Knowledge, Perceptions, Attitudes, and Behaviors of Healthcare Workers Regarding Blood and Body Fluid Exposure in a Tertiary Medical Center - The Impact of the COVID-19 Pandemic

doi:10.21203/rs.3.rs-7435543/v1

Background

Blood and body fluid exposure (BBFE) is a serious incident in healthcare practice, often leading to injuries from contaminated sharps, causing infections like Hepatitis B and Hepatitis C. Compliance with safety precautions and reporting the incident remains low despite many implemented measures. The COVID-19 pandemic improved infection control practices, particularly PPE use, and heightened infection transmission awareness. Our study aims to assess healthcare workers' (HCWs) knowledge, perceptions, attitudes, and behaviors regarding BBFE, identify predictors of BBFE and failure to report it, and compare these parameters before and after COVID-19.

Methods

This cross-sectional study utilized survey data collected from HCWs at AUBMC using an anonymous LimeSurvey during two time periods—2013–2014 and 2023–2024 which are pre and post COVID-19 pandemic period. Data included demographics and assessments of knowledge, perception, attitudes and behaviors toward BBFE. The data was analyzed using chi-square, the independent samples t-test, and regression analysis. Separate analyses were performed for different staff categories to account for variations in exposure and training.

Results

BBFE was reported by 31.1% of HCWs, with significant differences across roles (p < 0.001). Exposure and BBFE reporting did not differ between pre- and post-COVID cohorts. A low attitude/behavior score was a significant predictor of BBFE incidents among students, residents, and nurses (p = 0.013, aOR = 0.66), and a low perception score was a significant predictor of failure to report incidents (p < 0.001, aOR = 0.21) in the same group.

Conclusion

Obstacles like fear of career impacts and procedural issues may still affect fully reporting such incidents. Knowledge alone did not ensure better safety practices, but HCWs' perceptions and attitudes influenced reporting BBFE and its occurrence in the first place. The study calls for a comprehensive approach that addresses both perceptual and procedural barriers to improve safety and reporting, especially in the post-COVID-19 context, where stronger interventions are still needed.

Blood and body fluid exposure

infection control

occupational safety

healthcare workers

Blood and body fluid exposure (BBFE) is a major occupational hazard in healthcare settings worldwide. It most commonly occurs through needlestick injuries (NSIs) or contact with sharp objects, resulting in the penetration of mucous membranes or non-intact skin (1). Such injuries can lead to the transmitting of potentially dangerous pathogens like Hepatitis B and Hepatitis C. Following a percutaneous injury, approximately 10 of every 100 exposed individuals are at risk of contracting the Hepatitis C virus. Those at risk are not limited to healthcare workers (HCWs) in direct contact with contaminated needles, but also include janitorial staff and waste handlers (2). In response to the growing incidence of BBFE, significant investments have been made to prevent and control the rising incidence of BBFE. Policies and regulations have been set to keep a detailed documentation of each incident and ensure immediate access to post-exposure testing and prophylaxis. Due to the recognized burden of BBFE on HCWs, the Center for Disease Control and Prevention (CDC) has developed a set of precautions aimed at preventing the transmission of infections through sharp objects injuries (3). Although these precautions are widely promoted in various healthcare institutions, adherence remains low despite awareness of their importance (2, 4). The rate of BBFE is influenced by multiple factors, including awareness of exposure risk, adherence to safety policies, the level of HCW training, and frequency of injury reporting (5–8). However, underreporting remains a persistent problem. For example, a study conducted in China found that among 131 health science students exposed to sharp objects, only 34.4% had reported the incident to their supervisors (9). This is concerning since timely post-exposure prophylaxis following an injury significantly decreases the risk of seroconversion (10).

The emergence of the COVID-19 pandemic further complicated the challenge of BBFE prevention. Between January 2020 and May 2021, an estimated number of 80,000 to 180,000 HCWs worldwide died from COVID-19, reflecting their heightened infection risk as frontline workers (11). This elevated risk was linked to prolonged working hours and fatigue, which in turn contributed to errors such as improper use of personal protective equipment (PPE). As a result, new guidelines and operational protocols were introduced to reduce COVID-19 exposure and transmission among HCWs (12, 13). Stringent measures, including consistent PPE use and enhanced hand hygiene implemented to primarily limit COVID-19 spread and to help mitigate risks of BBFE. The increased mortality risk among HCWs highlighted emerging challenges and encouraged HCWs to adopt better and more targeted infection control practices.

