Prevalence and risk factors of sharp/needlestick injuries among clinical students in a tertiary hospital in eastern Uganda

Abstract

Background

Clinical students, like healthcare workers, are at risk of sharp or needlestick injuries and potential percutaneous exposure to blood and body fluids. They can acquire infections such as HIV and hepatitis B virus (HBV) through these injuries. This study determined the prevalence and factors associated with sharp injuries among clinical students at Mbale Regional Referral Hospital.

Methods

A cross-sectional study was carried out at Mbale Regional Referral Hospital among randomly selected clinical students. Data was entered in Microsoft Excel, cleaned, and exported to STATA version 14 for analysis.

Results

One hundred sixty (55.2%) clinical students had sustained a sharp injury in their clinical practice, with a self-reported prevalence of 46.6% in the last year. A significant proportion of these students, 93 (68.9%), experienced multiple sharp injuries. The common cause and site of injury were solid needles (72; 45%) and fingers (83.1%), respectively. Most students, 197 (67.9%), reported ward procedures not being supervised, and 124 (42%) students worked on ≥ 15 patients daily. Students who worked on ≥15 patients were more likely to sustain a sharp injury than those who attended to <15 patients daily (P = .000, OR: 6.3, 95% CI: 3.7%–10.8%).

Conclusion

This study showed a high prevalence of needlestick injuries among clinical students. The risk factors were the year of study, having not learned about infection control, and the number of patients attended to daily.

Keywords

clinical students needlestick injuries prevalence of sharp injuries infection control

Background

Globally, 3 million sharp injuries are estimated to occur annually among health workers in a medical setting (Alfulayw et al., 2021). Health workers are often at risk of sharp and needlestick injuries and potential percutaneous exposure to blood and other body fluids (Yazie et al., 2019). These injuries occur due to unsafe handling of sharps and needles during surgical operations, suturing, intravenous cannula insertion, intramuscular injections, blood sample collection, and disposal of the sharps and needles (Garus-Pakowska and Górajski, 2019).

Early and recent studies show that sharp and needlestick injuries may lead to the transmission of serious chronic infections like human immunodeficiency virus (HIV), hepatitis B virus (HBV), and hepatitis C virus (HCV) (Alhaj et al., 2019; Auta et al., 2017). The World Health Organization (WHO) estimated that over 40% of HIV and HCV cases in health workers resulted from sharp and needlestick injuries in 2002 (WHO, 2002). Over 90% of the infections resulting from sharp and needlestick injuries occur in developing countries due to resource-limited working conditions, lack of safety-engineered equipment, high prevalence of infectious diseases, and inadequate staffing of the health facilities (Gabr et al., 2018).

Due to inadequate staffing, clinical students who desire to learn new procedures are actively involved in medical procedures (Manyisa and van Aswegen, 2017). In their determination to learn new procedures, clinical students are likely to be at a higher risk for sharp and needlestick injuries (Nawafleh et al., 2019). Studies conducted in Nigeria among medical students and Haramaya University in Eastern Ethiopia among midwifery and nursing students reported high prevalence of sharp and needlestick injuries of 48% and 62.8%, respectively (Okoh and Saheeb, 2017; Yeshitila et al., 2015). It is also suggested that other factors like underdeveloped manual skills, limited clinical experience, and less knowledge on infection prevention and control may also lead to increased occurrence of sharp and needlestick injuries among clinical students (Nawafleh et al., 2019; Yeshitila et al., 2015). A study performed in Mexico among medical students and interns revealed a high prevalence of 58.2% sharp injuries, with students who are not trained on infection control and prevention twice more likely to sustain needlestick injuries than the trained ones (Garcia and Radon, 2017; Garus-Pakowska and Górajski, 2019).

In Uganda, where healthcare resources are limited, the prevalence of sharp and needlestick injuries among clinical students has also been reported as high. A few studies conducted in Uganda have shown the prevalence of needlestick injuries among clinical students ranging from 25% to 55%, with more than 50% of the cases stemming from potentially infectious sources (Hulme, 2009; Newsom and Kiwanuka, 2002). Moreover, studies indicate that blood-borne infections such as HBV, HCV, and HIV are transmitted through these injuries; for example, 11% of medical students at Makerere University in Kampala were infected with the hepatitis B virus through accidental sharp/needlestick injuries in 2005 (Pido and Kagimu, 2005). In the last 10 years, more training institutions for nurses and doctors have opened in Uganda. However, the prevalence of sharp and needlestick injuries among students in these institutions is not known. Busitema University Faculty of Health Sciences, Islamic University in Uganda, and Mbale School of Clinical Officers train doctors, nurses, anesthetists, and clinical officers at MRRH. The extent of sharp and needlestick injuries among the students training at this hospital is not known. Thus, this study aimed to determine the prevalence and factors associated with sharp and needlestick injuries among clinical students at Mbale Regional Referral Hospital.

