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KAP among
Assessment of knowledge, healthcare
attitude and practices among workers
healthcare workers in a tertiary
549
care hospital on needle stick
injury Received 27 October 2011
Revised 3 April 2012
Accepted 27 July 2012
Aradhana Bhargava, Bibhabati Mishra, Archana Thakur,
Vinita Dogra, Poonam Loomba and Sonal Gupta
Department of Microbiology, G.B. Pant Hospital, New Delhi, India

Abstract
Purpose – The study aims to assess healthcare workers’ needle-stick injury (NSI) knowledge,
attitudes and practices (KAP).
Design/methodology/approach – A cross-sectional study was conducted in a 600-bedded hospital
throughout six months. The data were collected using an anonymous, self-reporting questionnaire.
Participants were various healthcare workers (HCW) drawn through stratified random sampling and
their knowledge, attitude and practice regarding NSI were assessed.
Findings – There is significant difference in the mean knowledge, attitude and practice scores among
healthcare workers. Even though scores are better for doctors and nurses, practice scores were better
for technical staff. Healthcare workers, who had better practice scores, had suffered fewer NSIs. Since
this study is a cross-sectional, the population’s NSI incidence could not be calculated.
Practical implications – This study emphasizes that applying knowledge to practice is required to
prevent NSIs. Various recommendations to help prevent and deal with NSIs are made.
Originality/value – This study analyses healthcare workers’ NSI knowledge, attitude and practices,
and also assesses their correlation with NSI incidence, which has not been done previously.
Keywords India, Hospitals, Medical personnel, Needle-stick injury
Paper type Research paper

Introduction
An occupational blood exposure injury is defined as occupational exposure that may
place a worker at risk to HIV infection; it involves a percutaneous injury, contact with
mucous membrane or skin (especially when the healthcare worker’s skin is chapped,
abraded or afflicted with dermatitis or contact is prolonged or involves an extensive
area) with blood, tissue or other body fluids to which universal precautions apply
(National AIDS Control Organisation Guidelines, 2007). The 2003EPInet data reports
approximately 27 needle-stick injuries (NSIs) per 100 beds in teaching hospitals
(Diprose et al., 2000). While needle-stick injuries (NSI) can transfer bacteria, protozoa, International Journal of Health Care
viruses and prions; hepatitis B virus (HBV), hepatitis C virus (HCV) and the human Quality Assurance
Vol. 26 No. 6, 2013
immunodeficiency virus (HIV) transmission are more important. It is estimated that pp. 549-558
q Emerald Group Publishing Limited
0952-6862
The authors thank Dr Paras Agarwal for statistical help. DOI 10.1108/IJHCQA-04-2012-0035
IJHCQA annually, owing to NSI, that 66,000 HBV infections; 16,000 HCV infections and 1,000
26,6 HIV infections occur worldwide (Prüss-Üstün et al., 2005). Hepatitis B carries the
greatest transmission risk, with 37 percent to 62 percent of exposed workers eventually
showing sero-conversion and 22 percent to 31 percent showing clinical Hepatitis B
infection (CDCP, 2001; Werner and Grady, 1982). While hepatitis C transmission rate
has been reported at 1.8 percent (CDCP (2001); Lanphear et al., 1994), but newer, larger
550 surveys show only a 0.5 percent transmission rate (Jagger et al., 2002). The overall
HIV-infection risk after percutaneous exposure to HIV-infected material in the
healthcare setting is 0.3 percent (Tokars et al., 1993; Bell, 1997). Exposure to blood
products in teaching hospitals is a common. But these incidents are usually
under-reported (Eholie et al., 2002; McCormick et al., 1991), so NSI and blood exposure
injury data are lacking. Moreover, elaborate knowledge, attitude and practice (KAP)
studies are also lacking in a NSI contexts. Our study addresses NSI’s importance and
aims to determining NSI occurrence and awareness among healthcare workers (HCW)
regarding their KAP. We explore various measures to prevent these injuries such as
improving knowledge, attitude and practice. We try to integrate organizational
changes and recommend specific strategies for consistent and safe methods for dealing
with such incidents.

