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American Journal of Infection Control 43 (2015) e73-e78

Contents lists available at ScienceDirect

American Journal of Infection Control American Journal of


Infection Control

journal homepage: www.ajicjournal.org

Major article

Influence of multiple factors on the incidence of occupational blood


and body fluid exposures in health care workers in Guizhou, China:
A structural equation modeling approach
Mingtao Quan MD a, Lezhi Li MD b, *, Xiaoli Yuan MS c, Zhixia Jiang BS c,
Xuyao Wang MS d, Hualian Wu MS a, Xiaojuan Li BS a
a
Department of Critical Care Medicine, Affiliated Hospital of Zunyi Medical College, Zunyi, Guizhou, China
b
Xiang Ya Nursing School of Central South University, (Second Xiangya Hospital, Central South University), Changsha, Hunan, China
c
Department of Nursing, Affiliated Hospital of Zunyi Medical College, Zunyi, Guizhou, China
d
Zunyi Medical College, Zunyi, Guizhou, China

Key Words: Background: We investigated the influence of multiple factors on the incidence of occupational blood
Health care workers and body fluid exposures (BBFEs) in health care workers (HCWs) in Guizhou, China, using structural
Bloodborne equation modeling (SEM).
Occupational exposure
Methods: SEM tested in general hospitals was evaluated using survey data from a sample of 1,774 HCWs
Structural equation modeling
from 25 hospitals in Guizhou, China, between January and April 2014.
Results: The incidence of occupational BBFEs in HCWs was affected by HCWs’ knowledge of safe work
practices, HCWs’ belief in their ability to use safe work practices, HCWs’ use of safe work practices, the
workplace safety environment, sufficiency of the controls implemented at health care facilities, and
workloads. Knowledge of safe work practices had the most influence on the incidence of occupational
BBFE in doctors and laboratory technicians. Ability to use safe work practices had the most influence on
the incidence of occupational BBFEs in nurses.
Conclusion: The workplace safety environment, sufficiency of controls implemented at health care fa-
cilities, HCWs’ knowledge of safe work practices, HCWs’ belief in their ability to use safe work practices,
HCWs’ use of safe work practices, and workload influence the incidence of occupational BBFEs in HCWs.
Copyright Ó 2015 by the Association for Professionals in Infection Control and Epidemiology, Inc.
Published by Elsevier Inc. All rights reserved.

Occupational blood and body fluid exposures (BBFEs) may result October 2012 indicate 108,906 individuals have died from AIDS.7
in HIV, hepatitis B virus (HBV), and hepatitis C virus infections in There are 120 million people who have chronic HBV infection,8
health care workers (HCWs).1 In fact, the seroconversion rates of and >300,000 people die from HBV-related diseases each year.9
HIV, HBV, and hepatitis C virus are 0.1%-0.3%, 6%-60%, and 2%, The incidence of syphilis is rapidly increasing.10
respectively, after accidental percutaneous exposures.2 Developed Although occupational BBFE is a dangerous hazard faced by
countries have implemented procedures for avoiding BBFEs in HCWs on a daily basis, it is one of the most preventable. Exposure
HCWs3,4; however, in developing countries, the risk for blood and incidence in HCWs is influenced by multiple factors, such as
body fluidborne pathogen exposure remains a serious problem.5,6 knowledge, attitude, and practices of HCWs; use of safety devices;
HCWs in China may be at greater risk for occupation infection adherence to safety procedures; staff work load; and work envi-
than many other developed countries because the prevalence of ronment.11,12 Recognizing the factors affecting the incidence of
HIV and HBV infections in the general population is high. In China, occupational BBFE and the relationships between them may aid in
approximately 492,191 people live with HIV, and reports up to the prevention of health careeassociated infections.
A 4-dimensional analysis using a questionnaire and structural
equation modeling (SEM) was used to demonstrate the influence of
* Address correspondence to Lezhi Li, MD, Xiang Ya Nursing School of Central
multiple factors on the incidence of occupational BBFEs in HCWs in
South University (Second Xiangya Hospital, Central South University), Changsha
410008, Hunan, China.
Guizhou, China. SEM was selected because it allows for the esti-
E-mail address: 1181770407@qq.com (L. Li). mation of relationships between any manifest and latent contin-
Conflicts of interest: None to report. uous or categorical variables. SEM has broad applicability to clinical

0196-6553/$36.00 - Copyright Ó 2015 by the Association for Professionals in Infection Control and Epidemiology, Inc. Published by Elsevier Inc. All rights reserved.
http://dx.doi.org/10.1016/j.ajic.2015.07.014
e74 M. Quan et al. / American Journal of Infection Control 43 (2015) e73-e78

research that is not appropriately addressed by traditional regres-


sion techniques.12 Most previous reports focus on how a single
factor influences the incidence of occupational BBFEs in HCWs;
studies investigating the influence of multiple factors are limited.