Materials and methods

Study design

A cross-sectional study to identify risk factors for sharps/needlestick injuries was carried out for a period of 1 month from September to October 2020.

Study area

The study was carried out at Mbale Regional Referral Hospital, a teaching hospital located along Pallisa Road, Mbale City, eastern Uganda. Medical institutions training students at MRRH included Busitema University Faculty of Health Sciences, Islamic University in Uganda, Mbale College of Health Sciences, and Mbale School of Nursing and Midwifery. These institutions are located in Mbale city. Mbale city is located in the Eastern part of Uganda, lying between latitudes 1.08 and longitudes 34.175, covering an estimated area of 2,467 km².

Study population

The study population was clinical students rotating at Mbale Regional Referral Hospital. Clinical students are medical doctor, clinical officer, nursing, and midwifery students who were in their practicum training/rotations at the hospital. These were from Busitema University, Islamic University of Uganda, Mbale College of Health Sciences, and Mbale School of Nursing and midwifery.

Sampling technique

For hard copy questionnaires, simple random sampling was used, where participants were chosen by assigning numbers from 1 to 30 until the sample size was reached. In contrast, convenient sampling was used for electronic questionnaires, where the questionnaire link was sent to students. This was because data collection began during the COVID-19 pandemic, and all teaching institutions in Uganda were under quarantine as a measure to prevent the spread of the disease; thus, the researcher could conveniently access students through their emails and social media accounts obtained from the university registry.

Sample selection

Inclusion criteria

Clinical students rotating at Mbale Regional Referral Hospital who have consented to participate in the study were included.

Exclusion criteria

Clinical students who were rotating at MRRH for their first time placement were excluded.

Data collection tool

The structured questionnaire, both printed and electronic, was used to collect data. The questionnaire was pretested with 10 intern students at MRRH. The electronic questionnaire was sent through the students’ social media platforms, such as WhatsApp contacts, email addresses, and phone SMS inboxes obtained from the school registry. The electronic tool included a consent form, and only those who agreed to participate were redirected to the questionnaire. When universities and schools reopened for finalist clinical students on September 28, 2020, a set of printed questionnaires was administered to students who were in clinical practicum at MRRH and had not participated in the online survey. Informed consent was obtained before the administration of the questionnaire.

We used 18 items to measure respondents’ knowledge level regarding infections transmitted through, post-exposure management, and prevention of sharp/needlestick injuries by using true and false options. We selected 11 items to measure perception about sharp, infections transmitted, control, and prevention. We used five Likert scales (Strongly Disagree, Disagree, Uncertain, Agree, and Strongly Agree) to measure the level of agreement on each selected item which was later condensed to Agree, Uncertain, and Disagree.

Data management

Each questionnaire was assigned a code for identification. Completed questionnaires were downloaded, stored on a password-protected computer, and accessed for processing by the researchers only. The hard copy of the filled questionnaires was combined with the downloaded data set and cleaned. All collected data were double-checked for errors, cleaned, input into a Microsoft Excel spreadsheet, and exported to STATA version 14 for analysis. Coding involved assigning numbers to specific responses from the participants to facilitate the analysis. All files were password protected, and the password was accessible only to the researcher. Data were collected on demographics, occurrences, factors, knowledge, and perceptions of sharp/needlestick injuries.

Data analysis and presentation

Data were analyzed using STATA version 14, summarized into percentages, frequencies, medians, means, and standard deviations where appropriate, and then presented in tables and figures, like pie charts and histograms. Categorical data, such as sex, course, year of study, procedure type, injuring previous object experience, sharp/needlestick injuries, and work shift, were expressed in percentages and frequencies, while continuous variables like age, number of patients (injections), and number of injuries were categorized. The prevalence, knowledge, and perception of sharp injuries were determined by univariate analysis, while associated factors were determined by bivariate and multivariate logistic regression.

Results

Socio-demographic characteristics of respondents

Of the 322 students, 290 adult clinical students participated in the study, resulting in a response rate of 90%. The majority of the participants (45.2%) were from Busitema University, and 49.7% pursued a medicine course. Other participants were pursuing nursing, midwifery, or anesthesia courses. A majority (65.9%) of the participants were in the final year of study. The minimum and maximum age of participants was 19 and 43 years, respectively, and the mean age was 25.5 with a standard deviation of 4.7. A big proportion (67%) of the participants were below 25 years of age. A majority of students (51.4%) were female compared to (48.6%) male. About three-quarters (79%) of clinical students had been vaccinated against hepatitis B virus (Table 1).

