|Year : 2017 | Volume
| Issue : 1 | Page : 49-57
Determinants of behavior of health care workers at Mansoura National Hospital toward needlestick injuries and hepatitis B virus infection
AM Abdel Hamied
Department of Public Health and Community Medicine, Faculty of Medicine, Mansoura University, Mansoura, Egypt
|Date of Submission||27-Nov-2016|
|Date of Acceptance||28-Dec-2016|
|Date of Web Publication||24-May-2017|
A M Abdel Hamied
5th Floor, El Zahraa Tower, 35 El Emam El Gazaly Street, New Toriel, Mansoura City 35111, El Dakahlia Governorate
Source of Support: None, Conflict of Interest: None
Needlestick injuries (NSIs) are among the hazards and problems that can expose health care workers (HCWs) to infections. WHO estimates that 40% of cases of hepatitis B virus (HBV) infections among HCWs are a result of NSIs.
Aim of this was to illustrate the behavior of HCWs at Mansoura National Hospital toward NSIs and HBV infection.
Materials and methods
A cross-sectional study was conducted on 203 total hospital staff (99 males and 104 females) who fulfilled the inclusion criteria to participate in the study.
It was found that 37.9% of HCWs at Mansoura National Hospital were previously exposed to NSIs (included 64.9% of paramedicals and 44.1% of physicians); and 67.5% knew about the risk of NSIs. HCWs who were in routine close contacts with patients knew that diseases transmitted by NSIs included HBV (81.3%); 57.1% knew that HBV is more infectious than HIV; 63.4% knew about the existence of a vaccine to prevent HBV; 62.5, 49.1, and 55.4%, respectively, knew that wearing gloves, wearing eye protection, and hospital disinfection were protective measures against hepatitis B (HB) infection; 35.7% agreed that HB vaccine should be taken before working in the hospital. Regarding hospital staff, 76.8% of HCWs knew that HBV may be transmitted (included all physicians and 71.9% of paramedicals), 32% did not know the degree of vaccine protection, and 47.3% suggested that the vaccine gives relative protection. Also, 23.6% of HCWs were vaccinated against HB (included 48.5% of physicians), 53.7% washed their hands after patient contact, 18.7% used gloves, and 4.9% used eye protection.
There was a gap in knowledge, attitude, and behavior among HCWs regarding NSIs and risk of contracting HBV, and this gap can be reduced by provision of health education sessions at preplacement medical examination and then periodically.
Keywords: health care workers, hepatitis b, knowledge and behavior, needlestick injuries
|How to cite this article:|
Abdel Hamied A M. Determinants of behavior of health care workers at Mansoura National Hospital toward needlestick injuries and hepatitis B virus infection. Benha Med J 2017;34:49-57
|How to cite this URL:|
Abdel Hamied A M. Determinants of behavior of health care workers at Mansoura National Hospital toward needlestick injuries and hepatitis B virus infection. Benha Med J [serial online] 2017 [cited 2017 Sep 20];34:49-57. Available from: http://www.bmfj.eg.net/text.asp?2017/34/1/49/206903
| Introduction|| |
Needlestick injuries (NSIs) are among the hazards and problems that can expose health care workers (HCWs) to infections . Hepatitis B (HB), hepatitis C, and HIV are biological hazards affecting the health of HCWs. The most common mode of transmission of these diseases is through NSIs . Risk of transmission by NSI is ∼30% for hepatitis B virus (HBV) infection, 10% for HCV, and 1% for HIV . WHO estimated that 40% of cases of HBV infections among HCWs are a result of NSIs .
A previous study was conducted on HCWs at tertiary care hospitals of Pakistan, and it reported that nursing staff and females had poor knowledge and practices than doctors and males regarding NSIs. They found that 28.2% of HCWs were not wearing gloves during contact with patients, and 73% had poor practice by moving around with uncapped syringes. This kind of practice may be observed owing to increased workload on staff, stress, carelessness, and overflow of patients in particular at tertiary care hospitals .
A study done in Uganda among HCWs showed that 48.1% of them had previous exposure to HBV and 8.1% showed a seroprevalence of HBV markers indicating current infection . The prevalence of HBV infection is related directly to number of years worked as a HCW and to their ages, meaning the older the HCW and the more the number of years worked, the greater the chance of chronic infection .
Knowledge about the risk of contracting HBV is generally low among HCWs, and it also differs according to job. For example, previous study carried out on Iranian surgeons showed that most (77.9%) of them underestimated the risk of seroconversion after exposure from a patient infected with HBV .
