Safety and Health at Work xxx (xxxx) xxx

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Safety and Health at Work

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Original Article

An Assessment of the Knowledge, Attitude, and Practice

Toward Standard Precautions Among Health Workers From a Hospital
in Northern Cyprus
Gulifeiya Abuduxike*, Songul Acar Vaizoglu, Ozen Asut, Sanda Cali
Department of Public Health, Faculty of Medicine, Near East University, Cyprus

a r t i c l e i n f o a b s t r a c t

Article history: Background: The objective was to assess the knowledge level, attitude, and practice of health care
Received 17 April 2020 workers towards standard precautions, and to identify the related factors. Furthermore, it was attempted
Received in revised form to identify the proportion of having the experience of needle stick injuries (NSIs) and associated factors
9 July 2020
among participants.
Accepted 3 September 2020
Available online xxx
Methods: A cross-sectional study was conducted in a teaching hospital among 233 health workers using
a self-administrated questionnaire. The questionnaire included eight knowledge items, seven practice
items, and five attitude items. Based on the mean score of each category, responses were grouped into
Keywords:
Health care workers “satisfactory” and “unsatisfactory”. Univariate, bivariate, and multivariable logistic regression analyses
Needle stick injury were done.
Standard precautions Results: The mean age of the participants 32.95 (SD
9.70) and 62.2% of them were women. 57.5% of the
Northern Cyprus staff had a satisfactory level of correct knowledge (>5 correct answers), 37.3% had a satisfactory positive
attitude (>3 correct answers), and 30.9% had a satisfactory practice (>3 correct answers) towards
standard precautions. The occupation was one of the predictors as doctors were less likely to have
satisfactory knowledge and practice compared to nurses (OR ¼ 0.269, 95% CI: 0.10e0.70 and OR ¼ 0.248,
95% CI: 0.08e0.77, respectively). Out of 174 participants, 31.6% of them reported experiencing NSIs and
support staff were 71% less likely to experience NSIs compared to nurses & paramedics.
Conclusion: The findings revealed a substandard adherence of standard precautions among participants,
which highlighted the necessity of the provision of a periodic, tailored training program based on the
occupation and risk exposure.
Ó 2020 Occupational Safety and Health Research Institute, Published by Elsevier Korea LLC. This is an
open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).

1. Introduction hepatitis C virus, and human immunodeficiency virus (HIV)

comprised major risks to health workers, particularly HCWs who are
Healthcare workers (HCWs) play an important role in providing exposed to blood and body fluids through sharps or needlestick in-
prevention, diagnosis, treatment, and care to people in diverse juries (NSIs) during the care for the patients [1,3,5e7].
healthcare settings. According to the World Health Organization It was reported that of 35 million HCWs worldwide, about two to
(WHO), HCWs are all people who are involved in activities that aim three million of them every year experience NSIs that contributed to
at enhancing health, include those who provide health services such 40e65% of all hepatitis B virus and hepatitis C virus, and 4.4% of HIV
as doctors, nurses, laboratory technicians, pharmacists, and those infections globally [1,3,6e8]. Gabriella et al stated in a review that
providing health management and supporting services such as of- according to the nationwide surveillance report by the Italian Study
ficers, drivers, cleaners, and cooks [1,2]. Health workers are exposed Group for Occupational Risk of HIV infection (SIROH), of 24,009
to a number of occupational hazards in healthcare settings, including mucocutaneous exposures, 4% occurred in the laboratory, 65% took
biological, chemical, ergonomic, physical, and stress/violence [1,3e6] place in transporting and manipulating samples, 6% occurred while
Among these, blood-borne pathogens such as hepatitis B virus, performing phlebotomy to the patients, and 14% while cleaning and

* Corresponding author. Public health Department, Medical Faculty, Near East University, Near East Boulevard, ZIP: 99138, Nicosia, Cyprus.
E-mail addresses: gulifeiya.abuduxike@neu.edu.tr; gulpiya1@gmail.com (G. Abuduxike), svaizoglu@gmail.com (S. Acar Vaizoglu), ozenasut@gmail.com (O. Asut),
dr.sandacali@gmail.com (S. Cali).

2093-7911/$ e see front matter Ó 2020 Occupational Safety and Health Research Institute, Published by Elsevier Korea LLC. This is an open access article under the CC BY-NC-
ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
https://doi.org/10.1016/j.shaw.2020.09.003
2 Saf Health Work xxx (xxxx) xxx