Table 1.

Socio-demographic characteristics of clinical students.

Variables	Category	Freq	Percentage
Age	25 years and below	194	67
	26–30 years	55	19
	Above 30 years	41	14.1
Gender	Male	141	48.6
Gender	Female	149	51.4
School	Busitema University	131	45.2
	Islamic University in Uganda	76	26.2
	Mbale College of Health Sciences	47	16.21
	Mbale School of Nursing/Midwifery	36	12.4
Course	Medicine	144	49.7
	Nursing	139	47.9
	Anesthesia	7	2.4
Year category	Finalist	191	65.9
Year category	Semi-finalist	99	34.1
Hepatitis B vaccination	Vaccinated	61	21
Hepatitis B vaccination	Not vaccinated	229	79

Prevalence of needlestick injuries

Of the 290 students who participated in the study, 55.2% had ever sustained a sharp/needlestick injury in their entire clinical practice while 46.6% reported experiencing a sharp injury in the previous year of practice. The most common injury site was the finger (83.1%), followed by the hand (16.9%). The most common cause of injury was solid sharp/needles (72; 45%), followed by hollow needles. Injuries were sustained on all wards, with most occurring in the emergency/casualty ward (48; 30%) and surgical ward (35; 21.9%). Regarding circumstances contributing to needlestick injuries, the majority, 55 (34.4%), students reported rushing while conducting the procedure, while 40 (25%) reported the patient being uncooperative, as shown in Figure 1. The majority of clinical students, 45 (28.1%), sustained a sharp injury while performing drug administration by injections, followed by suturing (35; 21.9%) (Figure 2). Most injured students (30%) were rotating in the emergency/casualty and surgery wards (21.9%). Students were asked about the actions they took after sustaining a needlestick injury, and only 54 (47%) students reported having done all three recommended measures (Table 2).

Table 2.

Information regarding injuries.

Variable	Category	Frequency (n = 160)	Percentage (%)
Injury	In clinical practice	160 of 290	55.2
Injury	In the last 1 year	135 of 290	46.6
Type	Solid	72	45
	Hollow	58	36.3
	Ampoule/vial	30	18.8
Site of injury	Finger	133	83.1
Site of injury	Hand	27	16.9
Cause of injury	Self-inflicted	139	86.9
Cause of injury	Injured by someone else	21	13.1
Ward rotation	Emergency/casualty	48	30
	Pediatric	32	20
	Surgery	35	21.9
	Obstetrics and gynecology	28	17.5
	Medicine	17	10.6
Glove intact	Yes	146	8.8
Glove intact	No	14	91.2
Post-exposure action	Yes	115	71.9
Post-exposure action	No	45	28.1
Actions taken	Flashed under running water	31	27
	Test patient’s HIV/HBV status	19	16.5
	Report injury to the in-charge	7	6.1
	All the above	54	47
	None of the above	4	3.5

Factors associated with sharp/needlestick injuries

In bivariate logistic regression analysis, school, course, year category, hepatitis B vaccination, ward procedure supervision, number of patients worked on daily, and learning about sharp and infection control were significantly associated with NSI with P < .05 at a 95% confidence interval. Only significant variables (P < .05) were entered for multivariate analysis. By adjusting for potential confounders in multivariate logistic regression analysis, the only year of study, hepatitis B vaccination, the average number of patients attended to daily, and having learned about sharp and infection control were significantly associated with sharp injuries. However, participants’ school, course, and ward procedure supervision were not significantly associated with sharp injuries in multivariate analysis.

Finalist clinical students were three times more likely to sustain a sharp injury than semi-finalist clinical students (P = .000, OR: 3.1, 95% CI: 1.7–5.5). Students who had not learned about sharp and infection control were two times more likely to sustain sharp/needlestick injury than those who had learned about sharp/infection control (P = .012, OR: 2, 95% CI: 1.2–4). Students who attended to about 15 patients or above every day were six times more likely to sustain a sharp injury than those who attended to fewer than 15 patients (P = .000, OR: 6.3, 95% CI: 3.7%–10.8%). Unvaccinated clinical students were 2.7 times more likely to sustain a sharp injury than those who were vaccinated (P = .015, OR: 2.7, 95% CI: 1.2–6) (Table 3).

Table 3.

Factors associated with sharp/needlestick injuries.