METHODS

Ethical considerations

This study was approved by the ethics committees of all


participating hospitals.

Participants

A stratified sampling method was used to recruit 1,774 partici-


pants from 25 public hospitals for this study. Hospitals were
operating approximately 500 beds and situated in different regions
of Guizhou, China. Participants were registered nurses, licensed
doctors, and laboratory workers with at least 1 year of work
experience. These HCWs were selected because evidence suggests
they are at a high risk for occupational BBFEs.13

Data collection

A questionnaire survey was developed by a study team con-


sisting of 3 nurses, 2 investigators, and 2 statisticians. The ques-
tionnaire was administered to HCWs in Guizhou, China. In 2013, the
yearbook from the Statistics Bureau of Guizhou Province estimated
the number of registered nurses, licensed doctors, and laboratory
workers in the province at 10,020; therefore, a sample size of 383
valid respondents was required to reach a statistical significance of Fig 1. Measurement model.
P < .05. Accordingly, 1,774 copies of the questionnaire were
distributed, and respondents voluntarily and personally completed
the survey after being fully informed by the study team. Statistical analysis

Data were analyzed using SPSS version 18.0 (IBM Statistics,


Instrument Chicago, IL) was used for descriptive analyses, the KaisereMeyere
Olkin (KMO) measure of sampling adequacy, Cronbach a coefficient
The questionnaire was comprised of 3 sections. Section 1 measure of internal consistency, Bartlett test of homogeneity
included HCWs’ basic information, such as sex, age, job title, edu- of variances, and for correlation coefficient analysis to measure
cation, hospital grade, work experience, and career type. Section 2 the strength and direction of the linear relationship between 2
included questions about 6 factors that can influence the incidence variables. Amos 19.0 (IBM, Chicago, IL) was used for factor analysis.
of occupational BBFEs in HCWs: (1) the workplace safety environ-
ment, defined as the controls implemented at health care facilities RESULTS
(eg, warning signs, regular inspections, employee participation in
control management); (2) sufficiency of the controls implemented Basic information
at health care facilities, including the amount, availability, and
suitability of these controls; (3) HCWs’ knowledge of safe work There were 1,774 copies of the questionnaire distributed, and
practices, including the concept and methods of standard preven- 1,601 (90.25%) were returned. The mean age of respondents was
tion techniques and hand hygiene; (4) HCWs’ belief in their ability 30.33 years, 27.9% (n ¼ 477) were men, and the average duration of
to use safe work practices; (5) HCW’s use of safe work practices; work experience was 7.59 years. Of the respondents, 29.0% (n ¼ 464)
and (6) workload, assessed as time spent standing, work fatigue, were doctors, 60.2% (n ¼ 964) were nurses, and 10.8% (n ¼ 173) were
and shift work. Section 3 included questions on the incidence of laboratory workers.
occupational BBFE in the participants’ work environments.
Scoring in sections 2 and 3 was based on the 5-point Likert scale. Factor analysis
Section 2 was scored according to degree of satisfaction, where 5
points was extremely satisfied and 1 point was extremely unsat- The KMO value, Bartlett test statistic, and cumulative contri-
isfied. Section 3 was scored according to incidence of exposures, bution rate were 0.877, 1,945 (P < .01), and 65.16% (>60%),
where 5 points was the highest incidence and 1 point was has respectively, for the factors influencing the incidence of occupa-
never occurred. In sections 2 and 3 of the questionnaire, Cronbach a tional BBFEs in HCWs. The KMO value, Bartlett test statistic, and
coefficient was 0.781 (>0.70) and 0.940 (>0.70), respectively, cumulative contribution rate were 0.919, 9,974 (P < .01), and 79.93%
indicating excellent reliability. (>60%), respectively, for the incidence of occupational BBFE in
M. Quan et al. / American Journal of Infection Control 43 (2015) e73-e78 e75

Table 1 Table 2
Estimation of parameters for the measurement model Correlation coefficients between occupational BBFEs and their influencing factors