Numerous studies have reported an increase in HCWs’ adherence to infection prevention and control (IPC) measures during the pandemic. For instance, in one study, a significant majority (63.7%) of HCWs followed IPC protocols when caring for COVID-19 patients (13). Researchers attributed this improvement to heightened awareness and intensified educational efforts highlighting the importance of adequate training in driving behavioral change and preventing breaches in IPC (13). However, this positive trend was not universal. In Kampala City, Uganda, compliance with IPC measures among HCWs remained notably low during the COVID-19 pandemic, despite the elevated risk of disease transmission in healthcare settings. Factors associated with compliance included the availability of COVID-19 wards, religious beliefs, age, and specific departments within healthcare facilities (14).

In the post-pandemic period, HCWs show improved compliance with PPE guidelines for BBFE compared to pre-pandemic levels (15–19). Increased awareness and training have led to better PPE utilization during procedures involving body fluids exposure, while the strict enforcement of PPE regulations by health authorities further enhanced adherence among HCWs.

In summary, BBFE remains a significant occupational hazard in healthcare settings, and the COVID-19 pandemic has reinforced the importance of stringent infection control practices. Improved compliance with these measures may provide a dual benefit of reducing the risk of both COVID-19 and bloodborne pathogen exposures. Ongoing efforts to enhance HCW training, ensure adherence to safety protocols, and promote accurate reporting of BBFE incidents are essential for mitigating these occupational risks (20).

In line with the above, our study aims to assess the knowledge, perceptions, attitudes, and behaviors of healthcare professionals and staff at the American University of Beirut Medical Center (AUBMC) regarding BBFE. By identifying patterns and knowledge gaps, this research seeks to inform policy reassessment and guide the development of targeted interventions to reduce accidental exposure events. Furthermore, the study will investigate predictors of exposure and reporting incidents, offering valuable insights into the impact of the COVID-19 pandemic on HCW behaviors related to BBFE.

Aim

The aim of this cross-sectional study is to describe the knowledge, perception, and attitude/behavior regarding BBFE among HCWs in a tertiary medical center, AUBMC. It will further investigate how those parameters differed between pre- and post-COVID-19 periods by comparing data gathered before and after the pandemic. Also, the study aims to determine the predictors of BBFE and failure to report such exposures among 2 separate groups. The first group consists of medical students, resident physicians, and nurses, while the second group consists of laundry and housekeeping staff at AUBMC. Findings are based on data collected through two survey-based questionnaires administered at separate time intervals (before and after the COVID-19 pandemic).

Population and Setting

Our study integrates survey data collected at two separate time intervals—2013–2014 and 2023–2024—at AUBMC. Both surveys targeted the same population of HCWs and received Institutional Review Board (IRB) approval. A comparative analysis of data points before and after the COVID-19 pandemic was performed. AUBMC is one of the largest tertiary medical centers in the Middle East, serving as both a teaching hospital and a hub for various clinical and research activities.

Data Collection

The survey administered in 2013–2014 was paper based, with written consent obtained from participants beforehand. On the other hand, the 2023–2024 survey was administered via LimeSurvey software to an anonymous list of AUBMC medical students, residents, and nurses, to be completed online except laundry and housekeeping staff, who completed paper-based surveys.

The LimeSurvey was sent in English and was to be completed by participants who had agreed to a consent form before that. Physical copies of the survey - translated to Arabic - were distributed to hospital laundry and housekeeping staff, who have agreed to be part of the study, by their supervisors. Oral consent was obtained from study participants of this group. The survey was anonymously completed privately at home. The surveys were returned enclosed in envelopes, maintaining the confidentiality of respondents.

The survey used in the 2023–2024 was similar to the previous version, with only minor changes in questions. For example, participants form the newer survey were asked about previous COVID-19 infection and whether they were vaccinated or not as well as four additional “knowledge questions” not included in the prior survey. 142 participants completed the 2023–2024 survey and 157 completed the 2013–2014 survey.