Knowledge about the existence of a vaccine to prevent HBV has been found to be high among HCWs from around the globe. For example, this was known by 98% of Moroccan laboratory technicians, nurses, midwives, physicians, and surgeons ; 85.1% of Pakistanian medical students ; and 83.7% of dental and 95.4% of medical students in India . However, HCWs may not know the efficacy and duration of protection .
Negative attitudes toward the risk of contracting of HBV were found among 74.7% of Nigerian dental auxiliary workers . Also, it was found that 34.7% of the unvaccinated Nigerian medical students had never given HB vaccination .
| Aim|| |
Aim of this work was to study determinants of behavior of HCWs at Mansoura National Hospital toward NSIs and HB infection.
| Materials and methods|| |
This cross-sectional study was conducted at Mansoura National Hospital during the period from August 2014 till June 2015. This work was carried out on HBV because it is the only hazard of NSIs that has a vaccine. The Ethical committee at our organization (Faculty of Medicine Mansoura University) approved this study. The study sample included 203 hospital staff (99 males and 104 females) who fulfilled the inclusion criteria and accepted to participate in the study. The inclusion criteria were as follows:
- All HCWs (males and females) at Mansoura National Hospital.
- Hospital staff included physicians (68 individuals, with 14 consultants, 23 specialists, seven assistant specialists, 14 residents, and 10 laboratory physicians), nursing staff (26 individuals), laboratory technicians (16 individuals), radiology staff (seven individuals), pharmacy staff (eight individuals), service personnel (34 individuals), and administrative staff (44 individuals).
Verbal consent was taken from the studied group before conducting the study.
An interviewer-administrated questionnaire fulfilling the requirements of the study to collect the following required data was completed by the participants:
- Sociodemographic data: age, sex, residence, marital status, and educational level.
- Occupational history: specialty, duration of employment, pre-employment and periodic medical examinations, laboratory investigations, type of contact with patients (routine close contact, occasional or infrequent contact), and self-report of NSI.
- Items of knowledge about nature of blood–borne infections, modes of transmission, ways of protection, importance of HB vaccine, and vaccination history.
- Items of attitude and behavior of HCWs toward safe work practices adopted to counteract hazards encountered at work.
Procedure of the study
A total of 203 participants worked 8 h per day through three work shifts (from 8 a.m. to 4:00 p.m., from 4:00 p.m. to 12 p.m., and from 12 p.m. to 8 a.m.). The average time to complete the questionnaire ranged from 0.5 to 1 h. Two visits to hospital were done per week.
Qualitative data were described using number and percentage. Difference between categorical variables was tested using χ2-test, odds ratio, and 95% confidence interval. Continuous quantitative variables were presented as mean±SD. P value less than 0.05 (5%) was considered to be statistically significant.
| Results|| |
[Table 1] shows that 39.9% of HCWs in Mansoura National Hospital were aged from 35 to 44 years, with mean age of 39.7±2.8. The number of HCWs of urban residency was 95 (46.8%), which included 50.5% of the males and 43.2% of the females, and of rural residency was 108 (53.2%), which included 49.5% of the males and 56.7% of the females. More males were urban residents, whereas more females were rural residents. Approximately 67.5% of the studied group were married, 31% were illiterate or completed basic education, 21.7% completed the secondary level of education, and 47.3% were university graduates. There was a statistically significant difference regarding the level of education between male and female groups (P=0.014).
[Table 2] showed that 33.5 and 28.1% of HCWs were physicians and paramedicals, respectively. Approximately 55.2% of HCWs were in routine close contact with patients, and 18.2% had a duration of employment of more than 15 years. There was a high statistically significant difference regarding occupational specialty and type of contact with patients.
[Table 3] showed that 37.9% of HCWs were previously exposed to NSIs (included 64.9% of paramedicals and 44.1% of physicians). There was a high statistically significant difference between various occupational specialties regarding NSIs (P<0.001).
|Table 3 Self-report of exposure to needlestick injury among the studied group|
Click here to view
[Table 4] showed that 67.5% of HCWs knew about the risk of NSIs (included 88.2% of physicians and 70.2% of paramedicals). Regarding the practice of hospital staff toward injuries, 39.4% did nothing, 41.9% induced some bleeding after NSI (most common method among physicians and paramedicals), and 18.7% applied sterilization.
|Table 4 Distribution of knowledge and practice about needlestick injuries among the studied group|
Click here to view
[Table 7] Showed that 76.8% of HCWs at Mansoura National Hospital knew that HBV may be transmitted in the hospital (included all physicians and 71.9% of paramedicals). There was a high statistically significant difference between groups (P<0.001). Regarding the degree of protection of HB vaccine, 42 (20.7%) answered absolute protection, 96 (47.3%) answered relative protection, and 65 (32%) did not know about the degree of protection. There was a high statistically significant difference between the groups (P<0.001).
