection as well as the diseases that can potentially be transmitted through unsafe injection practices.Only about 19% of the respondents had good knowledge of the risks.In addition, 60% of the healthcare workers could not identify HIV and the hepatotropic viruses as bloodborne pathogens with potential of transmission through unsafe injection practice.It is alarming that the healthcare workers cannot demonstrate adequate knowledge of these diseases, in an era when africa is experiencing outbreak of haemorrhagic diseases that can equally be transmitted through unsafe injections. 21he findings of this study contradict the study of Onyemocho and colleagues who found knowledge of injection safety among prison healthcare workers to be adequate. 14However, poor knowledge of injection safety was earlier reported in the southern region of Nigeria. 22the current study respondents' knowledge of injection safety was better when compared with the findings from southwestern Nigerian hospitals where the respondents' knowledge of injection safety was below 22%. 23Similarly, a recent study, reported over 75% of a tertiary hospital healthcare workers were not aware of good injection safety practices. 24e study also found that the healthcare workers do not comply with good injection safety practices.Most (60%) of the healthcare workers reported reusing needles, not disposing of sharps in a designated sharps container, recapping used needles and failing to observe hand hygiene before and / or after an injection (Table IV).These practices put the healthcare workers, patients and the community at risk of infections.the most disturbing unsafe practice was the reuse of needles which is an easy way of spreading infections such as HIV or hepatitis.25,26 the high incidence of needlestick injuries among the healthcare workers was probably due to their poor injection safety practices.Previous studies on injection safety reported a high incidence of needlestick injuries among Nigerian healthcare workers.22,23 the rate of needlestick injury being higher among doctors followed by nurses supported the findings of over a decade review of occupational exposure and post-exposure prophylaxis (PEP).27 the practice of needle recapping was equally observed and reported among ethiopian healthcare workers.28 accidental exposure of healthcare workers to contaminated needles could expose them to the risk of infection such as HIV and effective PEP can eliminate the risk.29 In this study, over 87% of the exposed healthcare workers reported their injuries and almost 92% where offered advice on testing and prophylaxis.this proved that the healthcare workers were aware of PeP and its potential advantage in halting occupational infection transmission.These findings are in contrast with previous studies where poor reporting of needlestick injuries among some Nigerian healthcare workers were reported.16,23

Limitations
This study surveyed all the (consented) healthcare workers in Birnin kudu General Hospital who are directly or indirect involved in injection safety.the study participants were given up to 2 days to fill and return questionnaires given to them.this may introduce some information bias as may have referred to other sources for answers.However, this may not be the case considering the low level of knowledge demonstrated and poor self-reported practices.In addition, observation of practice might be a better way of establishing the level of the healthcare workers' behaviours towards safe injection.However, due to some constraints, the study data were collected using self-administered questionnaires with no observation of injection practice.Thus, the study findings were based on healthcare workers' self-reported knowledge and practice of injection safety.this will give a platform to carry out another study with incorporation of the lessons learnt from this study.another limitation is that this study did not check supplies of injection safety commodities or find out the how and why the healthcare workers re-use needle and syringes.equally, the study did not assess re-training and supportive supervision, for these make the difference as far injection safety practice.

Conclusions
Despite national efforts to inform the Nigerian healthcare workers on the importance and risks associated with unsafe injections, this study established that the healthcare workers do not possess a good knowledge of the concept of injection safety.equally, there is a wide gap between the fair knowledge and the practice of injection safety among the healthcare workers.the study further established that re-use of syringe and needle is still a problem in Nigeria.this highlights the need for training and re-training of the healthcare workers on the general concept of injection safety including healthcare waste management.It further underscores the need for government to ensure the provision of safe injection commodities and regular supportive supervision at all levels of healthcare delivery.
years of experience and needlestick injury.those with least years of experience were more likely to suffer injury from used needle (p = 0.009).

Table IV . Respondents' self-reported injection safety practices
30ck of good knowledge of the risks associated with, and the infections that can be transmitted through unsafe injections, supports the finding of a previous study where doctors and nurses were reported to have poor knowledge of blood-borne infection transmission following occupational exposure.30 the