Questionnaire Design and Variables

The survey included questions on demographics, self-rated health, lifestyle behaviors, sharps exposure, and reporting of exposure incidents. Participants were categorized according to their role within the healthcare system at AUBMC (medical students, resident physicians, nurses, and laundry/housekeeping staff). three sections addressed knowledge, perception, and attitudes/behaviors related to BBFE.

Knowledge-related questions assessed participants’ understanding of the risk of hepatitis B and HIV, as well as their familiarity with hospital policies for reporting and managing BBFE. Perception questions explored participants views on the benefit of reporting incidents, while attitude and behavior items examined their willingness to report and seek treatment following an exposure. Responses were given a score of 1 if they reflected a “positive” response such as a correct answer to a knowledge item, or an indication of awareness regarding the benefit of reporting BBFE. Scores were summed to produce a total score for each section: The knowledge section was scored out of 6, the perception section out of 5, and the attitudes/behaviors section out of 7. Comparisons of perception and attitude/behavior scores were possible between the pre-pandemic and pos-pandemic surveys. However, knowledge scores could not be compared, as four additional knowledge questions were added to the 2023 survey that were not present in the 2013 survey, making total scores non-comparable across the two periods.

The knowledge section aimed to assess participants' understanding in the following areas:

Awareness of the risks associated with hepatitis B and HIV.
Familiarity with hospital policies regarding BBFE and the reporting process.
Knowledge of the bodies responsible for monitoring BBFE incidents and covering associated expenses.

The perception section sought to evaluate participants' views on:

Their perceived knowledge regarding BBFE.
The perceived benefits of reporting BBFE incidents.
Their familiarity with the reporting process.
The likelihood of their colleagues reporting BBFE.

Lastly, the attitudes and behaviors section focused on assessing:

Participants' fear of reporting BBFE.
Feelings of intimidation regarding the reporting process.
Willingness to report exposures, seek treatment and utilize post-exposure prophylaxis.
Attitudes concerning the urgency of addressing BBFE incidents.

Only participants who fit the inclusion criteria were permitted to participate (over 18 years of age, healthcare worker at AUBMC, voluntary participation, and direct risk of blood and body fluid exposure).

Data Analysis

Survey data analysis was performed using IBM SPSS Statistics 25 (SPSS Inc., Chicago, IL, USA). Two main analyses were performed. First, demographic and lifestyle characteristics, BBFE incidence and reporting, as well as knowledge, perceptions, and attitudes/behaviors, were compared between pre-and post-COVID-19 cohorts. Categorical variables were analyzed using the chi-square test, and the continuous variables using the independent samples t-test. A p-value < 0.05 was considered statistically significant. Second, bivariate and multivariate analyses were conducted to identify predictors of BBFE incidents and of failure to report them. Separate analyses were conducted for laundry/housekeeping staff versus the rest of the categories (residents, medical students, and nurses), due to differences in exposure patterns, job responsibilities, and infection control status.

In bivariate analysis, categorical variables (e.g., sex, health rating, and pre-/post-COVID-19) were analyzed using Chi-square test, and continuous variables (e.g., age, knowledge, perception, and attitude/behavior scores) with the independent samples t-test. Variables with p-value ≤ 0.2 that were considered statistically significant, were entered into multivariable backward logistic regression model to calculate adjusted odds ratios (aOR) and 95% confidence intervals (CI). A p-value < 0.05 was considered statistically significant in multivariate analysis.

Outcomes assessed in Chi-square bivariate analysis were the frequency of sharp exposure and failure to report BBFE incidents and were analyzed against all other variables including demographic variables. The same outcomes were used in the t-test for continuous variables.

Ethical Considerations

This study was approved by IRB at AUBMC. All participants signed an informed consent before completing the questionnaire. Participants were informed of the risks and benefits of completing the survey and were allowed to withdraw at any time with no consequences.

A total of 299 participants were included in the study; 157 from the 2013-2014 (pre-COVID-19) survey and 142 from the 2023 survey. The mean age was 30.13 years (Table 1.2), with participants from the 2023 cohort being slightly older (p=0.002). A higher proportion of participants in the 2023 cohort were married (p=0.011) and reported lower alcohol consumption (p<0.001). Of the 142 participants surveyed post-COVID-19, 97.2% had received the COVID-19 vaccine, 2.8% had not, and 73.9% had been infected with COVID-19 (Table 1.1).