Method
We carried out our study among male and female HCWs in a large, tertiary, teaching
hospital. Infection control practices are routinely followed and taught in this hospital.
All healthcare workers exposed to needle-stick injury risk with varying experience
were included.

Study design
Respondents were drawn using a stratified random sample from HCWs in operating
theatres (OT), intensive care units (ICUs), clinical laboratories, radiology, major wards
and bio-medical waste handling departments. Demographic factors such as age, sex,
education, profession and service length were considered to derive the respondents’
epidemiological background. Male and females were equally represented and were
studied between November, 2009 and April, 2010.

Data collection
An anonymous, self-reporting questionnaire (Appendix, Figure A1), structured
specifically to obtain both qualitative and quantitative data to identify predictive
factors associated with NSIs was used to collect data. The questionnaire was divided
into the following sub-scales: baseline data; and NSI knowledge, attitudes and practice.
The questionnaire contained five questions; each pertaining to respondent knowledge,
attitude and practice, so that these categories could be assessed. Each correct answer
scored two and a zero was given to incorrect answers. Each category had a maximum
ten marks. Zero to four meant poor performance; five and six an average performance;
seven and above a satisfactory performance. The knowledge, attitude and practice
scores were calculated for each respondent and grouped based upon their professional
qualification. Each professional group’s mean score were compared. Findings were
analyzed under different headings to uncover various NSI aspects.
Approval KAP among
Study clearance was obtained from the institutional ethics committee. Subjects were
fully informed about the study’s design and purpose before written informed consent
healthcare
was obtained. workers
Data analysis
We used ratios, percentages, means, standard deviations, chi square and other data 551
interpretation methods. Statistical data were analyzed using Statistical Package for
Social Sciences v.12.0.

Findings
A total of 273 healthcare workers: 103 (37.7 percent) doctors, 88 (32.2 percent) nurses,
32 (11.7 percent) technical staff and 50 (18.3 percent) attendants responded (Table I).
Males and females were equally distributed. Most respondents were aged between
20-40 years, worked in the ICUs and were either graduates or postgraduates. Most
respondents had a good work experience in their respective fields.
Almost 44 percent had experienced an NSI and more doctors (58.3 percent) had been
exposed to blood or body fluids (Table II). Table III shows that more doctors and
nurses answered knowledge-related questions correctly. Regarding attitude related
questions, appropriate responses varied amongst professional groups (Table IV). More

Doctor Nurse Technician Attendant Total

(n ¼ 103) (n ¼ 88) (n ¼ 32) (n ¼ 50) n %

Gender
Male 69 12 18 40 139 50.9
Female 34 76 14 10 134 49.1
Age (years)
20-40 83 68 20 30 201 73.6
41-60 20 20 12 20 72 26.4
Location
ICU 24 60 4 35 123 45.1
OT 16 0 0 0 16 5.9
Ward 28 16 0 5 49 17.9
Laboratory 19 0 28 5 52 19.0
Radiology 16 4 0 0 20 7.3
Others 0 8 0 5 13 4.8
Education
,10th class 0 0 0 11 11 4
10th class 0 4 0 23 27 9.9
12th class 0 52 12 16 80 29.3
Graduate 42 28 18 0 88 32.2
Postgraduate 61 4 2 0 67 24.5
Service (years)
0-1 8 0 0 1 9 3.3
2-5 34 32 14 1 81 29.7 Table I.
6-10 33 28 8 18 87 31.9 Healthcare worker
.10 28 28 10 30 96 35.2 baseline characteristics
IJHCQA technical staff followed the NSI prevention precautions (Table V). The chi square test p
26,6 value for all knowledge, attitude and practice statements is less than 0.05. Mean
knowledge and attitude scores were best for nurses (7:77 ^ 1:88 for knowledge and
8:45 ^ 1:477 for attitude) and doctors (7:34 ^ 2:36 for knowledge and 7:96 ^ 1:28 for
attitude). They were lower for the attendants (3:12 ^ 2:027 for knowledge and 6:60 ^
1:355 for attitude). The mean practice scores were best for the technical staff
552 (8:75 ^ 1:41) and lower for the attendants (6:76 ^ 1:975 (Tables VI-VIII). The scores
increase proportionately with the HCWs qualifications except for postgraduate mean
practice scores; where the scores are less (Table IX). Even though the Knowledge
(7:04 ^ 2:454) and Attitude scores (8:00 ^ 1:766) among those experiencing NSI may
be better than those who were not exposed (knowledge: 6:19 ^ 2:836 and attitude:
7:73 ^ 1:354); HCWs having better Practice scores have less exposure to NSI (Exposed:
7:34 ^ 2:180 vs Not exposed: 8:42 ^ 1:737) (Table X).

