Knowledge,Attitude,and Practices Regarding Occupational HIV Exposure and Protection among Health Care Workers in China

Abstract

Background:

Health care workers (HCWs) seek, treat, and care for patients living with HIV/AIDS on a daily basis and thus face a significant risk to work-related infections. To assess the knowledge, attitude, and practices regarding occupational HIV exposure and protection among HCWs in low HIV prevalence areas of rural China.

Methods:

A cross-sectional questionnaire survey was carried out among all medical units in Pucheng County, Shaanxi, China.

Results:

Response rate of this study was 94%. The average overall knowledge score of HCWs was 10.9 of 21.0. Deficiencies in general, transmission, exposure, and protection knowledge were identified among HCWs at all levels. A high rate of occupational exposure (85%) and lack of universal precautions practice behavior were recorded. Significant predictors of universal precautions practice behavior were female sex, prior training, and greater knowledge about HIV/AIDS.

Conclusion:

Health care workers at various levels have inadequate knowledge on HIV/AIDS and do not practice universal precautions. Nurses and medical technicians at the county level faced more occupation risk than other HCWs. The key of AIDS training for different levels of HCWs should be distinguished.

Keywords

HIV occupational exposure prevention health care workers

Introduction

By the end of September 30, 2013, a total of 434 000 persons living with HIV/AIDS were reported in China. In 2862 counties of China, 94.6% reported AIDS epidemic. Only in 97 counties in China,¹ the number of persons living with HIV/AIDS was more than 1000. Although China is still considered a low endemic area for HIV, with an overall prevalence of 0.1% among adults, there is a continuous threat for this growing epidemic spreading to general population.^2
–4

Health care workers (HCWs) are exposed to HIV-infected patients on a daily basis. With lack of knowledge on HIV protection and inadequate safety measures, HCWs are at significant risk for work-related infections.^5,6 Not surprisingly, 20 730 HCWs in China were injured by needle sticks, and 30 HCWs might have been infected with HIV in the year 2000 alone.^7
–9 Another study reported that 86% of nurses had been stuck by sharps while working, and 76% had been splashed by blood or fluids in Heilongjiang Province, China.¹⁰

Most reports regarding occupational HIV exposure among HCWs were based on information from the developed nations or high prevalence areas.^6,11
–13 With the HIV epidemic spreading to remote rural areas of China, the risk of HIV exposure among HCWs in those areas is also growing.⁹ Li et al¹⁴ reported that 28% of HCWs in primary hospitals had contact with HIV-positive patients. This group of professionals from rural areas with low prevalence may be overlooked easily, making them highly susceptible to the risk of HIV infection. One such rural county with a relatively low HIV prevalence is Pucheng County, which is located in the east of the Shaanxi province of China. However, the incidence rates have been steadily increasing. Since the first reported HIV-positive patient in 2008, 10 HIV-positive cases have been detected from 2010 to 2011. No studies examining HIV-related knowledge and universal precaution practices for HCWs from this county have been conducted so far.

Hence, this study was aimed at assessing the extent of knowledge, attitude, and practices (KAP) regarding occupational HIV exposure and protection among HCWs in medical institutions of Pucheng County, China.

Materials and Methods

Study Design and Population

A census survey was conducted from October to November 2010 among HCWs at county, township, and village hospitals or clinics in Pucheng County, China. It has 4 county hospitals, 23 township health clinics, and 369 village clinics with a total of 1900 HCWs, including doctors, nurses, technicians, and administration staffs.