disinfecting the environment [10]. This report also suggested inade- healthcare settings who have the potential for exposure to infec-
quate compliance and a lack of knowledge about standard protections tious materials (e.g., blood, tissue, and specific body fluids and
(SPs) using personal protective equipment [10]. medical supplies, equipment, or environmental surfaces contami-
To reduce the occupational risks for HCWs, it is essential to educate nated with these substances)” [26]. Thus, a purposive sampling
and encourage health workers to practice SPs in healthcare settings, method was used, and all personnel working at the hospital at the
which is defined as “a group of infection prevention practices that time of the data collection were included in the study. Of the to-
apply to all patients, regardless of infection status. It is based on the tal 258 health workers, 233 of them responded to the questionnaire
principle that all blood, body fluids, secretions, excretions except with a respondent rate of 90.3%. The health workers included were
sweat, nonintact skin, and mucous membranes may contain trans- medical doctors, nurses, laboratory scientists, paramedics, phar-
missible infectious agents” [7,10,11]. Particularly, infection control macists, physiotherapists, administrators, drivers, and cleaning
education is one of the crucial components of the risk management staff that work at the hospital as all of them are known to be
training in healthcare settings; the training should highlight the exposed to different levels of hospital hazards.
implementation of a series of standard precaution measures and
enforce routine safe practices to protect both HCWs and service users 2.3. Study tools
[7,10]. The routine safety practices include hand hygiene; the use of
personal protective equipment; the safe use and disposal of sharps/ A structured self-administered questionnaire was constructed
needles; safe handling and disposal of clinical waste, spillage of blood, through an extensive literature review [7e9,13,17,25,28]. Content
and bodily fluids; decontamination of equipment and the environ- validation was done by four public health experts, and construct
ment; and safe management of linen [10,11,38,40,41]. validation was completed through a pilot testing of the question-
There are abundant studies published in this area to assess the naires before data collection [29]. Detailed information was pro-
knowledge, attitude, and practice of health workers in different vided to the participants regarding the purpose of the study and
countries toward universal precautions in various healthcare set- confidentiality. A written informed consent was taken from the
tings worldwide [5,7,9,12e18]. Most of them have reported a low participants before the data collection, and the data were collected
level of knowledge about infection control precautions under the supervision of the researchers. The questionnaire con-
[9,13,14,17,19,20] and poor adherence [7e9,13,20,21,39] with the sisted of 38 questions with four components. The first section
standard precautions among health professionals. Some studies included questions related to participants' sociodemographic
highlighted that factors such as having an infection-control policy, characteristics, such as sex, age (in years), nationality (Turkish,
providing periodic training programs on safety injections and Northern Cyprus, others), marital status (married, single, others),
precautionary practice, as well as establishing a well-developed education level, occupation, department, and work experience. The
infection reporting system in the healthcare settings significantly educational level indicated the highest level of schooling attained
affect the level of knowledge and compliance of health workers and was classified into three groups: “secondary or less,” “high
with the prevention strategies [7,15e18,20,22e25]. However, there school,” and “university or above”. Information on medical
is a vast information gap in this area as there is no single study done checkups status was assessed using questions: “Have you ever done
in the Turkish Republic of Northern Cyprus (TRNC) among HCWs. medical checkups before you start your current job?” and “Have
Thus, the objective of the study was to assess participants' you ever been asked to do routine medical checkups at your current
knowledge level, attitude, and practice of HCWs toward SPs, and to workplace?” with answers of “yes”, “no,” and “do not remember”.
identify the related factors attributed to the knowledge, attitude, Based on the responses, the occupation of the participants was
and practice toward SPs. Moreover, we attempted to identify the categorized into three groups: “doctors”, “nurses and paramedics,”
proportion of having the experience of NSIs and related factors that and “support staff”. Participants' departments were grouped into
increase the risks of NSIs among participants. The long-term aim of three, namely, “emergency and wards,” “clinics & polyclinics,” and
the study is to provide evidence-based recommendations for the “support & administrative units”.
stakeholders to develop adequate training programs and practical The second part comprised eight questions regarding the par-
guidelines in the healthcare settings in the country. ticipants' perceptions and knowledge regarding standard pre-
cautions, workplace hazards, and hospital safety and control
2. Materials and methods measures (Table 1). The knowledge toward standard precautions,
such as washing hands before and after touching the patient and
2.1. Study design and duration wearing gloves when touching the patients, was asked. Moreover,
participants' knowledge of the existence of infection control mea-
The cross-sectional study was conducted from March to April sures, the safety training program provided to them at the hospital,
2019 at the Kyrenia University Dr. Suat Günsel Hospital. The ethical and its adequacy was assessed. Responses to items of knowledge
approval was obtained from the ethics committee of Near East were “yes” or “no,” and correct responses were given a score value
University with a project number of YDU/2019/67-765 (approved of “1” according to the Disease Control and Prevention Center
on 28.03.2019). Meanwhile, official permission was obtained from guideline on standard precautions [27,28] (Table 1).
the hospital management to conduct the research among health The third part consisted of seven questions pertaining to the
personnel. practicing of standard precautions such as using protective clothing
that include goggles/eyeglasses, gowns, bonnets when caring for
2.2. Study setting and sampling patients. There were four questions regarding the safety precaution-
ary practices while performing injections. The practice of wearing
The study site was Kyrenia University Dr. Suat Günsel Hospital, gloves when they perform injections was asked with “yes” or “no”
which is among the four private health facilities situated in Kyrenia. responses. In addition, participants were asked if they change the
The private hospital has 150 beds consisting of all health units, gloves while contacting with another patient (yes or no). Lastly, there
including emergency, surgery, cardiology, internal medicine, pedi- were two questions regarding the practice of safe disposal of sharps/
atrics, gynecology and obstetrics, and operating rooms. In this needle waste, including whether they recap the needle again (always,
study, HCW was defined as “all paid and unpaid persons working in sometimes, never, or not applicable) and whether they dispose of the
 G. Abuduxike et al / KPAs assessment toward standard precautions among health workers 3