Discussion
Preventing NSI is essential in any workplace blood-borne pathogen prevention
program. Every healthcare facility should have a NSI prevention program supervised
by a hospital infection control committee. This entails educational and induction
programs designed to meet any shortcomings in HCW knowledge, attitude and
practice regarding NSI control guidelines. Our questionnaire assessed the

Doctor Nurse Technician Attendant

Table II. Total
Blood and body fluid n % n % n % n % n %
exposure
Yes 60 58.3 32 36.4 8 25 19 38 119 43.6

HCWs answering correctly

Doctors Nurse Technicians Attendants
(n ¼ 103) (n ¼ 88) (n ¼ 32) (n ¼ 50)
Knowledge statements n % n % n % n % p-value

K1: What should you do after

a needle-stick injury? 86 83.5 80 90.9 28 87.5 25 50 , 0.001
K2: Is there more possibility
of HBV than HIV
transmission by NSI?
True/false 103 100 84 95.5 14 43.8 7 14 , 0.001
K3: To which department do
you report NSI? 50 48.5 84 95.5 30 93.8 30 60 , 0.001
K4: HCV can be transmitted
Table III. by needle-stick injury?
Healthcare workers True/false 87 84.5 80 90.9 26 81.3 15 30 , 0.001
answering questions K5: What is the percentage
assessing NSI transmission of HIV and
“knowledge” on NSI HBV owing to needle-
correctly stick injury? 52 50.5 16 18.2 0 0 1 2 , 0.001
 HCWs answering correctly
KAP among
Doctors Nurse Technicians Attendants healthcare
Attitude statements
(n ¼ 103)
n %
(n ¼ 88)
n % n
(n ¼ 32)
%
(n ¼ 50)
n % p-value
workers
A1: Needles should be re-
capped/bent after use. 65 63.1 71 81.1 22 68.8 21 42 , 0.001 553
A2: Post exposure
prophylaxis is really
necessary. 91 88.3 71 81.1 30 93.8 34 68 0.005
A3: Needle-stick Injury
should be reported. 95 92.2 88 100 32 100 45 90 0.011
A4: Needles should be
discarded immediately Table IV.
after use. 91 88.3 88 100 28 87.5 50 100 0.001 Healthcare workers
A5: Gloves provide answering questions
protection against assessing “attitude” on
needle-stick injury. 68 66 52 59.1 12 37.5 15 30 , 0.001 NSI practices correctly

HCWs answering correctly

Doctors Nurse Technicians Attendants
(n ¼ 103) (n ¼ 88) (n ¼ 32) (n ¼ 50)
Practice statements n % n % n % n % p-value

P1: Do you use a needle

cutter/ syringe
destroyer? 95 92.2 84 95.5 32 100 35 70 , 0.001
P2: Do you use gloves for
phlebotomy procedures? 86 83.5 68 77.3 28 87.5 26 52 , 0.001
P3: Have you been Table V.
vaccinated against HBV? 91 88.3 71 81.1 28 87.5 49 98 0.048 Healthcare workers
P4: Do you recap needles answering questions
after use? 54 59.2 80 90.9 22 68.8 30 60 , 0.001 assessing their ‘practice’
P5: Do you report needle- about NSI Practices
stick injury? 71 68.9 64 72.7 30 93.8 30 60 0.010 correctly