[Table 8] showed that only 23.6% of HCWs at Mansoura National Hospital were vaccinated against HB (included 48.5% of physicians), 53.7% washed their hands after patient contact, 18.7% wore gloves (included 36.8% of physicians and 19.3% of paramedicals), and 4.9% used eye protection (included 13.2% of physicians and 1.8% of paramedicals). There was a high statistically significant difference between groups regarding all items of practice.
| Discussion|| |
This work was done to study the determinants of behavior of HCWs at Mansoura National Hospital toward NSIs and HBV infection. They included physicians, paramedicals, service personnel, and administrators. All of them were considered as HCWs. Our study revealed that 33.5 and 28.1% of HCWs at the hospital were physicians and paramedicals, respectively. Approximately 55.2% of HCWs were in routine close contact with patients and 18.2% had a duration of employment of more than 15 years. There was a high statistically significant difference regarding occupational specialty and type of contact with patients ([Table 2]).
The current study revealed that 37.9% of HCWs at Mansoura National Hospital were previously exposed to NSIs (included 64.9% of paramedicals and 44.1% of physicians) ([Table 3]). The high percentage of exposure among physicians and paramedicals was attributed to their routine close contact with patients. This was in agreement with a previous study conducted on HCWs in a tertiary care hospital in Delhi and showed that 79.5% of them had one or more NSI in their career . The average number of NSIs was 3.85 per HCW. Moreover, another study was conducted at one of the teaching hospitals in Tehran, Iran, and found that 67.8% of all participants had at least one NSI. Among different occupational groups, nurses had the highest rate of NSIs. Females had NSIs more than males .
Our study revealed that only 67.5% of HCWs knew that NSIs may occur at the hospital (included 88.2% of physicians and 70.2% of paramedicals) ([Table 4]). This was in agreement with a previous study conducted on HCWs at a tertiary care hospital in Pakistan which found that 45% of participants had a NSI in the past. Frequency of injury was significantly higher among doctors (P<0.001). This may be explained by the better practice of nurses owing to continuous training sessions on infection control whereas doctors might have no time to attend these training programs .
The current study revealed that when NSIs occurred, 39.4% of HCWs did nothing, 41.9% induced some bleeding (most common method among physicians and paramedicals), and 18.7% applied sterilization ([Table 4]). Similarly, a previous study found that most of HCWs, after the incident, let the wound bleed to reduce the potential viral load and then washed their hands . Furthermore, another study showed that 45.6% of respondents suggested wearing protective equipment .
In our study, 81.3% of HCWs who were in routine close contacts with patients knew that diseases transmitted by NSIs included HBV ([Table 5]). This was in agreement with a previous study that showed that NSI was the most important risk factor for HCWs for transmission of HBV . Similarly, another study showed that 13.3 and 10% of Pakistanian HCWs were unaware of the fact that HB and hepatitis C can be transmitted by NSIs . Good knowledge level among HCWs reflects the fact that, dissemination of information about these infections is very common from various platforms by targeting different groups of HCWs.
|Table 5 Knowledge about hepatitis B infection among the studied group according to type of contact with patients|
Click here to view
In our study, 57.1% of HCWs who were in routine close contact with patients knew that HB viral infection is more infectious than HIV ([Table 5]). Similarly, another study conducted in Dublin, Ireland, mentioned that 82% of nurses working in five wards knew HB was 100 times more infective than HIV .
This study revealed that 63.4% of HCWs who were in routine close contact with patients knew about the existence of a vaccine to prevent HBV ([Table 5]). Similarly, such knowledge was prevalent among 77.2% of Nigerian nurses, physicians, laboratory workers, and other cadres .
The current study revealed that 62.5, 49.1, and 55.4% of HCWs who were in routine close contact with patients knew that wearing gloves, wearing eye protection, and hospital disinfection, respectively, were protective measures against HB infection ([Table 5]). Similarly, a previous study found that 81% of Indian doctors, nurses, and laboratory technologists had knowledge about universal precautions . In contrast to our study, previous study revealed that only 34.2% of Nigerian nurses knew about universal precautions after occupational injuries .