used needle in the specific sharps container. The answer was 3. Results
described in 5 categories “always,” “sometimes,” “never,” “there is no
sharp container,” or “not applicable”. For each question, “1” score was The mean age of the participants was 32.95 (SD
9.70) and
given for the correct response of “always”, while the zero score was 62.2% of them were women. Table 1 illustrates the frequency of the
assigned to all other responses. The total score for practice ranged participants with the correct responses regarding each item
from zero to seven (0e7), whereas for the total knowledge score constituted the knowledge, practice, and attitude toward SPs.
ranged from zero to eight (0e8). Overall, higher proportions of participants had responded correctly
Participants' attitude toward standard precautions was assessed to the knowledge and attitude items compared with practice
using five questions which were focused on their attitude questions. The mean score (
SD) for knowledge items was 5.73
toward using masks, gloves, aprons, surgical caps, and eyeglasses and (
1.72), while the mean scores for the practice and attitude items
how often they should use those protections. The answer provided were 2.52 (
1.76) and 2.84 (
1.68), respectively. Based on the mean
were “no need to use at all”, “no need to change for each patient”, scores, 57.5% of the staff had a satisfactory level of correct knowl-
“change once per day” or “change for each patient”. Positive responses edge (>5 correct answers), 37.3% had satisfactory positive attitude
with the right attitude were given the score of “1”, while a zero score (>3 correct answers), and only 30.9% had a satisfactory practice (>3
was assigned to all other responses. Thus, the total attitude score correct answers) toward SPs.
ranged from zero to five (0e5). Two questions were asked regarding Most of the staff answered correctly to the knowledge items
their attitude on their daily job whether it is risky and stressful. An related to washing hands (69.4% and 84.5%), workplace safety
additional question was asked to know that if they were warned by (85.8%), the existence of the infection control committee (81.1%),
the hospital management when they did not use precautionary and training programs (74.7%). However, almost half of them did
equipment such as masks and gloves. The answers provided were not know if the training program was adequate (45.9%). Fewer
“yes,” “no,” or “do not remember”. participants answered correctly in the majority of the practice
In this study, the definition of WHO on sharps or NSIs was items, except questions related to using gloves when doing the
adopted as “a penetrating wound with an instrument that is injections (73.4%), change gloves for each patient (89.3%), and
potentially contaminated with blood or body fluid of another per- disposing of the used needles to the special container (98.0%).
son” [28]. Section four included questions regarding participants' About 47% of them reported that they did recap the used needle
experience on NSIs. A further question of “Have you ever had a before disposal. Moreover, participants had a positive attitude
needle stick injury while you were doing the injection or related toward using gloves (95.8%) and masks (70.4%), where fewer par-
activities?” was asked with the four possible descriptions (yes, no, ticipants stated that it is necessary to use the bonnet (63.4%), gown
do not remember, or not applicable). For the analysis, only the “yes” (57.7%), and eyeglasses (55.3%) for each patient as SP measures.
and “no” answers were included for the experience of NSI. Further The distribution of sociodemographic and other work-related
question was asked about where did they report to once they had characteristics of the participants by their occupation was pre-
an injury as an open-ended question and grouped the answers sented in Table 2. Except for gender, all other characteristics of the
accordingly. Information on any skin discomfort or disease caused participants have shown statistically significant differences be-
by the gloves was asked, and the answers for these questions were tween doctors, nurses/paramedics, and support staff. Support staff
“always,” “sometimes,” and “never”. consisted of 24 secretaries, 9 drivers, 20 technicians, 9 security
A pilot study was conducted among 50 health personnel working personnel, 15 cleaners, 16 porters, and 28 other office personnel.
at the Near East University Hospital to test the feasibility and internal Almost all doctors have shown to have a university or above edu-
consistency of the questionnaire. The questionnaires used for the cation level (p ¼ 0.000), more than 10 years of working experience
pretest were excluded from the final analysis. Some minor modifi- (p ¼ 0.000), married (p ¼ 0.005), and worked in the clinics, poly-
cations were done to improve the readability and quality of the clinics, emergency, and ward units compared with nurses/para-
questions. The reliability coefficient for the questionnaire (using medics and support staff (p ¼ 0.000). However, a significantly
Cronbach's alpha internal consistency coefficient) was 0.71. higher proportion of participants who worked as support staff were
from TRNC compared with other occupational groups (p ¼ 0.004). A
significantly higher proportion of doctors have reported that they
2.4. Data analysis had work-related diseases (p ¼ 0.011) and stated that their job is
stressful (p ¼ 0.001) compared with their counterparts.
The data were analyzed using IBM SPSS (Statistical Package for Table 3 shows the relationships between sociodemographic
the Social Sciences) version 23 (SPSS Inc., Chicago, IL, USA). characteristics of the participants having a satisfactory level of
Descriptive statistics including frequency, percentage, mean, and knowledge, practice, and attitude toward SPs. Younger participants
standard deviation (SD) were done to describe the characteristics of (<25 years compared with >30 years) and nurses/paramedics
the study sample. The total scores of participants' knowledge, shown a significantly higher tendency of having a satisfactory
practice, and attitude were dichotomized into satisfactory and knowledge compared with other occupational groups. Regarding
unsatisfactory categories based on the cutoffs which determined the practice of SPs, factors such as being a doctor, working in clinics
based on the mean scores. Namely, a satisfactory level of knowl- and polyclinics, and also having a university or above education
edge was score > 5, a satisfactory practice was score >3, and a level have significant relationships with having satisfactory prac-
satisfactory positive attitude was score > 3. Bivariate analysis using tice compared with their counterparts. On the contrary, having a
the Chi-square (c2) test [32] was done to examine the relationships lower education level and being a support staff were shown to be
between categorical variables such as a satisfactory level of significantly related to having a positive attitude, while a signifi-
knowledge, attitude, and practice regarding standard precautions cantly higher proportion of staff from other countries showed to
using contingency tables. The Fisher's exact test was used for some have a positive attitude compared with staff who were originally
variables where the expected cells are less than 5 [33]. Exposure from Turkey and TRNC. The experience of having a NSI did not show
variables having a p < 0.05 level of significance in bivariate analysis any significant relationship with having satisfactory knowledge,
was entered to construct the final model of multivariate logistic practice and attitude toward SPs among participants.
regression analysis. The odds ratio (OR) and confidence interval (CI) Of all, 174 participants answered the question regarding the
were presented with the p value set at <0.05. experience of NSIs and 31.6% (55) of them reported experiencing
4 Saf Health Work xxx (xxxx) xxx