Data Collection

The investigation lasted for 30 days. Data collection was carried out by 2 investigation teams each made up of 3 trained investigators. Two of them were completely independent research staffs, one of them came from the various sites. All of the investigators for this census were trained for survey methods, standards, and techniques. They administered questionnaires to participants in the county hospital and township health care centers. The investigation was anonymously carried out. The survey questionnaire was designed based on Regulations on AIDS Prevention and Treatment in China Center for Disease Control and Prevention (CDC) and other studies. Respondents were asked to complete a KAP questionnaire with 5 parts. The first part covered the participants’ characteristics (such as age, gender, occupation, title, unit level, and prior training on HIV/AIDS). The second part surveyed HIV/AIDS-related knowledge including general knowledge (5 items such as details on pathogen, incubation period, methods of disinfection, the class of disease, and how long can HIV be detected after infecting), transmission mode knowledge (9 items such as shaking hands, unprotected sex, having dinner with HIV-positive patients, transfusion of blood or blood products, mosquito bites, sharing seats and books, sharing toothbrushes, coughing and sneezing, and from HIV-infected mother-to-child), and occupational exposure and protection knowledge (7 items such as principles of prevention, universal precautions, providing care for patients living with HIV/AIDS, exposure to urine and sweat, exposure to blood or body fluids, measures taken after occupational exposures, and how long should the measures be taken). A score of 1 for correct answer and 0 for wrong or unknown answer was assigned. The sum of general knowledge score (5), transmission knowledge score (9), and occupational exposure and protection knowledge score (7) yielded an overall knowledge score of 21. The third part covered the HCWs’ attitudes that included fear, discrimination, and willingness to provide service to patients living with HIV/AIDS. The fourth part covered occupational exposure (2 items such as needle stick injury and splashes to the eyes) and universal precaution practice (6 items such as wearing gloves when working, proper disposal of sharps, washing hands after patient contact, not recapping the needles after use, taking protective measures after injury by sharps, and after a blood or fluid splash to the eye). Each participant rated the possibility of exposure and universal precaution practice on a scale from never (0), occasionally (1) to often (2). These scores were added to obtain occupational exposure score and universal precautions practice score. Finally, the last part covered the HCWs’ inclination toward HIV/AIDS training and what they hope to learn from such training, if provided in future.

The questionnaires were self-administered under the supervision of trained interviewers. A pilot study was carried out among 20 HCWs of a surgical section in Pucheng County hospital. Following which, a census was organized and implemented in 3 weeks. This was supported by the Health Bureau of County and CDC in the Pucheng County. Participants’ confidentiality was protected and all the procedures were approved by the Ethics Committee of the Xi’an Jiaotong University. All participants provided written informed consent after the research protocols were carefully explained to them.

Collation and Analysis of Data

In order to ensure the quality of the investigation, exclusion criteria were formulated before the survey. The questionnaire that showed absence for more than 5 options was excluded. The questionnaire with the obvious regularity option was excluded (e. g. all option were chosen 4). The questionnaire was excluded, which came from the same unit, and with same selection results.

The data were analyzed using SPSS (version 18.0; SPSS, Chicago, Illinois). Chi-square analysis tested occupational exposure differences among groups. Mean knowledge scores were calculated, and analysis of variance was compared among groups. Multiple linear regression analysis was used to examine the relationship between the behaviors of the universal precautions score and the characteristics of HCWs, general knowledge score, transmission knowledge score, occupational protection score, and occupational exposure score. A high correlation existed between age and work experience, and unit levels and education, so only age and unit levels were included in the final analysis. Variables significant at P < .05 were retained in the final multivariable model.

Results

Due to business trip, holiday, and refusal, 89 HCWs did not participate. Twenty-eight unqualified questionnaires were excluded. The participation rate of this survey was 94%, and 1783 HCWs completed the questionnaires. The average age of the HCWs was approximately 39 years; HCWs in village clinics were significantly older compared to the county and township hospitals (45 versus 35 years). Overall, there were equal number of male and female HCWs; however, there were a significantly higher proportion of females in the county compared to village clinics (71% versus 26%). More than 72% of HCWs finished secondary specialized or associated degree, but only 23% had received some prior training on HIV/AIDS. Detailed characteristics for these HCWs, stratified by their unit levels, are presented in Table 1.

Table 1.

