Epidemiology and risk factors of needlestick injuries among healthcare workers in Iran: a systematic reviews and meta-analysis

Background Occupational contact with blood and body fluids poses a significant risk to healthcare workers. The aim of this systematic review is to investigate the epidemiology and risk factors affecting needlestick injuries (NSI) in healthcare personnel in Iran. Methods In March 2020, researchers studied six international databases such as Medline/PubMed, ProQuest, ISI/WOS, Scopus, Embase, and Google Scholar for English papers and two Iranian databases (MagIran and SID) for Persian papers. Joanna Briggs Institute (JBI) Critical Appraisal Checklist was used to assess quality of studies. The method of reporting was based on the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) statement. Results A total of 43 articles were included in the analysis. Results showed that females (OR = 1.30, 95 % CI 1.06–1.58, P value = 0.009), younger age (OR = 2.75, 95 % CI 2.27–3.33, P value < 0.001, rotated shift workers (OR = 2.16, 95 % CI 1.47–3.15, P value < 0.001), not attending training courses (OR = 1.30, 95 % CI 1.07–1.56, P value = 0.006), working in the surgery ward (OR = 1.83, 95 % CI 1.33–2.50, P value < 0.001), less work experience (OR = 1.43, 95 % CI 1.04–1.95, P value = 0.025) apposed a greater risk factors for NSI among healthcare workers. Conclusion Based on the results of this review, factors such as young age, less work experience, work shift, and female gender are considered as strong risk factors for NSI injury in Iran. Preventive measures including education programs can reduce the burden of NSI among healthcare personnel.


Introduction
Needlestick injuries (NSI) are injuries caused by a needle head or a piece of broken ampule or other sharp object contaminated with blood or body secretions [1]. Occupational contact with blood and body fluids, followed by blood-borne infections, poses a significant risk to healthcare personnel [2]. At least 20 pathogenic pathogens can be transmitted following these injuries [3,4]. Worldwide, about 25% of Hepatitis B virus (HBV) and Hepatitis C virus (HCV) infections and about 2.5% of HIV infections occur among healthcare workers due to NSI [5][6][7]. According to the World Health Organization, about 3 million out of the 35 million healthcare workers are exposed to NSI each year [8]. The annual economic burden of NSI was estimated to be $302 million in Japan [9]. The annual incidence of NSI was estimated at 20.5 per 1000 nurses and 16 per 1000 physicians in Poland. Overall, there were approximately 13,576 cases of NSI damage in Poland in 2014 [10].
Ghanei Gheshlagh et al.'s study showed the prevalence of needle head injury among healthcare personnel in Iran is 42.5%, and this rate is higher in females than males (47 vs. 42%) [11]. NSI-related risk factors have not yet been properly identified in Iran. Studies have identified factors such as excessive and unnecessary injections, poor personnel training, female gender, high workloads, and excessive fatigue especially at nighttime as the most important causes of NSI [7,[12][13][14][15][16][17]. Moreover, a     [19,20]. Therefore, the aim of this systematic review is to investigate the epidemiology and risk factors affecting NSI in healthcare personnel in Iran.

Setting
The present study is a systematic review and metaanalysis of risk factors associated with NSI in medical personnel in Iran. The study was designed and conducted in 2020. The method of reporting the present study was based on the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) statement.

Study selection and data extraction Inclusion and exclusion criteria
Inclusion criteria The present study included only studies conducted in Iran and reported at least one factor affecting NSI.  Exclusion criteria Studies without full text did not provide the information needed to enter the study and those that received a qualitative assessment score of less than 3.

Definitions of some terms
NSI: Needlestick injury for at least 12 months Healthcare workers: A healthcare worker is one who delivers care and services to the sick and ailing either directly. The majority of people in this group are nurses.
Job stress: Job stress is a type of stress caused by conditions in the workplace affecting a person's performance. General Nordic questionnaire for psychological and social factors at work was used for assessing job stress.

Quality assessment
The Joanna Briggs Institute (JBI) Critical Appraisal Checklist was used for quality assessment of included studies. This checklist examines the quality of crosssectional studies. This checklist assesses 9 domains. The overall score above 7 indicates a high quality, between 4 and 6 shows medium quality, and below 3 shows poor quality.

Screening of studies
The initial search was conducted by two researchers (X and Y). Study screening, extraction of results, and quality assessment were performed independently by two researchers (A and B). If there was no agreement between  the two researchers, the team leader (C) would announce the final opinion on that article.