Table 1
Standard precaution items to measure the frequency of the participants with the correct responses.

Items for knowledge of SPs (yes ¼ 1) n/total %

Q1 Do you wash your hand before patient care? 161/232 69.4
Q2 Do you wash your hand after patient care? 197/233 84.5
Q3 Do you wear gloves while caring for the patient? 146/233 62.7
Q4 Do you think your workplace is safe in terms of hospital related infections? 200/233 85.8
Q5 Do you know if the infection control and prevention measures are adequate at your 126/233 54.1
workplace?
Q6 Do you know if there is an infection control and committee at the hospital? 189/233 81.1
Q7 Do you know if there is any workplace training and education program for workers? 174/233 74.7
Q8 Do you think the training program is adequate for workers? 143/233 61.4
Mean Knowledge score (
SD) ¼ 5.73 (
1.72), Range: 0e8

Items for practice of SPs (always [ 1) n/total %

Q1 Do you wear goggles/eyeglasses during patient care to protect from body fluids/bloods, 10/233 4.3
splashes or sprays?
Q2 Do you wear a gown during patient care to protect mucous membranes from body fluids/ 50/233 21.5
bloods, splashes or sprays?
Q3 Do you wear surgical cap (bonnet) when you care for patients? 29/233 12.4
Q4 Do you use your gloves when you perform injection for patients? 113/154 73.4
Q5 Do you change your gloves when you perform injection for another patient? 158/177 89.3
Q6 Do you recap the used needle after injection? 79/147 53.7
Q7 Do you dispose the used needle in the special sharps' container? 149/152 98.0
Mean Practice Score (
SD) ¼ 2.52 (
1.76), Range: 0e7

Items for attitude regarding SPs (Yes [ 1) n/total %

Q1 Do you think it is necessary to wear a mask when caring for patients? 143/203 70.4
Q2 Do you think it is necessary to use gloves when caring for patients? 205/214 95.8
Q3 Do you think it is necessary to wear a gown when caring for patients? 105/182 57.7
Q4 Do you think it is necessary to wear goggles/eyeglasses when caring for patients? 73/132 55.3
Q5 Do you think it is necessary to wear bonnet/cap when caring for patients? 90/142 63.4
Mean attitude score (
SD) ¼ 2.84 (
1.68), range: 0e5
AD, standard deviation; SP, standard protection.