Characteristics of Health Care Workers by Unit levels.^a

	Total	County	Township	Village	F/χ²	P Value
N	1783 (93.8)	738 (93.1)	383 (97.2)	662 (92.9)	–	–
Age
Mean ± SD, years old	38.5 ± 10.9	34.2 ± 8.2	35.2 ± 9.8	45.1 ± 11.0	249.3	.00
Female	906 (50.8)	523 (70.9)	210 (54.8)	173 (26.1)	282.6	.00
Work experience
Mean ± SD, year	16.0 ± 11.3	11.5 ± 8.5	12.4 ± 9.3	23.1 ± 11.4	272.9	.00
Education					630.9	.00
≤High school	334 (18.7)	39 (5.3)	57 (14.9)	238 (36.0)
Secondary specialized	694 (38.9)	165 (22.4)	175 (45.7)	354 (53.5)
Associate degree	595 (33.4)	390 (52.8)	136 (35.5)	69 (10.4)
≥Bachelors	160 (9.0)	144 (19.5)	15 (3.9)	1 (0.2)
Occupation					575.2	.00
Doctor	996 (55.9)	209 (28.3)	192 (50.1)	595 (89.9)
Nurse	439 (24.6)	325 (44.0)	79 (20.6)	35 (5.3)
Technician	277 (15.5)	161 (21.8)	85 (22.2)	31 (4.7)
Administration staff	71 (4.0)	43 (5.8)	27 (7.0)	1 (0.2)
Prior training on HIV/AIDS	417 (23.4)	212 (28.7)	69 (18.0)	136 (20.5)	20.9	.00

Abbreviation: SD, standard deviation.

^aN (%).

Table 2.

HIV/AIDS-Related Knowledge, Attitude, and Practice of HCWs by Unit Levels.^a

	Total	County	Township	Village	F/χ²
Knowledge^b
Overall knowledge score (21 points)	10.9 ± 2.6	10.6 ± 2.5	11.1 ± 2.8	11.2 ± 2.3	12.16^c
Basic knowledge score (5 points)	2.1 ± 1.1	1.9 ± 1.1	2.2 ± 1.1	2.2 ± 1.2	22.06^c
Transmission knowledge score (9 points)	7.1 ± 1.6	6.8 ± 1.7	7.3 ± 1.6	7.3 ± 1.4	17.20^c
Occupational exposure and protection knowledge score (7 points)	2.1 ± 1.5	2.2 ± 1.4	2.0 ± 1.5	2.1 ± 1.5	5.14^c
Attitude
Treat patients living with HIV/AIDS with the same respect as any other patients	1466 (82.2)	626 (84.8)	319 (83.3)	521 (78.7)	16.88^c
Do not feel afraid when contacting patients living with HIV/AIDS	945 (53.0)	319 (43.2)	207 (54.0)	419 (63.3)	74.66^c
Willing to provide services	1302 (73.0)	319 (72.8)	264 (68.9)	501 (75.7)	12.21^c
Risk of contracting HIV while working	1150 (64.5)	539 (73.0)	253 (66.1)	358 (54.1)	80.23^c
Practice
Got injured by sharps	1510 (84.7)	634 (85.9)	311 (81.2)	565 (85.3)	4.66
Often	273 (15.3)	189 (25.6)	39 (10.2)	45 (6.8)	109.93^d
Occasionally	1237 (69.4)	445 (60.3)	272 (71.0)	520 (78.5)
Never	273 (15.3)	104 (14.1)	72 (18.8)	97 (14.7)
Had blood or fluid splashes to their eyes	1008 (56.5)	439 (59.5)	195 (50.9)	374 (56.5)	7.54
Do not recap needle after use	465 (26.1)	232 (31.4)	89 (23.2)	144 (21.8)	19.02^d
Proper disposal of sharps immediately	1435 (80.5)	522 (70.7)	316 (82.5)	597 (90.2)	85.31^d
Wearing gloves when taking blood	1574 (88.3)	672 (91.1)	379 (83.3)	583 (88.1)	11.84^d
Washing hands after patient contact	1649 (92.5)	686 (93.0)	341 (89.1)	622 (94.0)	2.55
Taken measures after getting injured by sharps	1619 (90.8)	670 (90.8)	335 (87.5)	614 (92.7)	8.11^d
Taken measures after an eye splash	1432 (80.3)	595 (80.6)	286 (74.7)	551 (83.2)	16.74^d

Abbreviations: HCWs, health care workers; SD, standard deviation.