Exposure to needle or sharp injuries was reported by 31.1% of the participants; of these, 82.6% reported the incident, and 73% underwent the recommended testing (Table 1.1). 6.4% of medical students, 33.3% of resident physicians, 44.6% of nurses, and 48.6% of housekeeping/laundry staff overall admitted to accidentally pricking themselves with a needle or sharp object at least once (Table 1.6), and the difference across groups was statistically significant (p<0.001). No significant differences were found between pre- and post-COVID-19 cohorts in the frequency of BBFE incidents, reporting, and subsequent testing (Table 1.1).

Knowledge:

Table 1.3 demonstrates all the knowledge items asked; the last four were added only in 2023. Comparing responses to the common items between cohorts, participants in 2023 more accurately identified the risk of developing Hepatitis B (p=0.01) and HIV infection (p=0.013) from BBFE, as well as he person responsible for BBFE monitoring at AUBMC (p<0.001). In the 2023 survey, the most frequently cited prevention strategy was the no-recapping method. The mean knowledge score in 2023 was 3.29 ± 1.457 out of 6 (Table 1.2).

Perception and Attitudes/Behaviors:

In 2023, more participants reported being familiar with the steps to take after an injury (p=0.004), and the mean perception score in 2023 was significantly higher than in 2013-2014(p= 0.001) (table 1.4). For attitudes and behaviors, a greater proportion of individuals in 2023 reported fear of other HCWs’ reaction if they disclosed the injury (p=0.028). However, there was no statistically significant difference in mean attitude/behavior scores (Table 1.2).

Predictors of Failure to Report BBFE:

Table 2 shows the results of bivariate and multivariate analysis of predictors of failure to report BBFE incidents among medical students, residents, and nurses. In the bivariate analysis, results are presented as the p-value for the difference in means on independent samples t-test for continuous variables (age and perception score), and unadjusted odds ratios (uOR) on the chi-square test for the remaining categorical variables. Results for multivariate analysis are presented as the adjusted odds ratios (aOR) obtained using logistic regression. Age, perception score, smoking, and exercise were significant in the bivariate analysis at p-value<0.2. In the multivariate model, only perception score remained significant (p<0.001, aOR=0.21, 95% CI:0.08-0.50); indicating that lower perception scores independently predicted failure to report BBFE..

Predictors of BBFE Incidents:

Table 3 summarizes the predictors of BBFE incidents among students, residents, and nurses. Age, attitude/behavior score, male sex, alcohol consumption, and prior COVID-19 infection were significant on bivariate analysis at p-value<0.2. Having children was also significant but was excluded from the logistic regression because no medical students have children. On multivariate analysis, age (p=0.018, aOR=1.04, 95% CI:1.01-1.08) and attitude/behavior score (p=0.013, aOR=0.66, 95% CI: 0.481-0.919) remained significant.

Laundry and Housekeeping Staff:

For this group, only age and knowledge score were significant predictors of failure to report BBFE on bivariate analysis; logistic regression was not performed. As for the predictors of BBFE incidents among this group, attitude/behavior score, male sex, smoking, exercise, prior COVID-19 infection, and COVID-19 vaccination were significant on bivariate analysis, but none were significant in multivariate analysis. Analyses of data in the post-COVID-19 period for this group also yielded no significant predictors. This lack of significance may be attributed to the small sample size (n=38) (Table 1.6).

In our study, 31.3% of HCWs reported experiencing a needlestick or sharp injury. This prevalence is higher than the 14% reported among HCWs in Abha, KSA (21) and 19% in the UAE (22), but is closer to the rates reported in Iran (23) (47%) and Sudan (24) (46%). An even higher rate was reported in Egypt (25) (67.9%), suggesting possible regional or institutional differences in safety practices and preventive measures. A 2020 meta-analysis (26) estimated a global prevalence of NSIs among HCWs of 44.5%, which is similar to our finding.