NSIs at least once during the work. Table 4 illustrates the rela- attitudes of the health personnel who were working at a teaching
tionship between sociodemographic characteristics and job-related hospital toward workplace health and safety measures, which is
factors with experiencing NSIs during work. Being a nurse/para- remaining as a knowledge gap in Northern Cyprus. Furthermore, the
medic has shown to have a significantly higher tendency of expe- findings of this study, which revealed a substandard adherence of
riencing NSIs compared with other occupations. Meanwhile, it was health personnel toward standard precautionary measures, high-
shown that a significantly higher proportion of participants who lighted the necessity of the government-driven, nationwide studies
had the experience of NSIs reported being aware of the infection on this topic among health personnel from all public and private
control committee at their workplace. health facilities in the country. Such studies are essential to provide
The results of multivariate logistic regression analysis were evidence to develop specific strategies and customized training
presented in Table 5. Types of occupation have shown to be a sig- programs to improve the awareness, adherence, and compliance of
nificant predictor for the participants to have a satisfactory level of health personnel toward prevention measures in healthcare settings.
knowledge and practice toward SPs. Doctors were less likely to In the present study, all sociodemographic characteristics of the
have a satisfactory knowledge and practice compared with nurses participants except gender were shown statistical significant dif-
and paramedics (OR ¼ 0.269, 95% CI: 0.10e0.70 and OR ¼ 0.248, ferences between doctors, nurses and paramedics, and support staff.
95% CI: 0.08e0.77, respectively), whereas the support staff were Some differences (education, work experience, departments) were
four times more likely to have satisfactory knowledge toward SPs comparable with the findings from a study by Asmr Y. et al [8],
compared with nurses and paramedics (OR ¼ 4.017, 95% CI: 2.03e whereas some (gender, age) were inconsistent with a study con-
7.95). Moreover, participants who worked at the support units were ducted in Iran [29]. It was found that the correct answers for each
less likely to have satisfactory practice compared with nurses and knowledge, practice, and attitude items were much lower than the
paramedics. Interestingly, being a foreigner was the only predictor findings from a study by Askarian et al in the university-affiliated
attributed to having a satisfactory attitude as participants from hospital of Shiraz, Iran [29]. For instance, the proportion of
other countries had 2.93 (95% CI: 1.06e8.12) times the odds of answering correctly to the knowledge items related to washing
having a positive attitude compared with those who did not. Those hands before (69.4% vs 94.0%) and after (84.5% vs 94%) caring for
who worked as support staff at the hospital (OR ¼ 0.392, 95% CI: patients and wearing gloves (62.7% vs 95%) was much lower in our
0.18e0.86) tend to have fewer experiences of NSIs compared with study. The proportion of correct answers for all practice and attitude
nurses and paramedics. items was much lower than that for knowledge items, and this was
in line with the aforementioned study. Such discrepancy might be
4. Discussion due to the differences in study designs and study participants in
these studies as a majority of these study participants were doctors
One of the key strengths of the present study was to provide [29], surgeons [30], and some were only conducted among nurses
evidence-based information on the knowledge, practice, and [31]. Particularly, the usage of goggles/eyeglasses (4.3%), gowns
 G. Abuduxike et al / KPAs assessment toward standard precautions among health workers 5

Table 2
Distribution of sociodemographic characteristics and some work-related factors of the participants by occupations (N ¼ 233).

Doctors Nurses/paramedics Support staff Total c2 p

n % N % n % n %
Total 38 16.3 74 31.8 121 51.9 233 100
Gender
Male 20 52.6 26 35.1 42 34.7 88 37.8 4.271 0.118
Female 18 47.4 48 64.9 79 65.3 145 62.2
Age (years)
<25 d d 18 24.3 15 12.4 33 14.2 57.33 0.000*
25e30 2 5.3 40 54.1 56 46.3 98 42.0
>30 36 94.7 16 21.6 50 41.3 102 43.8
Marital status
Married 27 71.1 29 39.2 63 52.1 119 51.1 14.66 0.005*
Single 8 21.1 43 58.1 54 44.6 105 45.1
Divorced 3 7.8 2 2.7 4 3.3 9 3.8
Nationality
Turkish 21 55.3 32 43.2 38 31.4 91 39.1 15.50 0.004*
TRNC 15 39.5 40 54.1 63 52.1 118 50.6
Others 2 5.2 2 2.7 20 16.5 24 10.3
Department
Emergency and ward units 8 21.1 22 29.7 42 34.7 72 30.9 31.93 0.000*
Clinics and polyclinics 29 76.3 37 50.0 35 28.9 101 43.3
Support units 1 2.6 15 20.3 44 36.4 60 25.8
Work experience
<5 years 2 5.3 46 62.2 96 79.4 144 61.8 104.37 0.000*
5e10 years 8 21.2 18 24.3 20 16.5 46 19.7
>10 years 28 73.7 10 13.5 5 4.1 43 18.5
Education level
High school or less 1 2.6 2 2.7 54 44.6 57 24.5 159.89 0.000*
College and undergraduate 9 23.7 70 94.6 59 48.8 138 59.2
University or above 28 73.7 2 2.7 8 6.6 38 16.3
Work-related diseases
Yes 5 13.2 1 1.4 2 1.7 8 3.4 13.04 0.011*
No 28 73.6 64 86.5 103 85.8 195 84.1
Don't remember 5 13.2 9 12.1 15 12.5 29 12.5
Perceived workplace risk
Yes (risky) 36 94.7 66 89.2 99 81.8 201 86.3 4.86 0.088
No 2 5.3 8 10.8 22 18.2 32 13.7
Perceived workplace stress
Yes (stressful) 36 94.7 72 97.3 97 80.2 205 88.0 14.71 0.001*
No 2 5.3 2 2.7 24 19.8 28 12.0
* Fisher's exact test.