^aN (%).

^bMean ± SD.

^c P value < .05.

^d P value < .01.

Knowledge

Majority (81%) of HCWs knew what causes AIDS; however, only 17% of them knew the incubation periods for HIV. Most of them also knew that HIV could be transmitted through blood transfusion (90%), sexually transmission (89%), and perinatal transmission (90%). However, only 33% knew that HIV cannot be transmitted through mosquito bites. As shown in Table 3, the overall HIV/AIDS-related knowledge of HCWs is poor with an average overall knowledge score of 10.9 of 21. This is due to the low scores for general knowledge and occupational exposure and protection knowledge (2.1 of 5 and 7, respectively), despite a high score for transmission knowledge (7.1 of 9). Less than half of HCWs (40%) had knowledge about universal precautions for occupational exposure to HIV. Overall knowledge score of HCWs in village level was higher than that of county.

Table 3.

HIV/AIDS-Related Knowledge, Attitude, and Practice of HCWs by Occupation.^a

	Doctor	Nurse	Medical Technician	Administrative Staff	F/χ²
Knowledge^b
Overall knowledge score (21)	11.65 ± 2.68	10.95 ± 2.93	10.53 ± 2.63	10.15 ± 2.87	19.13^c
Basic knowledge score (5)	2.25 ± 1.11	1.95 ± 1.08	1.67 ± 1.04	1.65 ± 1.14	26.40^c
Transmission knowledge score (9)	7.27 ± 1.41	6.86 ± 1.84	6.82 ± 1.79	6.80 ± 1.79	10.74^c
Occupational exposure and protection knowledge score (7)	2.13 ± 1.46	2.13 ± 1.51	2.04 ± 1.43	1.70 ± 1.49	2.403
Attitude
Treat patients living with HIV/AIDS with the same respect as any other patients	824 (82.7)	365 (83.1)	221 (79.8)	56 (78.9)	7.411
Do not feel afraid when contacting patients living with HIV/AIDS	588 (59.0)	203 (46.2)	124 (44.7)	30 (42.3)	36.991^c
Willing to provide services	746 (74.9)	310 (70.6)	198 (71.5)	48 (67.6)	6.422
Risk of contracting HIV while working	612 (61.4)	314 (71.5)	180 (65.0)	44 (61.8)	15.142^d
Practice
Got injured by sharps	855 (85.8)	393 (89.5)	218 (78.7)	44 (62.0)	44.849^c
Often	105 (10.5)	96 (21.9)	65 (23.5)	7 (9.9)	94.773^c
Occasionally	750 (75.3)	297 (67.7)	153 (55.2)	37 (52.1)
Never	141 (14.2)	46 (10.5)	59 (21.3)	27 (38.0)
Had blood or fluid splashing to their eyes	589 (59.1)	252 (57.4)	147 (53.1)	20 (28.2)	27.481^c
Do not recap needle after use	232 (23.3)	149 (33.9)	71 (25.6)	13 (18.3)	20.336^c
Proper disposal of sharps immediately	871 (87.4)	347 (79.0)	176 (63.5)	41 (57.7)	105.354^c
Wearing gloves when taking blood	884 (88.8)	411 (93.6)	235 (84.8)	44 (62.0)	2.611
Washing hands after patient contact	937 (94.1)	423 (96.4)	242 (87.4)	47 (66.2)	5.032
Taken measures after injured by sharps	927 (93.1)	406 (92.5)	237 (85.6)	49 (69.0)	57.102^c
Taken measures after an eye splash	830 (83.3)	337 (76.8)	221 (79.8)	44 (62.0)	18.802^c

Abbreviation: SD, standard deviation.