Variables	Category	Not injured n (%)	Injured n (%)	COR (95% CI)*	AOR (95% CI)**	P-value
School	Busitema University	68 (52.3)	63 (39.4)	1	1
	Islamic University in Uganda	32 (24.6)	44 (27.5)	1.5 (0.8–2.6)	0.8 (0.3–2)	0.662
	Mbale College of Health sciences	23 (17.7)	24 (15)	1.1 (0.5–2.2)	0.7 (0.3–1,6)	0.457
	Mbale Nursing School	7 (5.4)	29 (18.1)	4.5 (1.8–11)	1.3 (0.3–4.8)	0.711
Course	Medicine	76 (58.5)	68 (42.5)	1	1
	Nursing	51 (39.2)	88 (55)	1.9 (1.2–3.1)	1 (0.4–2.5)	0.947
	Anesthesia	3 (2.3)	4 (2.5)	1.5 (0.3–6.9)	3.9 (0.7–22.5)	0.125
Year category	Finalist	67 (51.5)	124 (77.5)	3.2 (2–5.4)	3.4 (1.9–6.3)	0.000
Year category	Semi-finalist	63 (48.5)	36 (22.5)	1	1
Hepatitis B vaccination	Not vaccinated	12 (9.2)	49 (30.6)	4 (2.2–8.6)	2.7 (1.2–6.2)	0.016
Hepatitis B vaccination	Vaccinated	118 (90.8)	111 (69.4)	1	1
Ward procedure supervision	Not supervised	74 (56.9)	123 (76.9)	2.6 (1.5–4.2)	1.6 (0.9–28)	0.127
Ward procedure supervision	Supervised	56 (43.1)	37 (23.1)	1	1
No. Of patients	Below 15 patients	104 (80)	62 (38.7)	1	1
No. Of patients	15 and above	26 (20)	98 (61.3)	6.3 (3.7–11)	5.2 (2.7–9.6)	0.000
Learned about infection control	Learnt	111 (85.4)	104 (65)	1	1
Learned about infection control	Not learnt	19 (14.6)	56 (35)	3.1 (1.8–5.6)	2 (1.2–4)	0.012

n= frequency %= percentage.

Knowledge concerning needlestick injury

Regarding blood-borne pathogens, only 67.2% knew that hepatitis A could not be transmitted through needlestick injury, 89.1% knew that hepatitis B could be transmitted through needlestick injury, and 98.6% knew that HIV could be transmitted through needlestick injury.

While handling sharp, 283 (97.6%) reported that safe collection and disposal of sharp can reduce the risk of injury. Two hundred thirty three (80.3%) students agreed that safety boxes should be emptied before they are extremely full. Two hundred fifty-five (87.9%) students reported that needle recapping could cause sharp injury; however, only 212 (73.1%) answered correctly if it was necessary to recap used sharp/needles.

In regards to preventing these injuries, 149 (51.4%) students agreed that wearing personal protective equipment like gloves for all patient care contacts is a useful strategy for reducing the risk of sharp injuries and, in turn, reducing transmission of infectious disease organisms. More so, 235 (81%) stated that safety management policies could prevent sharp injuries.

Regarding hepatitis B vaccination, the majority had knowledge regarding hepatitis B vaccination, that is, 44 (84.1%) of the students correctly answered whether the pre-vaccination test was not necessary and 208 (71.7%) knew that schedule 0, 1, 6 was used. However, only 36.6% students believed that post-vaccination test was necessary in relation to hepatitis B immunization. Only 53.8 % of the students knew that hepatitis C infection could not be prevented by vaccination (Table 4).

Table 4.

Knowledge concerning needlestick injuries (the correct responses).

Variable	Category	n (%)
Disease transmitted through sharp injuries	Hepatitis A	195 (67.2)
	Hepatitis B	259 (89.1)
	HIV	286 (98.6)
Vaccination can prevent hepatitis C		156 (53.8)
We haven’t learned about standard precautions for sharp and infection control		96 (33.1)
Handling sharp after use	Used sharp disposed of in regular trash cause injury	251 (86.6)
	It is necessary to recap the used sharp/needles	212 (73.1)
	Safety boxes should be emptied prior to fullness	233 (80.3)
	Needle recapping can cause a needlestick injury	255 (87.9)
	Safe collection and disposal of sharp can reduce the risk of injury	283 (97.6)
Prevention of sharp injuries	Wearing personal protectives like gloves can prevent sharp injury	149 (51.4)
Prevention of sharp injuries	Hospital safety management policies can prevent sharp injury	235 (81)
Hepatitis B vaccination	Pre-vaccination test is not necessary	244 (84.1)
	Schedule 0,1,6 is used	208 (71.7)
	Post-vaccination test is necessary	106 (36.6)
Post-exposure prophylaxis	Flash the part under running water and put pressure	221 (76.2)
	Maintain confidentiality on injury	185 (63.8)
	Test the blood of the patient for HIV and HBV	284 (97.9)
	Post-exposure prophylaxis can be taken if the patient is negative	219 (75.5)

n= frequency %= percentage.