Regarding reporting of BBFE incidents, 82.6% of our participants reported their incidents, which is much higher than rates in KSA (47.3%) (21), Poland (54.8%) (27), the UK (51%) (28), and the UAE (58.8%) (29). In Sudan, only 34% of HCWs reported their injury (24). Barriers to reporting BBFE have been previously stated and include fear of negative career consequences, lack of awareness protocols (30), and doubts about the value of reporting. In our study, perception score was found to be a significant predictor of failure to report. Psychological factors such as shame, guilt, or fear of being blamed can also prevent reporting. Other barriers include a lengthy and cumbersome reporting process (31, 32), and concerns that reporting may disrupt patient care.

In our study, the highest prevalence of BBFE was reported among housekeeping and laundry staff (48.6%) and nurses (44.6%). This is higher than the 35% NSI prevalence reported in a meta-analysis of nursing students worldwide (33) but is similar to the prevalence reported by Bouya et al. (26) (42.8%). Medical students in our study had a lower prevalence (6.4%) than that reported in the United States (30%) (34) and Europe (34%)(35). These differences may be explained by their lower exposure to sharp objects like blades and needles compared to clinical staff of nurses and housekeepers (20).

As shown in Table 1, BBFE incidents were reported at 28.2% pre-COVID-19 and 34.8% post-COVID-19, with a p-value of 0.224, indicating no statistically significant difference between the two periods. Similarly, reporting failures were 20.5% pre-COVID-19 and 14.6% post-COVID-19, with a p-value of 0.458. Regression analysis (Tables 2 and 3) showed that the pre-/post-COVID-19 period was not a predictor of either BBFE or failure to report. This suggests that the pandemic did not significantly affect these behaviors.

These findings challenge the expectation that increased safety awareness and training during pandemic would lead to fewer incidents and higher reporting. Possible explanations include normalization of risk, persistent stigma around reporting, and insufficient institutional changes to facilitate reporting. Some HCWs may perceive minor incidents as unworthy of reporting, while others may experience compliance fatigue. Collectively, these factors suggest that increasing awareness alone is insufficient to improve reporting rates; yet, eliminating reporting barriers and fostering a supportive safety culture are essential.

Although BBFE and its reporting rates did not differ significantly between pre- and post-COVID-19 cohorts, differences emerged in other outcomes. Post-COVID-19 respondents answered the first three knowledge questions correctly, suggesting greater awareness of BBFE transmission risks. This may reflect increased interest in infectious disease control during the pandemic (36). Similar patterns are reported elsewhere; for example, Cheng, Hsin-Chung, et al. found higher infection control knowledge among dentists in 2020 compared to 2018 (37). However, in our study, low knowledge scores were not significant predictors of BBFE or failure to report, a finding consistent with Malaysian data showing no link between knowledge scores and NSI incidents among medical students (38). Other studies show that training alone on occupational infection prevention does not necessarily reduce injury risk (39). This suggests that while knowledge of the risks of pathogen exposure and the precautions that should be ideally implemented is important, consistent application of preventive strategies and competency in practice may have greater impact on BBFE rates (40, 41).

Perception scores also increased post-COVID-19, with more respondents reporting familiarity with post-BBFE protocols. The pandemic’s demonstration of rapid disease spread in 2020 may have heightened HCWs’ perception of occupational exposure risks. Notably, a low perception score was the only independent predictor of failure to report BBFE incidents among students, residents, and nurses. This aligns with earlier research reports like that of a study done in 2008 on blood exposure in paramedics that showed that reporting likelihood was tied to perceived transmission risk, like when injuries were deep. Moreover, the belief that reporting would provide the proper management was associated, though non-significantly, with higher reporting rates(42).

Attitude and behavior scores did not differ significantly pre- and post-COVID-19, but post-COVID-19 respondents were more likely to report fear of colleagues’ reaction to an injury. Fear of reputational harm or negative career impact has been documented previously. For example, a 2011 study done on European medical students reported that 45% of those surveyed expressed fear of career impact (35). This was also reported by 8% in a study done in Bangalore, India dental professionals (43). However, in New South Wales, Australia, 90% of surveyed nurses described their managers as approachable after an NSI (44). In our sample in Lebanon, 14% of participants feared colleagues’ reaction Highlighting the variability of this barrier across contexts. Attitude/behavior also emerged as an independent predictor of BBFE frequency among students, residents, and nurses. Similarly, a Thai study found that nurses with lower attitude scores were more likely to sustain injuries (45). Additionally, age independently predicted BBFE in our study, with older age associated with higher incidence. Although older age is often assumed to correlate with more experience and reduced risk, this is not always the case, and our data did not account for this factor.