^an (%).

^bMean ± SD.

^c P value < .01.

^d P value < .05.

The overall knowledge of doctors (11.65) and nurses (10.95) was higher than that of medical technician (10.53) and administrative staff (10.15; F = 19.13, P < .01).

Attitude

Health care workers had a very positive attitude toward patients living with HIV/AIDS. More than 80% of them stated that patients living with HIV/AIDS should be treated with the same respect as other patients and 73% of them willing to provide services to this population. However, only about half of them (53%) were not afraid when contacting patients living with HIV/AIDS and 65% of them felt they were at risk of contracting HIV infection while at work. County HCWs had a better attitude about treating patients with the same respect; but village clinic HCWs were more willing and not afraid to provide services to patients living with HIV/AIDS.

Practice

A very large proportion of HCWs (85%) reported injury with sharps, and in more than half (57%) blood or fluid splashed to their eyes. Further analysis of results showed that 25.6% of the HCWs in county hospital had often got injured by sharps (Table 3). More nurses (21.9%) and medical technicians (23.5%) than doctors (10.5%) and administrative staffs (9.9%) had often got injured by sharps. Compared to village professionals, county professionals had a significantly poor performance with regard to proper disposal of sharps immediately after use (90% versus 70%). Although majority of them took protective measures after the exposure, only 26% did not recap needles after using. The dangerous practice of recapping needle was extremely high in HCWs at all the unit levels (69% versus 78%). Similarly, overall occupational exposure and protection practices were not up to the required standards.

Predictors of Universal Precautions

In the multiple linear regression model, female sex (β = 0.12, 95% confidence interval [CI]: 0.02-0.23), prior HIV/AIDS training (β = 0.17, 95% CI: 0.05-0.30), occupational exposure knowledge (β = 0.17, 95% CI: 0.05-0.3), transmission knowledge (β: 0.12, 95% CI: 0.09-0.15), and occupational protection knowledge (β: 0.08, 95% CI: 0.04-0.12) were the significant predictors of the universal precautions practice score (Table 4). Interestingly, other factors such as age, occupation, title, and unit levels were not associated with universal precautions practice.

Table 4.

Predictors of Universal Precautions Practice among HCWs.^a,b

	Unadjusted			Adjusted
	β Coefficients (95% CI)	t	P Value	β Coefficients (95% CI)	t	P Value
Female sex	0.08 (−0.03 to 0.19)	1.46	.15	0.12 (0.02 to 0.23)	2.31	.02
Prior HIV/AIDS training	0.12 (−0.01 to 0.25)	1.83	.07	0.17 (0.05 to 0.3)	2.70	.01
Occupational exposure knowledge score	0.17 (0.10 to 0.23)	5.17	.00	0.16 (0.1 to 0.22)	5.00	.01
Transmission knowledge score	0.13 (0.10 to 0.16)	7.51	.00	0.12 (0.09 to 0.15)	6.91	.01
Occupational protection knowledge score	0.08 (0.05 to 0.13)	4.27	.00	0.08 (0.04 to 0.12)	4.04	.01
Unit level	−0.12 (−0.18 to −0.06)	−3.88	.00	−0.04	−1.44	.15
Occupational title	−0.18 (−0.24 to −0.11)	−5.04	.00	−0.03	−1.19	.23
General knowledge score	0.09 (0.04 to 0.14)	3.77	.00	0.02	0.75	.45
Marital status	−0.12 (−0.23 to −0.00)	−2.00	.05	0.02	0.60	.55
Occupation	−0.05 (−0.12 to 0.01)	−1.64	.10	0.00	0.03	.81
Age	0.00 (0.0 to 0.01)	−0.24	.81	0.03	0.01	.99

Abbreviations: CI, confidence interval; HCWs, health care workers.