(21.5%), and bonnets (12.4%) of HCWs in our study was much lower [7,18,30,33,34]. However, support staff had shown a significantly
than that in other studies [14,18,29,32,33]. However, the proportion higher level of knowledge compared with nurses which is incon-
of participants that reported to be trained with workplace health sistent with the findings from several other studies [6,33,36]. This
and safety precautions in our study was higher (74.7% vs 48.5%) than might be due to the differences in sample size, sampling methods,
the findings from a study by Beyamo et al, which questioned the and compositions of our study participants. In the present study,
efficiency of the training as the practice and attitude of the HCWs nurses consisted of about 32% (74) of total participants, which was
were not adequate in the present study [39]. The insufficiency of the considerably low in comparison with other studies [6,18,30,34].
training program was also confirmed by the majority of the partic- Most of the sociodemographic (such as gender, marital status)
ipants as 61.4% of them reported that the training was not adequate. and work-related characteristics (work experience) of the partici-
Furthermore, a study done in the United Kingdom by Cutter and pants in our study were shown no significant relationships with
Jordan (2012) has reported that the relationship between attending their knowledge, practice, and attitude toward SPs. These findings
the training and the usage of the double glove and eye protection are comparable with the results from some studies [29,33], whereas
was not found significant, but attending the training was found contrary to the study findings from other developing countries,
significantly related to the usage of safety devices among HCWs [28]. where the gender [6,7,31,36], marital status [35], and work experi-
Our study found that the proportions of participants with a ence [6,34e36] were shown to be significant factors related to their
satisfactory level of knowledge, practice, and attitude were 57.5%, knowledge and compliance toward SPs. In the present study, bivar-
30.9%, and 37.3%, which were substantially low compared with the iate analysis of the independent variables with the knowledge level
findings from studies done in Iran [29], Egypt [34], Malaysia [22], showed that a higher proportion of the younger participants (<25ys)
Ethiopia [7,35], and Turkey [6]. One of the studies done in Ethiopia had satisfactory knowledge (66.7% vs 48%, p < .05) compared with
reported that 88.6% of the participants had good knowledge, while older personnel (>30ys), which is consistent with the findings from
60.2% of them had a good practice, and nurses had better SPs a study by Hakim et al in Egypt [38]. However, Beyamo et al reported
practices (74%) compared with doctors (21.8%) [7]. Similarly, the that older HCWs (>30ys) were more likely to comply with the SPs
results of the logistic regression of the present study revealed that than younger counterparts (<25ys), whereas our study did not show
the types of occupation were one of the factors that significantly a statistically significant difference with age [39]. Moreover, the
attribute to participant's knowledge and practice regarding SPs, same study also found that participants with shorter work experi-
and nurses had better SPs compliance and knowledge compared ence (5ys) were 2.5 times more likely to comply with the SPs than
with doctors, which was comparable with several studies those who have more than 10 years of work experience [39]. In
6 Saf Health Work xxx (xxxx) xxx

Table 3 Table 4
Relationships between sociodemographic characteristics of the participants by Relationships between some sociodemographic and job-related factors with having
having a satisfactory level of knowledge, practice, and attitude (N ¼ 233). the experience of sharps and needle stick injuries (NSIs) at the workplace (N ¼ 174).