Standardized Factors influencing BBFEs Pearson correlation


parameter P HCWs’ use of safe work practices 0.462*
Items estimation C.R. value HCWs’ knowledge of safe work practices 0.442*
Workplace safety environment HCWs’ belief in their ability to use safe work practices 0.384*
SCF01 (Warning signs) 0.814 37.238 <.05 Sufficiency of controls 0.293*
SCF02 (Regular inspection) 0.881 40.308 <.05 Workplace safety environment 0.283*
SCF03 (Employee participation 0.842 d Workload 0.198*
in management)
BBFE, blood and body fluid exposure; HCW, health care worker.
HCWs’ knowledge of safe work practices
*P<.05.
PF05 (Concept of standard prevention) 0.750 34.357 <.05
PF05 (Knowledge of hand hygiene) 0.898 41.676 <.05
PF07 (Methods of standard prevention) 0.865 d
Workload
practices, and HCWs’ use of safe work practices and a significant
EF04 (Long standing time) 0.704 21.217 <.05 positive relationship with increased workloads (all P < .05).
EF05 (Irregular work time) 0.713 21.378 <.05
EF06 (Work fatigue) 0.781 22.407 <.05 Hypothesis model
EF06 (Working the night shift for 0.615 d
a prolonged amount of time)
Sufficiency of controls implemented Based on these observations, the study investigated the
at health care facilities following hypotheses: (1) appropriate and sufficient safety mea-
EF01 (Enough) 0.783 38.394 <.05 sures implemented in the workplace, HCWs’ knowledge of safe
EF02 (Suitability) 0.860 44.980 <.05
work practices, and HCWs’ belief in their ability to use safe work
EF03 (Availability) 0.904 48.905 <.05
SCF04 (Quality) 0.867 d practices reduce the incidence of occupational BBFEs in HCWs; (2)
HCWs’ use of safe work practices high workloads increase the incidence of occupational BBFEs in
PF08 (Proper hand hygiene) 0.865 d HCWs; (3) appropriate and sufficient safety measures implemented
PF09 (Using protective facilities when 0.914 41.235 <.05 in the workplace and HCWs’ knowledge of safe work practices in-
I potentially contact blood and body fluids)
PF10 (Putting sharps into the sharps container 0.698 30.701 <.05
crease HCWs’ belief in their ability to use safe work practices and
HCWs’ belief in their ability to use safe HCWs’ use of safe work practices; (4) HCWs’ belief in their ability to
work practices use safe work practices increases HCWs’ use of safe work practices;
PF01 (I can do my work well) 0.620 18.950 <.05 and (5) HCWs’ belief in their ability to use safe work practices and
PF02 (I believe I can perform 0.687 20.252 <.05
HCWs’ use of safe work practices reduce the incidence of occupa-
standard prevention)
PF03 (I can perform standard 0.637 19.316 <.05 tional BBFEs in HCWs (Fig. 2).
prevention, even with difficulty) After validation of the hypothesis model, HCWs’ knowledge of
PF04 (I am capable of taking 0.632 d safe work practices, HCWs’ belief in their ability to use safe work
care of patients with BPs) practices, and HCWs’ use of safe work practices were shown to
Occupation exposure
influence the incidence of occupational BBFEs in HCWs.
OICB01 (Sharps injury) 0.921 d
OICB02 (Direct contact with contaminated 0.970 75.729 <.05
blood and body fluids) Modified model
OICB03 (Mucous membrane exposure) 0.922 65.172 <.05

BPs, blood prevention standard; C.R., critical ratio; HCW, health care worker. A structural equation model of the factors influencing the inci-
dence of occupational BBFEs in HCWs was constructed. The model
HCWs. These results indicate the scale had excellent construct was modified, and fit was assessed. The c2 ¼ 670.994, df ¼ 235, c2/
validity and was suitable for factor analysis. df ¼ 2.855 (<3), indicating the hypothesized model was acceptable.
Therefore, a measurement model was developed (Fig. 1). The The goodness-of-fit index, adjusted goodness-of-fit index,
measurement model had good construct validity,14 whereby c2 ¼ comparative fit index, non-normed fit index, and incremental fit
663.75, df ¼ 231, and c2/df ¼ 2.873. The goodness-of-fit index, index were >0.9 at 0.967, 0.957, 0.981, 0.978, and 0.981, respec-
adjusted goodness-of-fit index, comparative fit index, incremental tively. The root mean square residual, standardized root mean
fit index, and non-normed fit index were >0.9 at 0.967, 0.957, 0.981, square, and root mean square error of approximation were <0.08 at
0.981, and 0.978, respectively. The root mean square residual, 0.049, 0.034, and 0.034, respectively. These indices indicate that the
standardized root mean square, and root mean square error of model was plausible.12,15
approximation were <0.08 at 0.047, 0.033, and 0.034, respectively. Figure 3 shows that the workplace safety environment, suffi-
These indices indicate that the measurement model was plau- ciency of the controls implemented at health care facilities, HCWs’
sible.12,15 As shown in Table 1, the measurement indexes of all latent knowledge of safe work practices, HCWs’ belief in their ability to
variables are significant (C.R. ¼ 1.96, P < 0.05) with all Standardized use safe work practices, and HCWs’ use of safe work practices were
parameter estimations for the measurement models over 0.60, negatively correlated with the incidence of occupational BBFEs in
indicating all latent variables have good clustering validity and HCWs, whereas increased workloads were positively correlated
models have good fitness. with the incidence of occupational BBFEs in HCWs. HCWs’ knowl-
edge of safe work practices had both direct and indirect impacts
Correlation analysis of factors influencing occupational BBFEs and had the strongest impact on the incidence of occupational
BBFEs, followed by HCWs’ belief in their ability to use safe work
Correlation analysis of factors influencing the incidence of practices, HCWs’ use of safe work practices, sufficiency of the
occupational BBFEs in HCWs is shown in Table 2. Incidence of controls implemented at health care facilities, workplace safety
occupational BBFEs in HCWs had a significant inverse relationship environment, and workloads.
with the workplace safety environment, sufficiency of the controls The HCW population was stratified into subgroups according to
implemented at health care facilities, HCWs’ knowledge of safe occupation. Three subgroups were identified, comprising doctors,
work practices, HCWs’ belief in their ability to use safe work nurses, and laboratory technicians. The subgroups were subjected
e76 M. Quan et al. / American Journal of Infection Control 43 (2015) e73-e78