^aUniversal precaution behaviors include wearing gloves, not recapping needles, proper disposal of sharps, washing hands after patient contact, taking protective measures after being injured by sharps, and after an eye splash.

^b R ² = .12.

Training Requirement

An overwhelming majority of HCWs (85%) stated that they would like to participate in HIV/AIDS training. About training approaches, half of them would like to join “expert lectures,” while the other half were interested in “feature film” approach. They also revealed that the topics of most interest for these future trainings would be universal precautions, transmission mode knowledge, and diagnosis and treatment of HIV/AIDS.

Discussion

This unique study demonstrated that overall HIV/AIDS-related knowledge was inadequate in HCWs of rural China. An overall fear and inhibition with regard to providing services to patients living with HIV/AIDS was observed. Furthermore, they had a high rate of occupational exposure and did not practice universal precautions, thus making them highly susceptible to contracting HIV infections. Females with prior training and greater knowledge about HIV/AIDS practice behavior with significantly better universal precautions.

Greater lack of knowledge about HIV/AIDS was shown by the respondents of the current study compared to other research.^5,16 In fact, the overall knowledge score of HCWs from similar studies was 8.6 of 10, compared to 10.9 of 21 in the current study.¹⁷ Particularly, knowledge about occupational exposure and universal precaution was very low. Although the transmission knowledge score was high, nontransmission issues, especially the “mosquito bites can’t spread HIV,” were answered correctly by less than 40% of HCWs. This lack of transmission knowledge may explain HCWs’ fear of getting infected while working with HIV-infected patients, as also observed by a previous study.¹⁵

Most HCWs could actively work with patients living with HIV/AIDS. Some, however, did feel afraid with HIV-positive patients around and were concerned about the risk of infection to self. Although working in fields with a high rate of occupational exposure, they lacked awareness about methods of protection. To be able to reduce the risk of HIV infection, HCWs should have an adequate grasp of knowledge regarding universal precautions.

About 85% of HCWs in the current study stated that they had got injured by sharps, which is consistent with the studies in developing countries,^18,19 however, much higher than reported in those studies in developed countries (37%).²⁰ In the United States, it has been reported that approximately 500 000 percutaneous blood exposures might occur annually among HCWs.¹³ As also reported by an earlier study, HCWs in the county hospitals experienced a higher risk than those in township and village clinics in this study.¹⁴ Unfortunately, recapping of needles remained a frequent behavior and this matches the findings of other research studies, which suggest the lack of injection safety in developing countries.^21
–23 Promoting adherence to standard universal precautions may be the best method of reducing risk in medical institution. It is also highly recommended that HCWs in medical institution should have enhanced training in HIV/AIDS-related knowledge. Thus, provision of simple equipment such as gloves and ensuring workers are trained in safety methods can be very efficacious for reducing risk in HCWs.⁵

More HCWs in county hospital received AIDS training than that in township and village clinics. The HCWs’ score of occupational exposure and protection knowledge in county were higher than that of those in the village level. In county level, 31.4% HCWs did not recap needle after use, which was higher than that reported in village (21.8%); 25.6% of HCWs in county often got injured by sharps, which was significantly higher than those in township and village. However, HCWs’ score of general and transmission knowledge in county hospital was lower than that in village level. The county HCWs were less likely than the village HCWs to dispose of sharps properly. This suggested that the HCWs in county level had more resource than those in townships and villages. Health care workers in county level faced more occupation risk than those in townships and villages. Health care workers in village level was fuzzy on recap needle sleeve after use. Based on the above discussion, the key of AIDS training should be distinguished for different levels of HCWs.

