Prevalence and associated factors of needlestick and sharp object injuries among healthcare workers in Ethiopia: a systematic review and meta-analysis

Background Needlestick and sharp object injuries affect healthcare workers. However, there are limitations in the evidence available for informed decision-making by stakeholders, as individual research shows inconsistent results. Therefore, this study aims to assess the pooled prevalence of needlestick and sharp object injuries and their associated factors. Methods MEDLINE/PubMed, EMBASE, Web of Science, Google Scholar, and other databases were searched from 5 September 2023 to 10 October 2023 using the following search terms: “Prevalence” OR “Burden” OR “Magnitude” AND “Associated factors” OR “related factors” OR “Risk factors” OR “determinants” OR “Predictors” AND “Needle stick Injury” OR “Sharp Injury” OR “Health care Workers” OR “ Health Care Personnel” OR “Nurses” OR “Professional” AND “Ethiopia”. Results The pooled prevalence of needle sticks and sharp objects injury was 40.5 (95% CI: 35.0, 45.9). Needle-stick (AOR, 2.3; 95% CI: 1.6, 3.3, P < 0.001], absence of routine precaution [AOR, 2.3; 95% CI: 1.1, 4.5, P < 0.01] and lack of training (AOR = 2.4; 95% CI: 1.4, 4.1, p < 0.001) had increased odds of needle-sticks and sharp objects injury. Conclusion Forty percent of healthcare workers in Ethiopia have experienced needlestick and sharp object injuries. The identified factors included recapping, absence of routine precautions, and lack of training. Systematic Review Registration PROSPERO, identifier (CRD42023462311).


Introduction
Needlestick and sharp object injuries affect healthcare workers (HCWs) in both industrialized and developing nations, although their severity and extent may vary.The World Health Organization (WHO) estimates that illnesses related to the workplace account for around 11% of the global disease burden (1).In US hospitals, an estimated 385,000 injuries occur annually (2).The burden is significantly more in the facilities of the countries of sub-Saharan Africa, including Ethiopia (3)(4)(5).The rapid expansion of service delivery and production industries in Ethiopia needs adequate attention to protect the health and safety of HCWs.Poor-quality equipment, substandard work practices, and a high burden of communicable diseases force the country to do so.The Awareness status, nature of medical devices, handling practices for sharp objects, and use of personal protective equipment (PPE) are among the major determinants for exposure to needlestick and sharp object injuries (6,7).
Healthcare workers may sustain injuries during blood sample collection, surgical procedures, intravenous line administration, needle recapping, and due to inadequate waste disposal methods (8).The greatest risk, following needlestick and sharp object injuries, is the transmission of blood-borne infections from patients to HCWs (4).The type of injury, the amount of blood delivered to the HCWs during the exposure, the immunological status of the worker, and source patient factors all influence the risk of transmission (9).Globally, 3 million HCWs are exposed to blood-borne viruses annually; of these, 2 million are linked to HBV, 900,000 are linked to HCV, and 300,000 are linked to HIV (10).The risk of acquiring HBV, HCV, and HIV infections via needlestick and sharp object injuries can range from 2% to 40%, 3% to 10%, and 0.2% to 0.5%, respectively, if the source patient is positive (11,12).
As far as we know, there is no nationally representative empirical study finding on the prevalence and associated factors of needlestick and sharp object injuries among HCWs in Ethiopia.However, numerous scattered and limited research studies have been carried out to determine the magnitude of needlestick and sharp object injuries and associated factors (13).One published study in 2019 had limited scope since it only focused on needlestick injuries, excluding injuries due to other sharp objects (14).The main objective of this systematic review and meta-analysis is therefore to estimate the national pooled prevalence and associated factors of needlestick and sharp object injuries.The results of the study will be used to provide nationwide insight for occupational health and safety policymakers and implementers to inform, plan, implement, and evaluate their strategies.

Objectives
The aim of this study is to assess the pooled prevalence of needlestick and sharp object injuries and associated factors among healthcare workers in Ethiopia.

Study review protocol
This study was conducted in accordance with the guidelines of Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA).The protocol was registered in the international prospective register of systematic reviews (PROSPERO) under an identification code CRD42023462311.

Inclusion criteria
Full-text papers published in English from Ethiopian healthcare facilities that passed quality assessment standards and reported both needlestick and sharp object injuries were included regardless of their study design and publication time.These included studies were conducted before 10 October 2023.
Population (P) stands for healthcare workers/healthcare providers/health professionals, while intervention or exposure (I) stands for determinants/predictors/factors affecting needlestick and sharp object injuries.Comparison (C) is not applicable, while the outcome (O) of the study was the pooled prevalence of needlestick and sharp object injuries among healthcare workers.