On post-exposure prophylaxis measures, 221 (76.2%) students reported flashing the part under running water and applying pressure to arrest bleeding as post-exposure action, while 105 (36.2%) agreed that after sustaining a sharp injury, they needed to report the injury to the ward in charge. About 71 (24.5%) clinical students agreed that post-exposure prophylaxis drugs could be taken even if the source patient was negative, while 284 (97.9%) students believed to test the blood of the patient should be tested for HIV and HBV (Table 3). However, among the students who sustained a sharp injury, only 16.5% tested the patients’ HIV/HBV status, 27% flushed the injured part under running water, 6.1% reported the injury to the in-charge, and only 54% did all the recommended measures.

Perception of clinical students towards sharp/needlestick injury

Clinical students agree to the statement “Every health professional student has a chance to get a sharp/needlestick injury” 267 (92.1%). Two hundred fifty-seven (88.6%) also agree that “increased workload can lead to sharp/needlestick injury,” though 238 (82.1 %) clinical students disagree that “If healthcare workers get infected with HIV infection, they should resign from their profession.”

Two hundred seventy-one, 271 (93.4%) clinical students agreed that “The standard precautions to handle sharp objects must always be followed as improper handling can lead to getting the infection,” and 237 (81.7%) believed that “The infections transmitted from sharp/needlestick injuries are life-threatening.” Regarding this statement, “We haven’t learned about standard precautions for sharp/needlestick injuries,” only 25.9% agreed; however, 90.4% believed that “Confidence and skillfulness can prevent needlestick injury, although there is a risk of infection.”

Most of the students (82.1%) agree that “Unavailability of protective equipment can predispose a person to get sharp/needlestick injuries,” and 231(79.7%) believed that “Handling sharp/needles without wearing gloves is better than wearing gloves.” However, 234(80.7) students disagreed that “Reporting after a sharp/needlestick injury is not useful.”

More than three-quarter, (96.6%) of students stated that “Every health professional student should be immunized against hepatitis B infection.” Two hundred sixty-two (90.3%) students believed that “Health education for universal precaution on needlestick injuries to clinical students can reduce the prevalence of sharp/needlestick injuries among them” (Table 5).

Table 5.

Perception responses about susceptibility to sharp injuries.

Perception	SA/A n (%)	U n (%)	D/SD n (%)
Every health professional student has a chance to get sharp/needlestick injury	267 (92.1)	7 (2.4)	16 (5.5)
Increased workload can lead to sharp/needlestick injury	257 (88.6)	17 (5.9)	16 (5.5)
If healthcare workers get infected with HIV infection, they should resign from their profession	17 (5.8)	35 (12.1)	238 (82.1)
The standard precautions to handle sharp objects must always be followed as improper handling can lead to getting the infection	271 (93.4)	6 (2.1)	13 (4.5)
The infections transmitted from sharp/needlestick injuries are life-threatening	237 (81.7)	7 (2.4)	46 (15.9)
Although there is a risk of infection, confidence and skilfulness can prevent needlestick injury	262 (90.4)	12 (4.1)	16 (5.5)
Unavailability of protective equipment can predispose a person to getting sharp/needlestick injuries	238 (82.1)	15 (5.2)	37 (12.7)
Handling sharp/needles without wearing gloves is better than wearing gloves	34 (11.7)	25 (8.6)	231 (79.7)
Reporting after a sharp/needlestick injury is not much useful	51 (17.6)	5 (1.7)	234 (80.7)
Every health professional student should be immunized with the hepatitis B vaccine	280 (96.6)	3 (1)	7 (2.4)
Health education for universal precaution on needlestick injuries to clinical students can reduce the prevalence of sharp/needlestick injuries among them	262 (90.3)	7 (2.4)	21 (7.3)

SA (Strongly agree), A (Agree), U (uncertain), A (Agree), SD (Strongly disagree).

Discussion

Healthcare worker trainees in pursuing their profession, especially nurses, medical, and anesthesia students, face stressful clinical events, placing them at an increased risk of needlestick injury.

Prevalence of sharp/needlestick injuries

Our study found that 160 (55.2 %) clinical students had sustained sharp/needlestick injuries in their clinical practice. These findings agree with studies carried out among Nursing and Midwifery Students at Haramaya and Jigjiga University in eastern Ethiopia and among nursing students in Nanjing, China, that reported a high prevalence of sharp/needlestick injury of 64.8% and 60.3%, respectively (Zhang et al., 2018). However, our study findings were contrary to the study conducted in Bangalore, India, where only 25% of students experienced a sharp/needlestick injury (Vijay et al., 2017). Our study finding is higher than that reported from a study conducted among nursing students in Uganda, where a low prevalence of 25% was reported (Hulme, 2009). The difference could be a result of a big sample size used in our study compared to the one used in Hulme, 2009. The high prevalence of sharp injuries could be attributed to limited experience in procedures carried out a factor identified to be associated with sharp injuries (Garcia and Radon, 2017). Also, it is possible because of inadequate ward procedure supervision and many patients attended per day.

