Occupational Health Hazards among Healthcare Workers in Kampala, Uganda

Objective. To assess the occupational health hazards faced by healthcare workers and the mitigation measures. Methods. We conducted a cross-sectional study utilizing quantitative data collection methods among 200 respondents who worked in 8 major health facilities in Kampala. Results. Overall, 50.0% of respondents reported experiencing an occupational health hazard. Among these, 39.5% experienced biological hazards while 31.5% experienced nonbiological hazards. Predictors for experiencing hazards included not wearing the necessary personal protective equipment (PPE), working overtime, job related pressures, and working in multiple health facilities. Control measures to mitigate hazards were availing separate areas and containers to store medical waste and provision of safety tools and equipment. Conclusion. Healthcare workers in this setting experience several hazards in their workplaces. Associated factors include not wearing all necessary protective equipment, working overtime, experiencing work related pressures, and working in multiple facilities. Interventions should be instituted to mitigate the hazards. Specifically PPE supply gaps, job related pressures, and complacence in adhering to mitigation measures should be addressed.


Background
Worldwide, the healthcare workforce represents 12% of the working population [1]. Healthcare workers operate in an environment that is considered to be one of the most hazardous occupational settings [2][3][4]. In addition to the usual workplace related exposures, healthcare workers encounter diverse hazards due to their work related activities [5,6]. In spite of this knowledge, the healthcare work environment continues to be neglected by governments and organizations [7]. A higher annual prevalence of back pain (77%) among healthcare workers compared to other occupational groups has been reported [8][9][10][11]. Back injuries are associated with a direct cost of $37,000 and an indirect cost ranging from $147,000 to $300,000 [8]. In fact, ergonomic related injuries pose a significant health risk to workers and yet it is the most prevalent occupational injury in healthcare industry [12]. Healthcare workers are exposed to blood-borne infections which usually expose them to diseases such as HIV, TB, and hepatitis B and hepatitis C [1]. Substantial morbidity and mortality among these workers inevitably lead to loss of skilled personnel and adversely impact healthcare services which are already strained in many low and middle income countries.
In sub-Saharan Africa, the scarcity of human resource for health is described as a humanitarian resource crisis due to significant emigration of trained professionals, difficult working conditions, poor salaries, low motivation, and high burden of infectious diseases, particularly HIV/AIDS [13][14][15]. Evidence from sub-Saharan Africa indicates that healthcare workers are frequently exposed to chemical, biological, physical, and psychosocial occupational hazards [6,16]. They 2 Journal of Environmental and Public Health are constantly in contact with patients that expose them to infections and thus require proper protective measures to reduce their risk of acquisition of disease or injury. Data on occupational hazards among healthcare workers and their mitigation measures remain scarce in most of sub-Saharan Africa and Uganda in particular. Understanding the predisposing factors for occupational hazards among healthcare workers is needed to inform occupational health and safety policy and programs for healthcare workers. This study assessed the occupational hazards and their control measures in eight major hospitals in Kampala, Uganda. To select the respondents, sampling proportionate to size was used to determine the number of healthcare workers to be interviewed from each hospital. At the hospital, all healthcare workers who were present at the facility were considered for the study. In cases where the number of workers present was higher than the required number of respondents, simple random sampling was used to select those to be interviewed.

Studied Population.
The study population comprised a range of healthcare workers working in selected health facilities. These included doctors, nurses, clinical officers, and midwives. Table 1 shows the general characteristics of the studied healthcare workers. Of the 200 participants, the majority were females (71.5%), were of age over 30 years (55.0%), were married (53.5%), were Christians (86.5%), and earned over 500,000 Uganda shillings (approx. US $200) per month (52.5%). Just over half were nurses (50.5%), 41% worked in private health facilities and 53.0% had practiced for five or more years. Most of them (70.5%) worked beyond their normal working time, 28.0% worked in more than one facility, 38% consumed alcohol, and 75.0% had less than 8 hours of sleep daily. Fifty nine (59) percent did not exercise frequently and most of them (83.5%) reported to have experienced job related pressures. None smoked tobacco.

Data Collection.
A standardized structured questionnaire adapted from the National Institute of Occupational The questionnaire collected data on the sociodemographic characteristics of the respondents including age, marital status, education level, and their work history. In addition, data was collected on the occupational health and safety practices of the healthcare workers, the hazards that they experienced in their work places, and the control measures in place to mitigate those hazards. The questionnaire was administered by a team of trained research assistants.

Data Management.
Field inspection of questionnaire data was carried out daily after the field interview was conducted, and any errors were immediately verified and corrected. The quantitative data generated was entered in Epidata 3.02 and then entered into Stata 12.0 (StataCorp, College Station, TX) statistical software for analysis.