Factors Satisfactory Satisfactory Satisfactory Factors NSI experience Total c2 p

knowledge practice attitude
Yes No
% (n) % (n) % (n)
n % n % n %
Total 57.5 (134/233) 30.9 (72/233) 37.3 (81/217)
Total 55 31.6 119 68.4 174 100
Gender ns Ns ns
Occupation
Male 62.5 (55) 35.2 (31) 40.0 (32) Doctors 15 27.3 19 16.0 34 19.5 10.64 0.005
Female 54.5 (79) 28.3 (41) 35.9 (49) Nurses & paramedics 27 49.1 41 34.5 68 39.1
Support staff 13 23.6 59 49.5 72 41.4
Age (years) a Ns ns
Recapping the used needle
<25 66.7 (22) 30.3 (10) 37.5 (12)
Yes 23 50.0 47 54.7 70 53.0 0.26 0.610
25e30 64.3 (63) 28.6 (28) 38.7 (36) No 23 50.0 39 45.3 62 47.0
>30 48.0 (49) 33.3 (34) 35.9 (33) Disposing the used syringe to the special sharp's container
Marital status ns Ns ns Yes 48 100.0 86 96.6 134 97.8 1.65 0.271*
No d d 3 3.4 3 2.2
Married 56.3 (67) 30.3 (36) 41.3 (45)
Have ever had any training about SPs
Single 59.0 (62) 30.5 (32) 34.3 (34) Yes 40 72.7 85 71.4 125 71.8 0.03 0.859
Divorced 55.6 (5) 44.4 (4) 22.2 (2) No 15 27.3 34 28.6 49 28.2
Nationality ns Ns a Perception on the adequacy of the SPs training
Turkish 56.0 (51) 38.5 (35) 34.1 (29) Adequate 34 61.8 71 59.7 105 60.3 0.07 0.787
Not adequate 21 38.2 48 40.3 69 39.7
TRNC 58.5 (69) 26.3 (31) 33.9 (37)
Perceived workplace risk
Others 58.3 (14) 25.0 (6) 65.2 (15) Yes (risky) 52 94.5 103 86.6 115 89.1 2.47 0.116
Occupation c C a No 3 5.5 16 13.4 19 10.9
Doctors 44.7 (17) 57.9 (22) 23.7 (9) Perceived workplace stress
Yes (stressful) 52 94.5 106 89.1 158 90.8 1.35 0.246
Nurses and paramedics 79.7 (59) 23.0 (17) 32.4 (24)
No 3 5.5 13 10.9 16 9.2
Support staff 47.9 (58) 27.3 (33) 45.7 (48)
Awareness of having an infection control committee at workplace
Department ns A ns Yes 51 92.7 92 77.3 143 82.2 6.10 0.009*
Emergency and ward units 62.5 (45) 33.3 (24) 37.7 (26) No 4 7.3 27 22.7 31 17.8
Clinics and polyclinics 61.4 (62) 37.6 (38) 33.7 (34) Work-related diseases
Yes 2 3.6 5 4.2 7 4.0 2.83 0.242
Support units 45.0 (27) 16.7 (10) 44.7 (21)
No 43 78.2 103 86.6 146 83.9
Work experience ns Ns ns Don't remember 10 18.2 11 9.2 21 12.1
<5 years 62.5 (90) 27.1 (39) 41.1 (53) SP, standard protection.
5e10 years 50.0 (23) 32.6 (15) 35.6 (16) * Fisher's exact test.

>10 years 48.8 (21) 41.9 (18) 27.9 (12)

Educational level ns A b
High school or less 57.9 (33) 24.6 (14) 56.3 (27) workplace, and this is lower than that in several studies in devel-
College & Undergraduate 60.9 (84) 28.3 (39) 34.4 (45) oping countries [7,8,33,37]. Asmr Y. et al reported that having the
University above 44.7 (17) 50.0 (19) 23.7 (9) experience of NSIs was not statistically associated with their
NSI experience (174) ns Ns ns knowledge level which is similar to the findings in our study [8].
Yes 20.1 (35) 10.3 (18) 10.1 (17) However, the study also found that having NSI experience was
No 40.2 (70) 27.0 (47) 26.6 (45) reversely related to their practice of SPs [8], which was not seen in
ns: nonsignificant (p > .05). Raw percentages are presented.a,b,c,d the present study. It was found that 53.7% of the participants in our
a
p < .05. study had recapped the used needle during work, and the pro-
b
p < .01. portion is lower than the percentage of HCWs suffered from NSIs
c
p < .001.
d (67.9%) in a study conducted at the University of Alexandria
Fisher's exact test.
teaching hospitals. The study also revealed that recapping used
needle was one of the most common risk factors to have a higher
contrast to these results, there were no statistically significant dif- risk of NSIs as it accounted for over one-third (36%) of NSIs among
ferences found between working experience and the knowledge, HCWs [8]. Similar to our findings, another study by Arinze- Onyia
practice, and attitude regarding SPs in our study. et al among 629 HCWs at the University of Nigeria Teaching Hos-
The findings of our study showed that the types of departments pital has reported that 52.9% of HCWs recapped needle, and 42.5%
in which HCWs were working have shown to be a significant pre- of them discard both syringes and used needle into the safety box
dictor of the compliance toward SPs as the personnel from the without recapping [19].
support units were 58% less likely to practice SPs than the HCWs in A study by Cutter and Jordan (2012) reported that among nurses
emergency and ward units (OR ¼ 0.420, 95%CI: 0.18e0.99). This (43%) and surgeons (57%) of total 315 HCWs, 58.1% of them had NSIs
finding is in line with the findings of the study done by K. Nichol during the last five years, which is considerably higher than our
et al in Canada [35]. In our study, positive attitudes toward work- results [28]. This is most probably due to the higher proportion of
place health and safety precautions among participants were low doctors in this study than ours. The study also found that the
which is in line with a study conducted in Iran [29], and partici- type of the profession was one of the predictors for sustaining an
pants from other countries have shown to have three times more NSI at five years, which is comparable with the results of our study.
likely to have positive attitudes compared with the participants However, doctors were more likely to have NSIs than nurses,
originally from Turkey. This might be due to the sample size and the whereas in our study, nurses were at higher risk than doctors and
data collection method of our study. support staff [28]. Moreover, the results of the logistic regression
Of 174 participants who answered questions on NSIs, 31.6% (55) analysis have shown that support staff were about 61% less likely to
of them reported to have experienced NSIs at least once in their experience NSIs than nurses. Other work-related factors did not
 G. Abuduxike et al / KPAs assessment toward standard precautions among health workers 7

Table 5
Factors related to the satisfactory level of knowledge, practice, and attitude and the experience of having NSIs at workplace: multivariate logistic regression analysis.