In the current study, only 23% of HCWs in medical institution received HIV/AIDS-related training, while Li et al¹⁴ reported 73% of HCWs had received HIV-related training in Yunan, China. Another study found that the mean pre-workshop knowledge score was 16 (24), while the mean post-workshop knowledge score was 20 (24).²⁴ Thus, participation in training improved the score on HIV/AIDS knowledge significantly.^25,26 It is hypothesized that such training would have a positive impact on their work. In addition, hospitals should be equipped with sufficient personal protective equipment and encouraging voluntary reporting and an active surveillance system.²⁷

A number of limitations should be considered while interpreting the results of this study. It was carried out in medical institutions of a low HIV prevalence area such as Pucheng County. Hence, the findings should be extrapolated with care as they might not apply to all the HCWs in China, especially the urban settings. However, this study gives a vivid picture of the situation in the remaining parts of China where the overall HIV prevalence is also low. Since an equal number of participants from the county, township, and villages were surveyed, we were able to identify the areas of concern for HCWs at different unit levels. In fact, the response rate (94%) for this study was remarkably higher compared to similar studies conducted in developed countries.^28,29 This high participation rate ensured quality and reliability of the census results. Due to the cross-sectional nature of this study, a temporal association between HIV/AIDS-related knowledge and training and the universal precaution behavior could not be established. Hence, we recommend a longitudinal study to identify the true impact of HIV/AIDS training on improving the knowledge of HCWs and ultimately better universal precautions practice behavior.

Conclusion

In summary, rural HCWs in low HIV prevalence areas of rural China have inadequate AIDS/HIV exposure and protection knowledge and do not practice universal precautions. A high rate of occupational exposure occurred among HCWs in low HIV prevalence areas of rural China. Nurses and medical technicians in county level faced more occupation risk than other HCWs. As mentioned earlier, we recommend that medical technicians should be trained and enhance their capabilities to protect themselves from occupational exposure. The key of AIDS training should be distinguished for different levels of HCWs. Expert lecture and feature film can be considered favorite approaches of HCWs to gain HIV/AIDS knowledge.

Footnotes

Acknowledgments

We thank the staff of CDC and Health Bureau in Pucheng County for their help with the data collection.

Declaration of Conflicting Interests

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

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This survey was supported by 2 grants: one from the Ministry of Science and Technology, People’s Republic of China (2007BAI07A12), the other from Xi’an Jiaotong University (xjj2014138).

References

Zhang

Zhou

. Recapturing public health sciences for HIV/AIDS in China. Public Health. 2011;125 (5):266–268.

Zhang

Detels

Liao

Cohen

. China’s HIV/AIDS epidemic: continuing challenges. Lancet. 2008;372(9652):179103.

Chen

Peeling

Yin

Mabey

. The epidemic of sexually transmitted infections in China: implications for control and future perspectives. BMC Med. 2011;9:111.

Liu

Wang

. A model of expanding HIV/AIDS education in Chinese rural areas. Int J STD AIDS. 2010;21 (2):87–92.

Wang

Fennie

Burgess

Williams

. A training programme for prevention of occupational exposure to bloodborne pathogens: impact on knowledge, behaviour and incidence of needle stick injuries among student nurses in Changsha, People’s Republic of China. J Adv Nurs. 2003;41 (2):187–194.

Lee

. Occupational transmission of bloodborne diseases to healthcare workers in developing countries: meeting the challenges. J Hosp Infect. 2009;72 (4):285–291.

Smith

Wei

Zhang

Wang

. Needlestick and sharps injuries among a cross-section of physicians in Mainland China. Am J Ind Med. 2006;49 (3):169–174.

Rapiti

Prüss-Üstü

Hutin

. Sharps injuries: Assessing the burden of disease from sharps injuires to health-care worker at national and local levels. Environmental Burden of Disease Series, No. 11. Geneva: World Health Organization; 2005:1–45.

Wilburn

Eijkemans

. Preventing needlestick injuries among healthcare workers: a WHO-ICN collaboration. Int J Occup Environ Health. 2004;10 (4):451–456.

10.

Chen

Han

. Knowledge, attitudes, perceived vulnerability of Chinese nurses and their preferences for caring for HIV-positive individuals: a cross-sectional survey. J Clin Nurs. 2010;19 (21-22):3227–3234.

11.