Findings from our study reveal a high 1-year self-reported prevalence of sharp/needlestick injury of 135 (46.6.4%). This finding is compared with a report from India, where 36.5% of students had a sharp injury in the last 1 year (Vijay et al., 2017). However, our study finding is lower than a cross-sectional study carried out in Ethiopia, where students experienced a sharp/needlestick injury in the last 1 year (62.8%) (Yeshitila et al., 2015). The high prevalence from our study could be due to poor techniques and skills in the procedure performed and non-adherence to standard precautions, a factor which has been reported to be associated with the occurrence of needlestick injuries (Hulme, 2009). Other reasons for this could be work overload, recapping of needles, and lack of personal protective equipment. However, a lower 1-year self-prevalence of 11% and 13.9% has been reported in studies conducted in the UK and Australia, respectively (Smith and Leggat, 2005). This low 1-year self-reported prevalence could be attributed to the presence of adequate personal protective equipment like gloves, safe needle handling practices, and safe and proper waste disposal in the UK and Australia, compared to developing countries like Uganda.

Factors associated with sharp/needlestick injuries

According to this study, 75 (25.9%) clinical students had not learned about infection control, among whom 74.7% sustained a sharp/needlestick injury. Students who had not learned about sharp and infection control were two times more likely to sustain sharp/needlestick injury than those who had learned (P = .012, OR: 2, 95% CI: 1.2–4). Similar findings were reported in a study conducted in Ethiopia, where nursing students who had learned about infection prevention were 0.44 times less likely to sustain a sharp injury than those who did not learn (Yeshitila et al., 2015). Studies conducted in Mexico and China also report that students not trained on sharp and infection control were twice likely to sustain a sharp injury compared to those that were trained (P = .04 OR: 3.21, 95% CI: 1.44–7.17) and (OR: 2.1, 95% CI: 1.4–3.2), respectively (Garcia and Radon, 2017; Zhang et al., 2018). Students, while in their clinical training, are in a daily encounter with sharp and infections thus, students need to be trained on handling sharp and infection control before and during their ward training.

Another important factor was the year of study. Most of the sharp injuries occurred in finalist clinical students (124; 77.5%) compared to semi-finalists (36; 25.2%). Finalist clinical students were three times more likely to sustain sharp/needlestick injuries than semi-finalists (P = 0.000, OR: 3.1 95% CI: 1.7–5.5). Similar findings were reported in a study conducted among dental undergraduate students at Ajman University of Science and Technology in the United Arab Emirates, where 66% of injuries occurred among final-year students (Jaber, 2011). Moreover, Derek R. Smith and Leggat, 2005 reported that needlestick injuries were most likely to happen in third (final) year nursing students compared to second- and first-year counterparts. This might be because practical clinical experience culminates in the final year of study, and these students are gradually exposed to more needles and sharp activities as their competency improves and their clinical skills develop. This study thus suggests that there is a need for continued emphasis on sharp and infection control during students’ hospital practicum. However, being in the final year showed no significant association with needlestick injuries in a study conducted in Ethiopia (P = .833, 95% CI: 0.4–3.6) (Yeshitila et al., 2015). This disparity could be due to the different training conditions students are subject to in these different countries.

In this study, the prevalence of sharp/needlestick injuries among students who worked on 15 patients and above was six times greater than those who worked on fewer than 15 patients (P = .000, OR: 6.3 95% CI: 3.7%–10.8%). However, this is contrary to a study conducted among Ugandan health workers where a high rate of sharp injuries was found in health workers attending to less than 35 patients per day compared to those attending to more than 35 patients (Nsubuga and Jaakkola, 2005). This is possible because students are not experienced in handling many patients daily compared to already qualified health workers. More so, 35 is still a high number of patients compared to 15 patients and above. However, it is possible in our study that those who worked on above 15 patients were at a high risk of sharp injuries due to the invasive procedures they carried out. A study conducted among Chinese nursing students revealed that the night shift was a risk factor for sharp injuries. Nursing students who reported three or more night shifts per week were nearly six times more likely to experience sharp/needlestick injuries than those who did not work night shifts. This may be explained by a lack of sleep, resulting in inattention and less ability to concentrate when these students are providing treatments (Aluko et al., 2016). Poor quality sleep has been cited as a contributing factor of sharp injuries among nursing students (Zhang et al., 2018). Work overload resulting from working on many patients per day can also lead to the inability to concentrate and be attentive during procedures, thus likely to sustain a sharp injury. Our study, therefore, suggests that reduced workload may reduce the likelihood of sharp injuries.