Our study revealed that only 35.7% of HCWs at Mansoura National Hospital who were in routine close contact with patients agreed that HB vaccine should be taken before working in the hospital ([Table 6]). In contrast to our study, previous study conducted on HCWs at PHC centers in Kuwait showed that 87.1% reported their need to be protected from HBV infection, and 86.3% considered it necessary to receive the vaccine. Positive attitude toward vaccination was found owing to the belief in the efficacy of the vaccine and that the job of HCWs puts them at risk of HBV infection . Low attitude of HCWs in our study may be owing to them being worried about the vaccine’s adverse effects, vaccine not being available, bearing the cost of the vaccine and absence of educational tools about the importance of vaccination.
|Table 6 Attitude towards prevention of hepatitis B virus infection among the studied group according to type of contact with patients|
Click here to view
The practice of recapping of needles was found to be still common in health care settings. The present study revealed that only 33% of HCWs at Mansoura National Hospital who were in routine close contact with patients agreed that needles should not be recapped or bent after use ([Table 6]). Similarly, a previous study found that only 32.9% of Nigerian HCWs did not recap needles . On the contrary, other study revealed that 58.2% of Nigerian nurses said they never recapped needles .
Our study revealed that only 76.8% of HCWs at hospital knew that HBV may be transmitted in the hospital (included all physicians and 71.9% of paramedicals) ([Table 7]). This was in agreement with a previous study which showed that 54% of Nigerian HCWs knew that their job exposed them to an increased risk of acquiring HBV . Moreover, a previous study showed that 76.2% of HCWs were aware that HBV can be transmitted from patients to them . Similarly, another study showed that 80.9% of Nigerian HCWs reported that HBV can be acquired as nosocomial infection . In contrast to our results, previous study conducted among Pakistanian HCWs showed that they had a very low knowledge about HB infection .
|Table 7 Distribution of knowledge about hepatitis B vaccine among the studied group|
Click here to view
The present study revealed that 32% of HCWs at Mansoura National Hospital did not know the degree of protection of HB vaccine and 47.3% suggested that the vaccine gives relative protection ([Table 7]). These outcomes are supported by the findings from an Egyptian study conducted at Ain Shams University hospitals and revealed that 38% of junior doctors and nurses did not know the effectiveness of the vaccine and 47% were not sure about the duration of protection against HBV .
The present study revealed that only 23.6% of HCWs in hospital were vaccinated against HB (included 48.5% of physicians) ([Table 8]). This was in agreement with previous study conducted on Italian dentists and concluded that most participants were not immunized against HBV, because 42.8% considered it useless and 33.3% unsafe . In contrast to our results, previous study conducted on nurses in Dublin, Ireland, showed that 83% of nurses had completed a full course of HB immunizations . Moreover, similar study conducted on HCWs in tertiary care hospitals in India showed that only 55.4% of the screened HCWs were vaccinated, 27.7% had never been vaccinated, and 16.4% were unaware of their vaccination status .
|Table 8 Distribution of practice towards prevention hepatitis B infection among the studied group|
Click here to view
The great difference between our results and these results could be attributed to defective knowledge related to the benefits of the vaccine, and also to defective social influence (physicians, role models, friends, and spouse) and defective knowledge about disease and vaccine, whereas refusal was primarily related to concern about vaccine adverse effects and problems with vaccine access. So we need more specific educational efforts at Mansoura National Hospital to improve the level of awareness and increase acceptance rates of HB vaccine among hospital personnel. This was proved before by previous study carried out in Bangkok and showed that after dissemination of information, knowledge and attitudes improved significantly, and acceptance rates were increased from 56.9 to 77.7% .
Hand washing was found to vary from high, moderate, to low. The current study revealed that 53.7% of HCWs washed their hands after contact with patients ([Table 8]). Similarly, a previous study showed that 63% of Moroccan nurses correctly disinfected their hands . However, other study showed that 94.6% of Nigerian nurses, doctors, and laboratory scientists washed their hands after contact with patients .
Regarding use of gloves, in our study, only 18.7% of HCWs used gloves (included 36.8% of physicians and 19.3% of paramedicals) ([Table 8]). Similarly, a previous study showed that 24.4% of Moroccan nurses wore gloves when performing invasive procedures . Moreover, another study showed that 27% of Saudi Arabian nurses and paramedics wore gloves all the time . In contrast to our results, previous study showed that gloves were always used by 86.6% of Nigerian HCWs .