Yeh

Tsay

Adherence to management after occupational exposure to bloodborne pathogen among health care workers in Taiwan. Am J Infect Control. 2009;37 (7):609–611.

12.

Reda

Vandeweerd

Syre

Egata

. HIV/AIDS and exposure of healthcare workers to body fluids in Ethiopia: attitudes toward universal precautions. J Hosp Infect. 2009;71 (2):163–169.

13.

Bell

. Occupational risk of human immunodeficiency virus infection in healthcare workers: an overview. Am J Med. 1997;102 (5B):9–15.

14.

Liang

Lin

. Institutional support for HIV/AIDS care in China: a multilevel analysis. AIDS Care. 2008;20 (10):1190–1196.

15.

Delobelle

Rawlinson

Ntuli

Malatsi

Decock

Depoorter

. HIV/AIDS knowledge, attitudes, practices and perceptions of rural nurses in South Africa. J Adv Nurs. 2009;65 (5):1061–1073.

16.

Umeh

Essien

Ezedinachi

Ross

. Knowledge, beliefs and attitudes about HIV/AIDS-related issues, and the sources of knowledge among health care professionals in southern Nigeria. J R Soc Promot Health. 2008;128 (5):233–239.

17.

Zhang

Wang

Huo

Yang

Wang

. Knowledge, attitudes, and practices regarding blood-borne occupational exposure among reproductive health staff in Tianjin. Zhonghua Lao Dong Wei Sheng Zhi Ye Bing Za Zhi. 2014;32 (3):207–210.

18.

Chen

Han

Holzemer

. Nurses' knowledge, attitudes, and practice related to HIV transmission in northeastern China. AIDS Patient Care STDS. 2004;18 (7):417–422.

19.

Tarantola

Koumare

Rachline

A descriptive, retrospective study of 567 accidental blood exposures in healthcare workers in three West African countries. J Hosp Infect. 2005;60 (3):276–282.

20.

Rajkumari

Thanbuana

John

A prospective look at the burden of sharps injuries and splashes among trauma health care workers in developing countries: true picture or tip of iceberg. Injury. 2014;S0020-1383(14):122–123.

21.

Kermode

. Unsafe injections in low-income country health settings: need for injection safety promotion to prevent the spread of blood-borne viruses. Health Promot Int. 2004;19 (1):95–103.

22.

Phipps

Honghong

Min

Risk of medical sharps injuries among Chinese nurses. Am J Infect Control. 2002;30 (5):277–282.

23.

Ehlers

. Challenges nurses face in coping with the HIV/AIDS pandemic in Africa. Int J Nurs Stud. 2006;43 (6):657–662.

24.

Williams

Wang

Burgess

Gong

. Effectiveness of an HIV/AIDS educational programme for Chinese nurses. J Adv Nurs. 2006;53 (6):710–720.

25.

Alemie

. Exploration of healthcare workers' perceptions on occupational risk of HIV transmission a\t the University of Gondar Hospital, Northwest Ethiopia. BMC Res Notes. 2012;5:704.

26.

Kermode

Jolley

Langkham

Thomas

Holmes

Gifford

. Compliance with Universal/Standard Precautions among health care workers in rural north India. Am J Infect Control. 2005;33 (1):27–33.

27.

Mashoto

Mubyazi

Makundi, Mohamed

Malebo

. Estimated risk of HIV acquisition and practice for preventing occupational exposure: a study of healthcare workers at Tumbi and Dodoma Hospitals, Tanzania. BMC Health Serv Res. 2013;13:369.

28.

Farley

Hayat

Murphy

Sheridan-Malone

Anderson

Mark

. Knowledge, attitudes, and practices of OB/GYN nurses and auxiliary staff in the care of pregnant women living with HIV. J Assoc Nurses AIDS Care. 2014;25 (2):158–167.

29.

Foster

Lee

McGaw

Frankson

. Knowledge and practice of occupational infection control among healthcare workers in Jamaica. West Indian Med J. 2010;59 (2):147–152.