This study has several limitations. First, its cross-sectional design precludes causality about factors influencing BBFE. Reliance on self-reported data may introduce recall bias. Moreover, differences in survey administration methods—paper-based in 2013–2014 and online in 2023—could also affect participation and responses, introducing variability unrelated to COVID-19. In addition, the inclusion criteria focused on HCWs directly involved in patient care, overlooking other staff at risk for BBFE. The addition of a new knowledge question in the 2023 survey prevented direct comparison of knowledge scores over time. Despite these limitations, a key strength is the representative sample, which includes HCWs from multiple levels within the healthcare system, enabling a comprehensive understanding of BBFE incidents and reporting behaviors across professional groups.

This study highlights key findings on BBFE prevalence and reporting among HCWs in a tertiary medical center with 31.3% experiencing needlestick or sharp injuries. The reporting rate (82.6%) exceeded rates reported in previous studies, possibly reflecting greater awareness or improved institutional protocols. Nonetheless, barriers such as fear of career repercussions, lack of awareness, and procedural inefficiencies persist. While increased knowledge alone does not necessarily improve safety practices or reporting, HCWs’ perceptions predicted reporting and their attitude toward BBFE predicted injury rates. A comprehensive approach, addressing psychological and procedural barriers, fostering supportive work environments, and organizing reporting processes, is essential for reducing occupational exposures. Despite heightened infection control focus during COVID-19, our findings indicate that further interventions are needed to ensure lasting improvements in safety practices.

blood and body fluid exposure (BBFE)

needlestick injuries (NSIs)

healthcare workers (HCWs)

Center for Disease Control and Prevention (CDC)

personal protective equipment (PPE)

infection prevention and control (IPC)

American University of Beirut Medical Center (AUBMC)

Ethics approval and consent to participate: The study was approved by the Institutional Review Board at the American University of Beirut; all participants provided consent prior to answering the survey

Consent for publication: All authors have read the final version of the manuscript and agreed on publication

Availability of data and materials: Study data is available from the Principal Investigator upon request

Competing interests: The authors declare no competing interests

Funding: The study received no funding

Authors’ contributions: Z.A. data collection, manuscript drafting and formatting; R.A. data collection, subject recruitment; Z.K. data collection, manuscript drafting; L.A. manuscript editing; R.A. data collection; R.M. proposal writing; J.E. data collection; Z.A.K. conceptualization, survey design, data analysis, manuscript review

Acknowledgements: None

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Table 1.1 - Participant demographics, lifestyle characteristics, and BBFE stratified by period