Exclusion criteria
Studies that were not fully accessed, had difficulty in data extraction, had irretrievable full texts, and did not properly report the outcome of interest were excluded.In addition, articles with unrelated outcome measures or those with missing or insufficient outcomes were also excluded.

Selection of studies
All search results were exported to the EndNote X7 citation manager, and duplicates were removed.Articles were then screened and evaluated independently by authors GK and TF through a careful reading of the title and abstract.The titles and abstracts of studies that clearly mentioned the outcomes of the review were considered for further evaluation.
The full texts of the retained studies were further evaluated by the authors against the Joanna Briggs Institute (JBI) critical appraisal tool for cross-sectional study checklists based on the quality of their objectives, methods, participants/populations, and key findings.In case of disagreement between the authors, the differences were resolved by consensus for the inclusion.The overall study selection process is presented using the PRISMA statement flow diagram (Figure 1). to identify information that was pertinent and closely related to the variables of interest.

Searching strategies
The authors used selected keywords and MeSH terms with Boolean logic operators (AND, OR), both individually and in conjunctions, by extracting them from the review questions as follows.The search strategy included the following keywords: "Prevalence" OR "Burden" OR "Magnitude" AND "Associated factors" OR "related factors" OR "Risk factors" OR "determinants" OR "Predictors" AND "Needle stick Injury" OR "Sharp Injury" OR "Health care Workers" OR " Health Care Personnel" OR "Nurses" OR "Professional" AND "Ethiopia".A manual search of various repositories was conducted to retrieve unpublished studies.The overall search result was compiled using EndNote X7 citation manager software.The search was conducted between 5 September 2023 and 10 October 2023.

Data extraction
The authors (GK and TF) independently extracted data using the standardized data extraction format adapted from the JBI.The format developed for the first objective included the name of the first author with publication year, region, study design, sample size, and study response rate.
The data extraction format for the second objective included the most frequently reported predictors of percutaneous injuries.The included predictors were sex (male or female), recapping (yes or no), using personal protective equipment (yes or no), training (yes or no), and working hours per week (40 and below 40 h or more than 40 h).

Outcome measurements
Two objectives were addressed by this systematic review and meta-analysis.The first objective of this study was to assess the pooled prevalence of needlestick and sharp object injuries among healthcare workers in Ethiopia.The second objective was to determine the pooled effects of factors associated with needlestick and sharp object injuries among healthcare workers in Ethiopia.

Quality assessment and risk of bias
The JBI's critical appraisal checklist, developed for analytical cross-sectional study, was applied to evaluate the reliability and methodological validity of the included studies.The checklist has eight criteria that are measured with the options "Yes," "No," "Unclear," and "Not applicable."We classified "Yes" scores below 50%, 50%-80%, and more than 80% for each JBI criterion as indicating high, medium, and low publication bias, respectively.
To minimize bias, the authors (GK and TF) independently screened the studies.Funnel plot asymmetry and Egger's test were used to check for publication bias.After running Egger's test, a p-value of less than 0.05 as a cutoff point was used to declare the presence of publication bias.

Search results
This study covers the period from 5 September 2023 to 10 October 2023.A total of 355 articles were identified through electronic database search (345 articles) and manual search (10 articles), of which 27 articles were excluded due to duplication.Subsequently, 298 primary publications were excluded after a review of their titles and abstracts revealed that they were conducted in other contexts and were not relevant to our study.We removed another 11 articles for other reasons and finally included 22 primary research articles for the study, based on our eligibility criteria, after reading their entire texts (Figure 1).

Types of injuries
The attempt to classify injuries by needlesticks and other sharp objects to check the burden areas of the problem was unsuccessful due to the absence of clear classifications in the included studies (Table 2).

Overall quality of included studies
Based on the JBI critical appraisal checklist, the overall quality of the studies was supposed to be 22 × 8 = 176.Based on our evaluation, the quality score was 83.5% (147/176 × 100), which met the JBI requirement (Table 3).

Meta-analysis
The forest plot below indicated that the pooled prevalence of needlestick and sharp object injuries among healthcare workers in Ethiopia was 40.5 (95% CI: 35.0, 45.9).With regard to heterogeneity, I 2 was determined, and there was high heterogeneity as evidenced by I 2 = 96.18%and p < 0.001.Therefore, a random effects model was used to estimate the pooled prevalence of needlestick and sharp object injuries among healthcare workers in Ethiopia (Figure 2).