Statistical analysis
The heterogeneity of the studies was investigated by Cochran's test (with a significance level of less than 0.1) and its combination using I 2 statistics (with a significance level greater than 50%). In case of model heterogeneity, random effects were used by variance image method, and in case of non-heterogeneity, the fixed effects model was used. The odds ratio (OR) index was used to combine results from different studies. This index provided the ability to combine studies that reported results in different ways. All analyses were performed by CMA statistical software version 2.

Description of searched studies
A total of 312 reports were found initially. After removing duplicates, 251 reports remained for title and abstract review. In total, 59 studies met the inclusion criteria and entered into the second stage of evaluation. Eventually, 43 studies were included in the final analysis. It should be noted that the references to the published articles were also reviewed to add relevant studies. Reasons for exclusion were unrelated topic (191), unrelated study population [13], and repetitive results [4]. The flowchart of the studies are presented in Fig. 1.

Description of the included studies
Characteristics of the included studies [15, are listed in Table 1.

Results of quality assessment
Eight studies were judged to have a high quality, and 35 had a medium quality.

Results of heterogeneity
Results of the study heterogeneity for each of the risk factors are shown in Table 2.

Results of meta-analysis
Results for NSI risk factors including gender, age, education level, employment status, job stress, and marital status are as follows:    (Fig. 3).

Job stress
The healthcare workers with severe job stress were 36% more likely to experience NSI than those with moderate stress, although it was not statistically significant (OR = 1.36, 95 % CI 0.89-2.08, P value = 0.151) (see Fig. 6).

Marital status
There was no significant difference between singles and married healthcare workers in the NSI event (OR = 1.02, 95 % CI 0.86-1.21, P value = 0.820) (Fig. 7).

Shift working
Workers with rotating shifts were significantly more likely to experience NSI compared to fixed time workers (OR = 2.16, 95 % CI 1.47-3.15, P value < 0.001). Moreover, night-shift workers had higher likelihood of experiencing NSI compared with day-shift workers, but the difference was non-significant (OR = 1.63, 95 % CI 0.82-3.22, P value = 0.161) (Fig. 8).

Attending in training course
Healthcare workers who did not attend the training courses were significantly 30% more likely to experience NSI than those who did the training (OR = 1.30, 95 % CI 1.07-1.56, P value = 0.006) (Fig. 9).

Hepatitis B vaccination status
Workers with incomplete vaccination against hepatitis B were 23% less likely to experience NSI than those who were fully vaccinated, although non-significantly (OR = 0.77, 95 % CI 0.41-1.41, P value = 0.400) (Fig. 10).

Ward
Healthcare workers in the surgery department were 83% more likely to have NSI than workers in the medical department, which was statistically significant (OR = 1.83, 95 % CI 1.33-2.50, P value < 0.001) (Fig. 11).

Work experience
Healthcare workers with less than 10 years of experience were 43% more likely to have NSI than workers with more than 10 years of experience, which was statistically significant (OR = 1.43, 95 % CI 1.04-1.95, P value = 0.025). Moreover, healthcare workers with less than 5 years of experience had 35% higher chance of NSI than those with more than 5 years of experience, although the difference was not significant (OR = 1.35, 95 % CI 0.90-2.02, P value = 0.146) (Fig. 12). Summary of risk factors associated with NSI among HCW in Iran is presented in Fig. 13.

Publication bias
The results of the Egger (P = 0.737) and Begg test (P = 0.552) revealed no evidence of publication bias. The funnel plot for assessing publication bias is shown in Fig. 14.