Qualification Mean n Standard deviation

Doctors 7.34 103 2.366

Nurses 7.77 88 1.880
Technicians 6.13 32 1.963 Table VI.
Attendants 3.12 50 2.027 Healthcare workers’
Total 6.56 273 2.704 mean knowledge scores

socio-epidemiological parameters and HCW knowledge, attitude and practice, and the
various factors associated with NSI.
Our response rate was 100 percent. More doctors (58.3 percent) were exposed to NSI
compared to 36.4 percent nurses. This is consistent with Jensen and Thomsen’s (1994)
IJHCQA findings who reported that 77.6 percent of doctors had a blood exposure accident
26,6 followed by 66.7 percent nurses. Other studies however report that nurses were the
most exposed healthcare personnel (Shanks and Al-Kalai, 1995). The doctors’ high
NSI-rate in our study can be explained by doctors having frequent contact with
patients while drawing blood samples, inserting IV lines and performing surgical
procedures. Attendant staff, especially bio-medical waste handlers, reported high NSI
554 rates (93 percent). This could be attributed to their occupational hazard awareness
levels and improper practices during waste disposal like non-segregation of waste at
the waste generation site (Albertoni et al., 1992). Technicians (25 percent) reported low
exposure to blood and blood products since they are careful and most wear protective
clothing while handling infective material in the laboratories. Hence they are protected
from direct contact with infectious substances.

Qualification Mean n Standard deviation

Doctors 7.96 103 1.283

Nurses 8.45 88 1.477
Table VII. Technicians 7.75 32 1.741
Healthcare workers’ Attendants 6.60 50 1.355
mean attitude scores Total 7.85 273 1.550

Qualification Mean n Standard deviation

Doctors 7.84 103 2.109

Nurses 8.45 88 1.787
Table VIII. Technicians 8.75 32 1.414
Healthcare workers’ Attendants 6.76 50 1.975
mean practice scores Total 7.95 273 2.010

Knowledge Attitude Practice

Educational qualifications n SD n SD n SD

, 10th class 2.18 2.089 6.00 2.000 6.73 1.384

10th class 3.7 2.643 6.96 1.605 6.3 2.267
Table IX. 12th class 6.75 2.513 8.05 1.713 8.23 1.591
Mean NSI scores Graduation 6.61 2.375 7.95 1.249 8.95 1.546
according to respondents’ Post-graduation 8.15 0.804 8.12 1.297 7.16 2.178
educational qualifications Total 6.56 2.704 7.85 1.550 7.95 2.010