Definition of Variables
(i) The occupational hazards were as follows. These hazards were broadly classified as biological and nonbiological. The broader classifications were generated as composite endpoints. Key questions asked included "Have you experienced any type of workrelated illness/injury/trauma (major and minor)? If yes: What was the cause?" Twenty structured responses included (1) slips, trips, and falls; (2) physical, psychological, sexual, and/or verbal abuse; (3) cuts/wounds/lacerations; (4) burns; (5) fracture; (6) sharp-related injuries (i.e., needles, etc.); (7) radon from X-rays and so forth; (8) chemical spill; (9) (20) nonionizing radiation. These responses were sorted to generated the composite classifications, biological or nonbiological. Consequently, (a) biological hazards were defined to include cuts/wounds/lacerations, sharp related injuries, direct contact with contaminated specimens/ biohazardous materials, bioterrorism, bloodborne pathogens, infectious diseases/infections, airborne diseases, vector borne diseases, and cross contamination from soiled materials; (b) the nonbiological hazards were defined to include physical, psychosocial, and ergonomic hazards: (1) the physical hazards included slips, trips, falls, burns, fracture, radiation from X-rays, noise, and nonionizing radiation; (2) the psychosocial hazards included physical, psychosocial, sexual, and verbal abuse and stress; (3) the ergonomic hazards were musculoskeletal injuries such as muscle aches/strains/ sprains and carpel tunnel syndrome.
2.6. Data Analysis. Data was analyzed using STATA 12 statistical software. To assess associations and independent predictors, we conducted binary and multivariate logistic regression modeling. The outcome variables used were experiencing either a biological or nonbiological hazard. Associations were run between the respondent characteristics and the outcome variables to obtain the significant associations. A value of less than 0.05 was considered for a factor to be associated with experiencing the hazard.

Ethical Considerations.
Ethical approval to carry out the study was obtained from Makerere University School of Public Health, Higher Degrees, Research and Ethics Committee, and the Uganda National Council of Science and Technology. Permission to conduct the study was obtained from the hospitals administration and each participant provided written informed consent.

Control Measures for Occupational Health Hazards.
We made an inquiry into the occupational measures in place to control occupational health hazards. Table 6 shows the health facility and individual measures that were in place to control occupational health hazards. The major control measures provided by the health facilities were availing separate areas and containers to dispose medical waste (92.0%) and safety tools and equipment (90.0%). More than half (53.5%) of the health facilities provided health workers with personal protective equipment. Almost all healthcare workers had received HIV screening examination (97.0%) and 91.0% had received BCG vaccination. Regarding the hand washing practices, most health workers washed their hands before and after every procedure (79.5%) and after handling soiled materials (68.5%). Forty six percent of health workers washed hands when they were evidently dirty while slightly over half (53.5%) did so after using the toilet.

Discussion
This study highlights that half of respondents had experienced an occupational health hazard, mostly sharp related injuries and stress. The likely predictors for both biological and nonbiological hazards were not wearing all the necessary personal protective equipment, were working overtime, and were job related pressures. In addition, nonbiological hazards were predicted by working in multiple health facilities. The mitigation measures to control the hazards were mainly availing waste disposal facilities for the medical waste and provision of safety tools and equipment.
These findings are largely comparable to previous studies conducted in low and middle income countries. Ziraba in Uganda, Nsubuga in Uganda, Orij in Nigeria, De Castro in Philippines, and Adib-Hajbaghery in Iran reported that sharp related injuries and stress were the major health related hazards experienced by healthcare workers in their studies [6,[18][19][20][21].
In our study, we established that using all the necessary personal protective equipment was associated with reduced exposure to both biological and nonbiological hazards. This finding supports evidence by Hayden et al., who reported that use of PPEs reduced acquisition of illnesses in hospital settings [22]. Indeed, use and compliance with utilization of PPEs has for long been recognized as important infection control measure in the healthcare industry [23,24] which should be emphasized to minimize exposure to occupational hazards.
In addition, we found that respondents who worked overtime had increased likelihood of experiencing both biological and nonbiological hazards. This is consistent with previous 6 Journal of Environmental and Public Health literature that reported increased risk of experiencing occupational hazards [21,[25][26][27][28][29][30][31]. Long working hours results in prolonged exposures to hazards and limited recovery time [32,33] which translates into physiologic depletion that continues to the next workday [34]. Other studies have shown that working long hours is also associated with adverse health effects [31,35,36] and unhealthy behaviors [37]. This mode of work has also raised concern about patient safety [38]. We also found that respondents who experienced work related pressures were more likely to report occupational hazards. Work related pressures have been reported to have negative impacts including the compromise of patient care thus resulting to a diminished quality of life for both healthcare workers and patients [39,40]. Another interesting finding although not significant at multivariate analysis was the association between working in a government health facility and experiencing occupational hazards compared to private health facilities. Reasons for this discrepancy may need to be explored further. Although many health facilities provided waste disposal facilities for the medical waste and safety tools and equipment as control measures for occupational health hazards, simple measures like hand washing were not fully embraced. The proportion of health workers who reported washing hands after recommended procedures was lower than has been reported by previous studies [41,42]. On the other hand, it was encouraging to establish that the majority of health workers had been screened for HIV and 8 in 10 health workers had been vaccinated against hepatitis B.

Study Limitations.
This study was carried out in the major hospitals which limit generalizability to small and rural health facilities. The results could have been affected by recall bias as respondents were required to recall past experience. This being a cross sectional study, cause effect could not be established. Nevertheless, this study provides useful information on occupational health hazards in this low income context.

Conclusion
Healthcare workers continue to face several hazards in their workplaces. The factors associated with experiencing hazards include not wearing all necessary protective equipment, working overtime, experiencing work related pressures, and working in multiple facilities. Interventions should be instituted to mitigate the hazards. Specifically PPE supply gaps,  job related pressures, and complacence in adhering to mitigation measures should be addressed.

Disclaimer
The funders had no role in the design, implementation and writing of the paper and decision to publish this paper.

Conflict of Interests
All authors declare no conflict of interests.