The current study revealed that 4.9% of HCWs used eye protection (included 13.2% of physicians and 1.8% of paramedicals) ([Table 8]). However, previous study showed that 43.8% of Iranian dentists, general practitioners, para clinicians, and surgeons used eye protection . Moreover, another study showed that 32.9% of UK surgeons used eye protection . The low usage of eye protection by HCWs in Mansoura National Hospital was attributed to unavailability of the eye protection.
| Conclusion and recommendations|| |
- A gap in knowledge, attitude, and behavior of HCWs at Mansoura National Hospital existed regarding NSI and risk of contracting HB infection. Although a sector of HCWs (physicians and paramedicals) was aware about the risk of infection and protective measures, and they were not adopting adequate safety measures routinely.
- We recommend establishing an occupational health unit inside the hospital to provide health education sessions for all hospital staff before placement, disseminate knowledge about HB vaccine, increase vaccine uptake by HCWs, provide anti-HBs testing after vaccination, offer safer injection devices, and strengthen supervision of workers on good practices.
- Record keeping and reporting of sharp injuries should be considered as an essential part of the infectious control process.
The author would like to acknowledge the contribution of all employees who participated in this study.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interests.
| References|| |
Ebrahimi H, Khosravi A. Needlestick injuries among nurses. J Res Health Sci 2007; 7:56–62.
Joseph NM, Elan S, Vadivu S, Kanungo R. Needle-stick injuries among healthcare workers of a tertiary care hospital in South India. Infect Control Hosp Epidemiol 2014; 35:103–105.
Hsieh W, Chiu N, Lee C, Huang F. Occupational blood & infectious body fluid exposures in a teaching hospital: a three year review. J Microbiol Immunol Infect 2006; 39:321–327.
Sadoh WE, Fawole AO, Sadoh AE, Oladimeji AO, Sotiloye OS. Practice of universal precautions among healthcare. J Natl Med Assoc 2006; 98:722–726.
Kumar A, Khuwaja AK, Khuwaja AM. Knowledge practice gaps about needle stick injuries among healthcare workers at tertiary care hospitals of Pakistan. J Ayub Med Coll Abbottabad. 2012; 24:50–52.
Ziraba AK, Bwogi J, Namale A, Wainaina CW, Mayanja-Kizza H. Sero-prevalence and risk factors for hepatitis B virus infection among HCWs in a tertiary hospital in Uganda. BMC Infect Dis 2010; 10:191.
Beltrami EM, Williams IT, Shapiro CN, Chamberland ME. Risk and management of blood-borne infections in HCWs. Clin Microbiol Rev 2000; 13:385–407.
Moghimi M, Marashi AS, Kabir A, Taghipour HR, Faghihi-Kashani AH, Ghoddoosi I et al.
Knowledge, attitude, and practice of Iranian surgeons about blood-borne diseases. J Surg Res 2008; 151:80–84.
Djeriri K, Laurichesse H, Merle JL, Charof R, Abouyoub A, Fontana L et al.
Hepatitis B in Moroccan HCWs. Occup Med 2008; 58:419–424.
Khan N, Ahmed SM, Khalid MM, Siddiqui SH, Merchant AA. Effect of gender and age on the knowledge, attitude and practice regarding hepatitis B and C and vaccination status of hepatitis B among medical students of Karachi, Pakistan. J Pak Med Assoc. 2010; 60:450–455.
Tibdewal H, Barad P, Kumar S. Comparing dental and medical student’s knowledge and attitudes toward Hepatitis B and C and HIV patients in India − a cross sectional study. J Int Oral Health 2009; 1:20–32.
El-Awady MY. Hepatitis B vaccination rates among medical personnel at Ain Shams University Hospital and obstacles to vaccine uptake. J Egypt Public Health Assoc 1998; 73:519–537.
Azondo CC, Ehigiator O, Ojo MA. Occupational risks and hepatitis B vaccination status of dental auxiliaries in Nigeria. Med Princ Pract 2010; 19:364–366.
Okeke EN, Ladep NG, Aqaba EI, Malu AO. Hepatitis B vaccination status and needle stick injuries among medical students in a Nigerian university. Niger J Med 2008; 17:330–332.
Sharma R, Rasania S, Verma A, Singh S. Study of prevalence and response to needle stick injuries among health care workers in a Tertiary Care Hospital in Delhi, Indian J Community Med 2010; 35:74–77.