Publication bias
Publication bias was detected, as we can observe in the funnel plot in Figure 3.In addition, Eggers' tests were done, and there was evidence for publication bias with a p-value of 0.4626.

Contributing factors
This systematic review and meta-analysis was not limited to the study of the pooled prevalence of needlestick and sharp object injuries.We reviewed contributing factors for needlestick and sharp object injuries using the adjusted odds ratio (AOR) of the included articles.That means that we excluded articles with crude odd ratios but without adjusted odd ratios.

Sex of the participants
There is no statistically significant association between the sex of the healthcare workers and the occurrence of needlestick and sharp object injuries in Ethiopia (Figure 4).This figure indicates the odds of a male's exposure to needlestick and sharp object injuries compared to a female's.

Needlestick recapping
According to the findings of this review, there was a statistically significant association between needlestick   5).

Standard precautions
According to the results of this review, there was a statistically significant association between the absence of routine follow-up of standard precautions and needlestick and sharp object injuries (AOR, 2.3; 95% CI: 1.1, 4.5, p < 0.01).Healthcare workers who did not follow standard precautions were 2.2 times more likely to suffer needlestick and sharp object injuries compared to their remaining counterparts.A heterogeneity test indicated an I 2 of 83.63% (Figure 6).

Training
The findings of the review indicated a significant association between training and needlestick and sharp object injuries.Healthcare workers who had not received training were 2.41 times more likely to be exposed to needlestick and sharp object injuries compared to healthcare workers who had been trained on injuries (AOR = 2.4; 95% CI: 1.4, 4.1, p < 0.001).A heterogeneity test indicated an I 2 = 88.25% (Figure 7).Funnel plot with pseudo-95% CI for the prevalence of needlestick and sharp object injuries in Ethiopia, 2023.Forest plot indicating the association between needlestick recapping and needlestick and sharp object injuries in Ethiopia, 2023.Forest plot indicating the association between following standard precautions and needlestick and sharp object injuries in Ethiopia, 2023.This study identified that needlestick recapping was another important factor for the occurrence of needlestick and sharp object injuries, a finding that is in accordance with previous studies in other countries (46,47).This finding confirms the need to create awareness among healthcare workers on how to follow standard precautions in general and, specifically, on how to avoid needlestick recapping.If healthcare workers are required to administer an excessive number of injections, the likelihood of unsafe injections and ensuing needlestick and sharp object injuries may increase.
Training was another crucial factor in preventing the occurrence of needlestick and sharp object injuries among the healthcare workers in our study, which is consistent with the studies conducted in other countries (48, 49).According to this study, healthcare workers who had no occupational health and safety training were more exposed to needlestick and sharp object injuries compared to their counterparts.

Limitations
This study has limitations that need to be considered when interpreting the results.One of the major limitations was the cross-sectional nature of the included studies, which could not establish a temporal relationship between needlestick and sharp object injuries and the independent variables.This results in a high chance of selection and information biases at the sample selection stage.There is likelihood for confounders to influence the results, resulting in incorrect interpretations.The second limitation of the study was the presence of heterogeneity among studies.The third limitation was the existence of publication bias, as could be observed from the funnel plot and Egger's test result.Fourth, the included studies were those with an abstract those fully tractable from major databases, which could affect the inclusiveness of the study.The last limitation was the disproportionate distribution of the studies in regions of Ethiopia, with the majority originating from the northern parts of the country.

Conclusions
According to this systematic review and meta-analysis, 40.5% of the healthcare workers in Ethiopia had experienced needlestick and sharp object injuries.The lack of occupational health and safety training, the lack of routine adherence to standard precautions, and the practice of needlestick recapping practices increased the odds of needlestick and sharp object injuries in Ethiopia.The impact of needlestick and sharp object injuries in Ethiopia extends beyond individual healthcare workers; it can also affect the productivity of the country.Therefore, it is essential to give adequate emphasis to these factors to minimize injuries, morbidity, and mortality due to needlestick and sharp object injuries.The implementation of workplace safety standards at health facilities, regular follow-ups, and on-the-job training programs are crucial to overcoming this challenge.

FIGURE 4 Forest
FIGURE 4Forest plot indicating the association between sex and needlestick and sharp object injuries in Ethiopia, 2023.

FIGURE 8 Forest
FIGURE 8Forest plot indicating the association between working hours and needlestick and sharp object injuries in Ethiopia, 2023.

TABLE 1
List of included studies with their key characteristics conducted in Ethiopia, 2023.

TABLE 2
Characteristics of injuries for the included studies conducted in Ethiopia, 2023.
Note: Ns means not specified

TABLE 3
Overall paper quality of eligible studies based on nine statements of JBI.