Discussion
The aim of this systematic review and meta-analysis was to investigate the risk factors of NSI among healthcare workers in Iran. A number of risk factors associated with NSI have been identified. Factors such as female gender, younger age, work experience, job stress, work shift,   [65][66][67] are inconsistent since they identified males are more likely than females to experience NSI. It seems that the occurrence of NSI in terms of gender cannot be judged with confidence.
Furthermore, age and work experience of healthcare workers were identified as important factors related to NSI. Health workers under 30 years were more likely (about 50%) to have NSI than workers over 30 years. In addition, workers with a work experience of less than 10 years were nearly twice as likely to be affected by NSI. Occupational accidents occur more among inexperienced HCWs than experienced counterparts. Reasons might include unfamiliarity with the work environment and work process, less training, less risk awareness, and lack of experience with the same accident (for her/himself or others). Similar reasons can be found in medical staff. The results of the present study showed that education is an effective factor, inexperienced and young staff receive less training than experienced staff. Tolesa Bekele et al. [68] found that HCWs under 30 years of age suffered from NSI almost twice as much as staff aged over 30 years. In a study by Marawan Gabr et al. [65], staff with less than 15 years of work experience were more likely to have NSI compared with staff with more work experience. In another study, Abimbola Oluwatosin et al. [67] found a significant association between age of staff and the incidence of NSI, where staff in the age group of 25 years and younger were more likely to have NSI than the age group of 46 and older. Similar findings have been reported in Rajput et al.'s study among nurses. Such studies also mentioned insufficient training and other factors mentioned above as the reason for more NSI in younger and less experienced staff.
Type of hospital ward showed a significant effect on the incident of NSI. Surgical ward posed a higher risk on the incident of NSI incident compared with other departments. In a similar vein, Marawan Gabr et al. [65] found the incidence of NSI in the surgical ward was significantly higher than the medical ward. Moreover, the most common injuries related to NSI occurred in the emergency department in two studies by Varun Goel  et al. [7] and Tolesa Bekele et al. [68]. The high incidence of NSIs in the surgery and emergency wards might be caused by high levels of stress resulting from exposure to high-risk patients, work sensitivity, and the need for extreme attention to patients which in turn reduces the nurses' focus during work and increases NSI likelihood.
Information about the type of healthcare profession in our study was limited. In Gańczak et al.'s study, being a doctor was associated with greater odds (OR = 4.2) of suffering from injures in surgical wards versus nurses [69]. A systematic review and meta-analysis by Bouya et al. [70] about job category and NSIs show that prevalence of NSIs was highest among dentists (59.1%). The prevalence of NSIs in other occupational groups was 42.8% for nurses, 46.4% for physicians, and 45.3% for nursing students [70]. On the other hand, in some studies, nurses are considered to have high risk of NSIs compared with other groups [71,72].
The present review found that Job stress is likely to increase NSI incident. Although no significant difference was found between severe and moderate job stress, staff with higher levels of stress had 36% more chance to experience NSI. In a study by Dilie et al., they showed that almost half of the staff with job stress experienced NSI [73]. Job stress can affect workers' physical, physiological, and psychological responses and, in turn, their mental, physical, or emotional activities leading to more  mistakes during work and reduced work performance [74]. Consequently, NSIs are quite likely among staff with higher job stress.
The present review showed that staff with rotational and night shifts are more likely to have NSI than others. Similar to the present findings, Marawan Gabr et al. showed that night shifts increase NSI likelihood. They found that staff with more than 2 night shifts per month were more likely to experience NSI [65]. One possible explanation could be the changes in body's natural physiological cycle as it is related to stress and NSIs. However, in a non-aligned study, Kasatpibal et al. found that most NSIs for nurses in the surgery rooms occurred during morning shifts. This is also justified by the high workload of nurses (e.g., surgeries) in the morning shift [75]. Therefore, it seems that the incident of NSIs might depend on the workplace situation and job type.
Training courses were also identified as one of the key factors affecting the occurrence of NSIs. The incidence of NSIs was shown to be approximately one third (30%) in those who took training courses. In a study by Kasatpibal et al. [75], the effect of training with and without practicing on the incidence of NSIs was assessed. Staff who had training without practicing were significantly (about 53%) more likely to experience NSI. In another study evaluating the effect of attendance in training sessions, staff who did not attend the training sessions suffered more NSIs than staff who attended training [65]. On-job training can play a crucial role in increasing their performance and reducing job risks due to being in a clinical environment and direct exposure to risk factors.
For this reason, in various studies, trained staff were less likely to face occupational hazards and injuries. These cases show a direct impact of clinical education on staff's performance and NSI incident.

Strengths and limitations
Previous meta-analyses conducted in Iran have estimated the prevalence of NSIs. However, the present study aimed to estimate the risk factors of NSI. Two limitations of this review were the lack of detailed information about the type of healthcare professions and the content of training packages.

Recommendations
It is recommended that healthcare authorities plan regular training programs for the prevention of NSIs in healthcare workers. In order to improve these training methods, staff evaluation should be done in different time periods, and possible mistakes should be corrected. Other recommendations are to establish uniform policies across all hospitals about the management of NSIs and performing periodic practical and verbal exams on personnel knowledge, attitude, and performance regarding prevention of NSIs.

Conclusions
In conclusion, this review identified key risk factors including young age, less work experience, work shift, and female gender for NSIs in Iran. Preventive activities based on known risk factors can reduce the burden of NSI on healthcare personnel.