Demographics	Pre-Covid-19 (N=157)	Post-Covid-19 (N=142)	Total (N=299)	p-value
Sex				0.372
Male	79/154 (51.3)	65/141 (46.1)	144/295 (48.8)
Female	75/154 (48.7)	76/141 (53.9)	151/295 (51.2)
Marital status				0.011
Not married	114/151 (75.5)	87/141 (61.7)	201/292 (68.8)
Married	37/151 (24.5)	54/141 (38.3)	91/292 (31.2)
Children				0.017
No children	122/155 (78.7)	88/133 (66.2)	210/288 (72.9)
Children	33/155 (21.3)	45/133 (33.8)	78/288 (27.1)
Household members including yourself				0.937
≤3	51/136 (37.5)	50/135 (37)	101/271 (37.3)
>3	85/136 (62.5)	85/135 (63)	170/271 (62.7)
Smoking				0.181
Nonsmoker	105/155 (67.7)	85/141 (60.3)	190/296 (64.2)
Smoker	50/155 (32.3)	56/141 (39.7)	106/296 (35.8)
Alcohol				<0.001
Doesn’t drink	81/156 (51.9)	101/140 (72.1)	182/296 (61.5)
Drinks	75/156 (48.1)	39/140 (27.9)	114/296 (38.5)
Exercise				0.985
Inactive	109/155 (70.3)	100/142 (70.4)	209/297 (70.4)
Active	46/155 (29.7)	42/141 (29.8)	88/297 (29.6
Do you have a primary care physician?				0.552
No	85/157 (54.1)	72/142 (50.7)	157/299 (52.5)
Yes	72/157 (45.9)	70/142 (49.3)	142/299 (47.5)
Health rating				0.452
Poor	5/157 (3.2)	2/142 (1.4)	7/299 (2.3)
Good	152/157 (96.8)	140/142 (98.6)	292/299 (97.7)
Have you ever pricked yourself by mistake with any needle or sharp objects in the hospital setting?				0.224
No	112/156 (71.8)	92/141 (65.2)	204/297 (68.7)
Yes	44/156 (28.2)	49/141 (34.8)	93/297 (31.3)
If yes, did you report the incident?				0.458
No	9/44 (20.5)	7/48 (14.6)	16/92 (17.4)
Yes	35/44 (79.5)	41/48 (85.4)	76/92 (82.6)
Did you do the required testing?				0.747
No	12/42 (28.6)	12/47 (25.5)	24/89 (27)
Yes	30/42 (71.4)	35/47 (74.5)	65/89 (73)
Have you been diagnosed with COVID-19 before?
No		37/142 (26.1)
Yes		105/142 (73.9)
Did you receive the COVID-19 vaccine?
No		4/142 (2.8)
Yes		138/142 (97.2)

Table 1.2 - Continuous variables in the study population stratified by period*

Variable	Pre-Covid-19 (N=157)	Post-Covid-19 (N=142)	Total (N=299)	p-value
Age	28.52 ± 8.5 (n=143)	31.82 ± 9.459 (n=136)	30.13 ± 9.133 (n=279)	0.002
Knowledge score		3.29 ± 1.457 (n=139)
Perception score	3.69 ± 1.1 (n=144)	4.09 ± 1.0 (n=139)	3.88 ± 1.047	0.001
Attitude/behavior score	6.38 ± 1.0 (n=137)	6.58 ± 0.8 (n=138)	6.48 ± 0.941	0.078

*Numbers represent averages for each group. Bolded values represent statistically significant p-values on independent samples t-test.

Table 1.3 - Knowledge about BBFE in the study population stratified by period*

Knowledge Question	Pre-Covid-19 (N=157)	Post-Covid-19 (N=142)	Total (N=299)	p-value
Multiple choice questions
The risk of developing Hepatitis B virus infection among non-vaccinated individuals exposed to sharps can reach up to…	39/157 (24.8)	55/142 (38.7)	94/299 (31.4)	0.01
The risk of developing HIV infection among individuals exposed to sharps is…	22/157 (14)	36/142 (25.4)	58/299 (19.4)	0.013
Who at AUBMC is responsible for monitoring BBFE?	0/157 (0)	57/142 (40.1)	57/299 (19.1)	<0.001
According to AUBMC policies, who covers the expenses of testing in case of BBFE?	127/157 (80.9)	108/142 (76.6)	235/299 (78.6)	0.309
Yes/no questions
Are you aware of the AUBMC policies regarding BBFE?		101/140 (72.1)
Are you familiar with the process of reporting BBFE at AUBMC?		106/140 (75.7)
Are you familiar with the strategies/procedures/equipment that can prevent BBFE?		91/112 (81.3)
Can you name two?
No recapping needles		76/127 (59.8)
Sharps container		56/127 (44.1)
Personal protective equipment		24/127 (18.9)
One hand technique		5/127 (3.9)

*Numbers represent proportion and percentage of subjects with correct answers. Bolded values represent statistically significant p-values on chi-square.

Table 1.4 - Perceptions about BBFE in the study population stratified by period*

Perception Question	Pre-Covid-19 (N=157)	Post-Covid-19 (N=142)	Total (N=299)	p-value
Indicate your knowledge level about the risk of getting an infection from BBFE	126/150 (84)	116/140 (82.9)	242/290 (83.4)	0.794
Does the benefit of reporting BBFE outweigh the effort needed to report the incident?	129/150 (86)	129/139 (92.8)	227/258 (88)	0.062
Do you consider yourself familiar with the steps you need to take if you prick yourself?	93/150 (62)	108/139 (77.7)	113/201 (56.2)	0.004
Do you think other people would report BBFE and do all the tests needed?	79/149 (53)	93/139 (66.9)	172/288 (59.7)	0.016
Do you think reporting BBFE will lead to a decrease in these events?	123/149 (82.6)	122/140 (87.1)	245/289 (84.8)	0.277

*Numbers represent proportion and percentage of subjects with perceptions indicative of a greater likelihood of reporting incidents. Bolded values represent statistically significant p-values on chi-square.