Seventy-nine percent of students were completely vaccinated against hepatitis B infection. These findings are high compared to a similar study conducted in Pakistan where almost two-thirds of health workers were not completely vaccinated against hepatitis B infection (Afridi et al., 2013). This may be reflected due to poor accessibility, affordability, and prioritization between these countries’ health systems. Although the majority of students were vaccinated in this study, students who were not/partially vaccinated against hepatitis B were almost three times at a greater risk of experiencing a sharp injury than those who were not vaccinated (P = .016, OR 4:, 95% CI: 1.2–6.2). Most unvaccinated students don’t know the dangers of sustaining needlestick injury and diseases transmitted, and thus are careless while handling sharp and, in turn, experience a needle prick injury. Thus, this study suggests that students should be immunized against hepatitis B infection before enrolling for their clinical training.

Knowledge of sharp and needlestick injuries

The majority of clinical students could correctly identify diseases transmitted through sharp/needlestick injuries; 259 (89.1%) and 286 (98.6%) responded correctly that hepatitis B and HIV could be spread via sharp injuries, respectively. However, 67.2% of students could not recognize that hepatitis A is not transmitted through sharp injuries. This was also seen in a study performed among health workers in Nigeria, where 86.2% of students were knowledgeable about infections transmitted through occupational exposures (Aluko et al., 2016). This could be explained that students had not learnt or been trained on sharp/infection control, which is a factor shown to be associated with sharp injuries.

While handling sharp objects, 87.9% of students in this study were aware that needle recapping can cause sharp/needlestick injuries, and 73.1% of participants knew that it was not necessary to recap sharp/needles. Recapping needles prior to disposal has been shown to increase the risk of experiencing a needlestick injury (Zhang et al., 2018). Similarly, 81.1 % and 70 % of students knew that used needles should never be recapped is contrary to the standard precautionary guidelines, which predispose students to sharp injuries (Aluko et al., 2016).

Regarding the prevention of sharp injuries, 51.4% agreed that wearing gloves can prevent sharp injury. This was also shown in a study conducted in Nigeria where 98.6 % of health workers reported that wearing gloves while handling sharp could reduce the risk of sharp injury (Aluko et al., 2016). This study found that 81% of students knew that hospital safety management policies could prevent sharp injury. However, this was different in a study performed among medical students where only 42% of students knew and were familiar with hospital management policies.

Our study revealed that 84.1% of students knew that pre-hepatitis B vaccination test was necessary and 71.7% also knew that schedule 0, 1, 6 was used. However, 65.4% of students did not know that post-vaccination test was necessary. This could be due to the fact that the post-vaccination test is rarely done in our health systems due to financial constraints, given it is essential, thus students have not seen it being done.

Regarding post-exposure actions taken, most of the students had knowledge on what steps to take after sustaining a sharp injury, except that more than half (36.2%) of clinical students believed that they should maintain confidentiality (don’t report) about the sharp injury. This was also seen in a study carried out among the nursing students in Nanjing, China, where 86.9% of the injured students did not report the injury (Zhang et al., 2018). This is contrary to the infectious disease control guidelines that recommend that we report the injury immediately to a fellow staff member or the ward in charge, be assessed for infection risk, and managed as per WHO guidelines (WHO, 2002). In this study, 28% of the injured students did not take any post-exposure actions. Among those that took post-exposure actions, only 47% followed all the recommended guidelines. This study thus suggests that more emphasis on post-exposure measures is needed.

Perception towards sharp/infection control

In our study, the majority of students agreed that every student has a chance to get injured, which was similar to a study performed in Abdulaziz University for Health Sciences, Saudi Arabia, where 65.1% students disagreed that sharp injuries are the least encountered in clinical practice (Khubrani et al., 2018). Different studies have shown high prevalence and incidences of sharp injuries among health workers and student trainees (Ebrahimi and Khosravi, 2007; Yeshitila et al., 2015).

Findings of this study show that most students had a positive perception towards the use of personal protective equipment, for example, 82.1% of students agreed that the unavailability of personal protective equipment can predispose a person to getting a sharp injury. About 79.7% of the students disagree that handling sharps without donning gloves is better than wearing gloves. The use of personal protective equipment has been identified as a factor in reducing the risk of a sharp injury (Zhang et al., 2018). However, a study among health workers in Uganda revealed that the perceptions and attitudes towards needlestick injuries did not significantly influence the occurrence of needlestick injuries (Nsubuga and Jaakkola, 2005).