Amini M, Behzadnia MJ, Saboori F, Bahadori M, Ravangard R. Needle-stick injuries among healthcare workers in a teaching hospital. Trauma Mon 2015; 20:e18829.
Zafar A, Aslam N, Nasir N, Meraj R, Mehraj V. Knowledge, attitudes and practices of health care workers regarding needle stick injuries at a tertiary care hospital in Pakistan. J Pak Med Assoc 2008; 58:57–60.
Ernest SK. Injection safety: knowledge and practice among health workers. Department of Paediatrics/Child Health, University of Ilorin, University of Ilorin Teaching Hospital, Nigeria. West Afr J Med 2002; 21:70–73.
Kapoor V, Gambhir RS, Singh S, Gill S, Singh A. Knowledge, awareness and practice regarding needle stick injuries in dental profession in India: a systematic review. Niger Med J 2013; 54:365–370.
Siddique K, Mirza S, Tauqir SF, Anwar I, Malik AZ. Knowledge attitude and practices regarding needle stick injuries amongst healthcare providers. Pakistan J Surg 2008; 24:243–248.
McGrane J, Staines A. Nursing staff knowledge of the hepatitis B virus including attitudes and acceptance of hepatitis B vaccination: development of an effective program. AAOHN J 2003; 51:347–352.
Samuel SO, Aderibigbe SA, Salami TAT, Babatunde OA. Health worker’s knowledge, attitudes and behaviour towards hepatitis B infection in Southern Nigeria. Int J Med Sci 2009; 1:418–424.
Shah R, Mehta HK, Fancy M, Nayak S, Donga BN. Knowledge and awareness regarding needle-stick injuries among healthcare workers in tertiary care hospital in Ahmedabad, Gujarat. Nat J Com Med 2010; 1:2.
Ofili AN, Asuzu MC, Okojie OH. Knowledge and practice of universal precautions among nurses in central hospital, Benin-City, Edo State, Nigeria. Niger Postgrad Med J 2003; 10:26–31. [Full text]
Soad AH, Ghadeer AA, Afaf EM, Ghizayel RA, Gamal M, Medhat KE. Knowledge, attitude and behaviour of healthcare workers regarding hepatitis B infection in primary health care, Kuwait. Green J Med Sci 2012; 2:77–83.
Ibeziako SN, Ibekwe RC. Knowledge and practice of universal precautions in a tertiary health facility. Niger J Med 2006; 15:250–254.
Ibekwe RC, Ibeziako N. Hepatitis B vaccination status among health workers in Enugu, Nigeria. Niger J Clin Pract 2006; 9:7–10.
Faiza H, Durreshahwar KK, Shan-E A, Faiza B, Afia Z. Knowledge and beliefs among health care workers regarding hepatitis B infection and needle stick injuries at a tertiary care hospital, Karachi. J Coll Physicians Surg Pak 2011; 21:317–318.
Di Giuseppe G, Nobile CG, Marinelli P, Angelillo IF. A survey of knowledge, attitudes, and behavior of Italian dentists toward immunization. Vaccine 2007; 25:1669–1675.
Sukriti XX, Pati NT, Sethi A, Agrawal K, Agrawal K, Kumar GT et al.
Low levels of awareness, vaccine coverage, and the need for boosters among health care workers in tertiary care hospitals in India. J Gastroenterol Hepatol 2008; 23:1710–1715.
Kamolratanakul P, Ungtavorn P, Israsena S, Sakulramrung R. The influence of dissemination of information on the changes of knowledge, attitude and acceptance of hepatitis B vaccination among hospital personnel in Chulalongkorn Hospital. Public Health 1994; 108:49–53.
Laraqui O, Laraqui S, Tripodi D, Ouazzani LC, Caubet A, Verger C et al.
Evaluation of knowledge, attitudes and practices in the healthcare setting in Morocco with regard to hepatitis B and C. Sante Publique 2009; 21:271–286.
Alam M. Knowledge, attitude and practices among healthcare workers on needle-stick injuries. Ann Saudi Med 2002; 22:396–399.
Kabir A, Tabatabaei SV, Khaleghi S, Agah S, Kashani AHF, Moghimi M et al.
Knowledge, attitudes and practice of Iranian medical specialists regarding hepatitis B and C. Hepat Mon 2010; 10:176–182.
Kerr H, Stewart N, Pace A, Elsayed S. Sharps injury reporting amongst surgeons. Ann R Coll Surg Engl 2009; 91:430–432.
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7], [Table 8]