Table X. Knowledge Attitude Mean practice

Correlation between Exposure n SD n SD n SD
HCWs mean knowledge,
attitude and practice Yes 7.04 2.454 8.00 1.766 7.34 2.180
scores and NSI exposure No 6.19 2.836 7.73 1.354 8.42 1.737
Doctors and nurses scored better than technical and attendant staff possibly because NSI KAP among
knowledge is in their academic curriculum and hence they are well aware of all hospital healthcare
infection control practices and procedures. The HCWs answered most NSI knowledge
questions correctly. There was significant knowledge deficiency regarding where NSIs workers
should be reported. Most HCWs were also less aware about HIV and HBV infectivity,
although doctors’ awareness was much better compared to other HCWs. Stein et al. (2003)
measured Birmingham Teaching Hospital doctors and nurses’ knowledge and attitude 555
towards and compliance with universal precautions. Overall knowledge of blood-borne
viral transmission from an infected person after NSI was low. These deficiencies can be
easily rectified by continuous medical education programs, banners and signboards in the
OPDs, wards, blood banks, biomedical waste department and other high risk areas.
Doctors and nurses performed significantly better than technicians and attendants
regarding attitudes. The doctors’ and nurses’ mean attitude scores were significantly
higher (7:96 ^ 1:283, 8:45 ^ 1:477 respectively) compared to technicians (6:13 ^ 1:963)
and attendants (6:60 ^ 1:355). Acceptable responses were obtained in most attitude
questions. However, about 37 percent of doctors, 19 percent nurses, 31 percent
technicians and 58 percent attendants believed that there is no harm in re-capping or
bending the needles after use even though re-capping needles is prohibited by the
Occupational Safety and Health Administration (OSHA) blood-borne pathogen standard.
Between 10-30 percent of NSIs occur while recapping used needles (Ruben et al., 1983;
OSHA, 1991; Janhan, 2005; McCormick and Maki, 1981; McCormick et al., 1991;
Krasinski et al., 1987; Yassi and McGill, 1991). Alam (2002) showed that 29 percent of
HCWs were unaware that needles should not be bent or re-capped after use. Another
question regarding protection that gloves provide against NSI, generated less acceptable
responses. Mast et al.(1993) suggest that healthcare workers were frequently unaware
that gloves may reduce blood contamination via NSI from the source to the recipient.
Regarding practice, technical and nursing staff scored highly (mean scores were 8:75 ^
1:414 and 8:45 ^ 1:787 respectively); while both doctors and attendant staff reported less
compliance to NSI prevention practices (mean scores were 7:84 ^ 2:109 and 6:76 ^ 1:975
respectively). Nursing and technical staff strictly adhere to most NSI guidelines and follow
all aseptic precautions as seen in practice assessment scores. They are also usually
monitored by the physician-in-charge, who emphasizes all infection control techniques.
About 31 percent of doctors, 27 percent nurses, 40 percent attendants and only 6 percent
technicians fail to report NSI incidents, which can be attributed to lacking knowledge
about the department where NSIs are reported and partly to HCW complacency.
Differences in adherence levels to infection control guidelines among HCWs has also been
reported (Ghabrah et al., 2007; Afif et al., 2002; Boyce and Pittet, 2002; Pettit et al., 2000). In
our study, knowledge and attitude scores increase with the respondents’ qualifications.
This is expected as education imparts awareness about the significance of NSI prevention
measures and the hazards related to blood and blood product exposure. Graduates have
higher practice scores compared to postgraduates because postgraduates are not following
the basic safety precautions despite understanding preventive measures.
Exposure to NSI does not correlate with HCW knowledge and attitudes. Ironically,
most HCWs experiencing NSI have higher knowledge and attitude scores. Those
having high practice scores; i.e. those following the NSI prevention measures properly
have lower exposure rates. Possessing NSI knowledge and its prevention practices is
not sufficient; rather putting this knowledge into practice is what makes the difference.
IJHCQA This is a cross-sectional study, which analyses all the past blood exposure incidences
26,6 and not total blood exposure accidents in a defined period. Hence, the NSI incidence
could not be documented. Incidence is an important indicator for infection control and
personnel safety monitoring.

556 Conclusions and recommendations

The old dictum, “prevention is better than cure” is true for NSI-related diseases. The
most effective way to protect workers from infectious diseases transmitted by NSI is a
comprehensive prevention program; including employee training, following
recommended infection control practice guidelines, effective disposal systems,
surveillance programs, improved equipment design and encouraging accident
reporting. We should have a staff health service facility in place, which maintains
records, registers NSI incidence and has protocols for managing and following-up NSI
cases. This is most important in all large healthcare facilities with a high
patient-turnover and NSI rates. Our study revealed important information regarding
HCW knowledge, attitude and practice concerning NSI. This information is helpful to
health sector planners and administrator who design strategies to improve healthcare
safety standards. Our study helps to identify work environment deficiencies. We feel
that studies and strategies to rectify the deficiencies should be designed and put to
practice at six-monthly intervals to support managerial interventions.

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Appendix

Figure A1.
Questionnaire used to
assess needle-stick injury
knowledge, attitude and
practice

Corresponding author:
Dr Aradhana Bhargava can be contacted at: bhargavaaradhana@yahoo.com

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