Table 1.5 - Behaviors and attitudes about BBFE in the study population stratified by period*

Attitude and Behavior	Pre-Covid-19 (N=157)	Post-Covid-19 (N=142)	Total (N=299)	p-value
I feel that reporting BBFE is a must	145/149 (97.3)	137/140 (97.9)	282/289 (97.6)	1
I am willing to report an injury if it happens to me	141/146 (96.6)	139/140 (99.3)	280/286 (97.9)	0.214
I would rather risk getting an infection from the BBFE than report the incident	130/145 (89.7)	131/140 (93.6)	261/285 (91.6)	0.234
I feel intimidated by the process of reporting BBFE	114/143 (79.7)	118/139 (84.9)	232/282 (82.3)	0.256
I am afraid of the reaction of other healthcare workers if they find out about the injury	118/146 (80.8)	126/140 (90)	144/186 (77.4)	0.028
I would recommend reporting every single injury	139/146 (95.2)	131/140 (93.6)	270/286 (94.4)	0.548
I would take the post-exposure drugs if indicated	141/146 (96.6)	136/139 (97.8)	277/285 (97.2)	0.723

*Numbers represent proportion and percentage of subjects with answers indicative of a greater likelihood of reporting incidents. Bolded values represent statistically significant p-values on chi-square.

Table 1.6 - Proportion of BBFE incidents in each participant category*

Needlestick/Sharp Injury	Participant Category				Total	p-value
	Medical Student (N=78)	Resident (N=87)	Nurse (N=93)	Housekeeping/Laundry (N=38)	N=299	<0.001
Yes	5/78 (6.4)	29/87 (33.3)	41/92 (44.6)	18/37 (48.6)	93/297 (31.3)
No	73/78 (93.6)	58/87 (66.7)	51/92 (55.4)	19/37 (51.4)	204/297 (68.7)

*Numbers represent proportion and percentage of subjects who have experienced BBFE in each category.

Table 2.0 - Bivariable and multivariable analysis of predictors of failure to report BBFE incidents among students, residents, and nurses

Predictors	p-value for difference in means or uOR (95% CI)	*aOR (95% CI)**
Age	0.002	NS
Perception score	<0.001	0.21 (0.08-0.50)
Smoking status	0.3 (0.061-1.1478)	NS
Exercise status	0.199 (0.024-1.647)	NS

*Adjusted for all variables with a p-value ≤ 0.2. “NS” means non-significant on multivariable analysis.

Table 3.0 - Bivariable and multivariable analysis of predictors of pricking incidents among students, residents, and nurses

Predictors	p-value for difference in means or uOR (95% CI)	*aOR (95% CI)**
Age	0.025	1.04 (1.01-1.08)
Attitude/behavior score	0.101	0.66 (0.481-0.919)
Male sex	0.631 (0.365-1.089)	NS
Alcohol consumption	0.631 (0.360-1.108)	NS
COVID-19 diagnosis	3.273 (1.038-10.317)	NS

*Adjusted for all variables with a p-value ≤ 0.2. “NS” means non-significant on multivariable analysis.

No competing interests reported.

Knowledge, Perceptions, Attitudes, and Behaviors of Healthcare Workers Regarding Blood and Body Fluid Exposure in a Tertiary Medical Center - The Impact of the COVID-19 Pandemic

Status:

Version 1

Abstract

Background

Methods

Results

Conclusion

BACKGROUND

METHODS

Aim

Population and Setting

Data Collection

Questionnaire Design and Variables

Data Analysis

Ethical Considerations

RESULTS

DISCUSSION

CONCLUSION

ABBREVIATIONS

Declarations

References

Tables

Additional Declarations

Status:

Version 1