Factors Satisfactory knowledge Satisfactory practice Satisfactory attitude Experience of having NSI

OR 95% CI OR 95% CI OR 95% CI OR 95% CI

Age (years)
<25 Ref
25e30 0.923 (0.38e2.23)
>30 1.383 (0.55e3.48)
Occupation
Doctors 0.269 (0.10e0.70)b 0.248 (0.08e0.77)a 1.380 (0.42e4.49) 1.237 (0.53e2.87)
Nurses and paramedics Ref Ref Ref Ref
Support staff 4.017 (2.03e7.95)c 0.621 (0.29e1.33) 0.89 (0.43e1.85) 0.392 (0.18e0.86)a
Department
Emergency and ward units Ref
Clinics and polyclinics 0.923 (0.97e1.95)
Support units 0.420 (0.18e0.99)a
Educational level
High school or less Ref Ref
College and undergraduate 1.360 (0.61e3.05) 0.481 (0.22e1.06)
University above 1.402 (0.40e4.88) 0.385 (0.11e1.32)
Nationality
Turkish Ref
TRNC 1.034 (0.55e1.95)
Others 2.933 (1.06e8.12)a
Aware of an infection control committee at workplace (Yes vs No) 0.349 (0.11e1.09)
CI, confidence interval); OR, odds ratio; Exp(B).
a
p < .05.
b
p < .01.
c
p < .001.

show any significant relationship with having NSIs experience training program, which is tailored to each occupation group based
among participants. Particularly, receiving education/training on their job descriptions and risk exposures. Having an actively
regarding SPs, self-perception of job risks, and stress were not functioning hospital infection control committee would positively
statistically significant in relation to having NSIs, which is in line affect HCWs' adherence with SPs. The results of this study might
with several other studies [6,8,18,30,37]. provide preliminary evidence to the stakeholders and government to
The study has a few limitations to be noted. First, the results of take action to conduct further nationwide studies on this topic to fill
this study should be evaluated with caution because of the study the gap in knowledge. Furthermore, in the long run, the systematic
design and the purposive sampling method used. Only one teach- improvement in HCWs' knowledge and practice toward SPs will
ing hospital was included as it is challenging to obtain permission improve the overall quality of the service delivery and economy of
to conduct research in the government hospitals and other health the entire healthcare system as a result of improving the health of
facilities in Northern Cyprus. The Kyrenia University Dr. Suat Günsel HCWs and reducing various hospital-associated infections.
Hospital is one of the two teaching hospitals under Near East
University, and because of lack of funding and limited timeline, it
Authors' contributions
was feasible to conduct the study in this hospital. Second, the small
sample size might be one of the disadvantages, and the result will
GA was involved in the study design, data collection, data entry,
not be able to represent all the HCWs in the island. Nevertheless,
analysis, and drafted the original manuscript. SAV was involved in
this study is the first of its kind to provide a brief glimpse on the
the study design, data collection, data entry, and analysis. OA and
topic in the local context. Most importantly, as one of the tangible
SC contributed to the study design particularly the questionnaire
outcomes of our study, researchers had conducted a four-hour
development, data collection, and data entry. All authors read and
training workshop to the study participants regarding the practice
approved the final manuscript.
of standard precaution measures, how to prevent from NSIs, what
to do and whom to report to when NSIs happened, etc. to improve
their general knowledge and practice of SPs and to create a safer Conflicts of interest
workplace by minimizing various hazards.
All authors have no conflicts of interest to declare.
5. Conclusion
Acknowledgments
The study has revealed that the majority of HCWs who partici-
pated in this study has an unsatisfactory level of knowledge, inad- The study was a part of the intern project of sixth-year medical
equate practice, and negative attitude toward standard precautions students in the Near East University. The authors would like to
at the workplace. The types of occupations were one of the attrib- thank all the intern students and study participants for their con-
utable factors to significantly influence their perception and tributions to this study. We would like to thank Int. Dr. Altan
compliance with SPs. Moreover, nurses have shown to be the highest Kamburca, Int. Dr. Osman Yangin, Int. Dr. Kerem Berk Toprak, Int. Dr.
risk group in experiencing NSIs among all. It is highly recommended _
Ibrahim Yangin and Int. Dr. Yusuf Abodan for thier contributions
for hospital management and stakeholders to provide a periodic during the data collection process.
8 Saf Health Work xxx (xxxx) xxx

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