Regarding prevention of sharp, 280 (96.6%) agreed that every clinical student should be immunized against hepatitis B disease as a strategy to prevent infection transmission. Among 290 students in this study, 79 students had been completely immunized against hepatitis B disease (Table 3). More so, 90.3% of students agreed that health education for universal precaution on needlestick injuries to clinical students can reduce the risk of sharp/needlestick injuries. All these are strategies students believe can reduce the likelihood of a sharp injury. In a study conducted among medical trainees, 188 (54%) felt insufficient safety training regarding infection. Awareness, learning, and training about sharp and infection control have reduced risk for needlestick injuries, P = .002 (Garcia and Radon, 2017). However, there was no significant association between this perception and sharp injuries (Ouyang et al., 2017). Our study suggests that there is a need to sensitize students on universal precautions, which might reduce the likelihood of sharp/needlestick injuries.

Study limitations

This study was carried out in one teaching hospital, which limits generalizability to all clinical students in the whole country of Uganda.

The results could have been affected by recall bias as respondents were required to recall past experience. More so, clinical students could have reported only injuries they thought were potentially infectious.

The study was initially affected by the outbreak of Coronavirus disease (COVID-19), where it was challenging to access study participants since all training institutions were instructed to send students home, but we resorted to online data collection until schools were opened for final-year medical students. Nevertheless, this study provides useful information about sharp/needlestick injuries and infection prevention and control.

Conclusion

This study showed a high prevalence of needlestick injuries among clinical students. The associated factors were the year of study, having not learned about infection control, and the number of patients attended to daily. A significant portion of clinical students had not learnt about infection prevention measures. Final year clinical students were more likely to sustain sharp injuries than semi-finalists. Students who worked on ≥15 patients were more likely to sustain a sharp injury than those who attended to <15 patients daily.

Recommendations

This study recommends carrying out awareness campaigns and training students on infection control before and during their deployment in clinical areas, as their health and the future of the health sector depend on them. Additionally, students should attend to ≤15 patients per day to avoid patient overload for students. Teaching institutions and hospitals should conduct regular and close supervision of students while carrying out procedures. Clinical students should be immunized against hepatitis B before they are deployed on wards, as it not only protects them but also sparks a need for them to observe infection prevention measures strictly. Further research is recommended to investigate the effects of sharp/needlestick injuries among clinical students during their training.

Footnotes

Acknowledgment

We acknowledge the administration of Busitema University Nursing Department, the Islamic University in Uganda, Mbale College of Health Sciences, Mbale Nursing and Midwifery School, and other stakeholders who supported and provided us with information pertaining to this research. We appreciate the immense contribution of the management and staff of Mbale Regional Referral Hospital, who allowed us to conduct this study on clinical students. We acknowledge the clinical students from Busitema University, Mbale School of Nursing, Mbale School of Clinical Officers, and the Islamic University in Uganda who participated in this study by filling out the questionnaires.

Author contributions

This work was carried out in collaboration with all authors. NE conceived and designed the study and participated in data collection, analysis, and manuscript writing. DN and RN were research mentors who took part in the study's conception, design, preparation for approval, and proofreading of the final result. LS and JSI contributed to data analysis, manuscript writing, and proofreading of the final manuscript. All authors read and approved the final manuscript version.

Declaration of conflicting interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: Research reported in this publication was supported by the Fogarty International Center of the National Institutes of Health, U.S. Department of State’s Office of the U.S. Global AIDS Coordinator and Health Diplomacy (S/GAC), and President’s Emergency Plan for AIDS Relief (PEPFAR) under Award Number IR25TW011213. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.

Ethical considerations

Ethical approval was obtained from the Mbale Regional Referral Hospital Research Ethics Committee (MRRH-REC) under REC number MMRH-REC OUT 018/2020. Permission to collect data was sought from the administration of MRRH, Busitema University, Islamic University in Uganda, Mbale College of Health Sciences, and Mbale School of Nursing and Midwifery.

Consent to participate

Participants consented and filled out the questionnaires individually to ensure privacy, confidentiality, and anonymity. The electronic questionnaire was designed with a consent form first, and whoever consented could be redirected to participate in the study. The filled electronic questionnaires were downloaded and kept in a protected computer, which was only accessible to the investigator. Participation was voluntary, and participants could withdraw from the study at any time without penalty. There were no risks or monetary benefits to participating in the study. Clinical students who had sharp/needlestick injuries before 72 hours had elapsed were advised to be assessed and given Post-exposure prophylaxis (PEP) as per the hospital and national infectious disease control guidelines.

ORCID iDs

Elisa Ndyamuhakyi

Jacob Stanley Iramiot

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