Fig 2. Hypothesis model.

to multiple group SEM. The results showed a good fit for the overall needlestick injuries in nurses is higher than other HCWs. These
model, but there were some between-group differences (Table 3). observations emphasize that nurses must not only have knowl-
edge of safe work practices, but also the ability to use them.
DISCUSSION HCWs who master the knowledge to prevent occupational BBFEs
increase their belief in their ability to use safe work practices,
This study established a theoretical framework to analyze the which increases their use of safe work practices, and reduce their
factors that influence the incidence of occupational BBFEs in HCWs probability of sustaining occupational BBFEs. These data suggest
in Guizhou Province, China. Results showed a significant inverse that improving HCW training in practices that prevent occupa-
correlation between the incidence of occupational BBFEs and tional BBFEs is important for reducing occupational BBFEs in
HCWs’ knowledge of safe work practices, HCWs’ belief in their HCWs.
ability to use safe work practices, HCWs’ use of safe work practices, The overall impact of the workplace safety environment on the
workplace safety environment, and sufficiency of the controls incidence of occupational BBFEs was 0.099. These findings indi-
implemented at health care facilities and a significant positive cate that convenient and quick access to safety medical devices,
correlation with increased workloads. such as needle-free devices, masks, gloves, goggles, and gowns,
The BBFEs dimension was directly influenced by HCWs’ may impact work practices and reduce the incidence of occupa-
knowledge of safe work practices, HCWs’ belief in their ability to tional BBFEs in HCWs. Although the workplace safety environment
use safe work practices, and HCWs’ use of safe work practices. did not have a direct impact on the incidence of occupational BBFEs
HCWs’ belief in their ability to use safe work practices and HCWs’ in HCWs, an appropriate workplace safety environment may
use of safe work practices had a mediating position in the rela- improve HCWs’ belief in their ability to use safe work practices and
tionship between the BBFEs dimension and the workplace safety increase HCWs’ use of safe work practices. Improved communica-
environment, sufficiency of the controls implemented at health tion and cooperation between HCWs and posting of safety and
care facilities, HCWs’ knowledge of safe work practices, and danger signs may improve the use of safe work practices by HCWs
workload. The BBFEs dimension was directly and indirectly influ- and indirectly influence the incidence of occupational BBFEs.
enced by HCWs’ knowledge of safe work practices. These obser- Increased workloads were positively correlated with incidence
vations are in accordance with previous reports.11,16 of occupational BBFEs in HCWs, with an overall impact of 0.071.
Multiple group SEM analysis showed that the ability to use Workloads were negatively correlated with the 2 mediating vari-
safe work practices had the most influence on the incidence of ables of HCWs’ belief in their ability to use safe work practices and
occupational BBFEs in nurses, which is different from factors that HCWs’ use of safe work practices, with coefficients of 0.12
influence the incidence of occupational BBFEs in doctors and and 0.19, respectively. These data suggest that HCWs with high
laboratory technicians. This difference may be a reflection of the workloads are less likely to use safe work practices. High workloads
tasks a nurse performs. Among the HCW population, nurses have include standing continuously for >4 hours and working 3 shifts or
the most contact with patients. In fact, the incidence of night shifts. These observations imply that an increase in human
M. Quan et al. / American Journal of Infection Control 43 (2015) e73-e78 e77

Fig 3. Modified model.

Table 3
Path coefficient of multigroup analysis

Exogenous latent variables Internal latent variables Doctors Nurses Laboratory technicians Total
HCWs’ knowledge of safe work practices BBFE 0.428 0.355 0.338 0.373
HCWs’ belief in their ability to use safe work practices BBFE 0.251 0.363 0.219 0.314
HCWs’ use of safe work practices BBFE 0.253 0.130 0.204 0.176
Sufficiency of controls BBFE 0.138 0.095 0.104 0.099
Workplace safety environment BBFE 0.068 0.093 0.068 0.091
workload BBFE 0.051 0.085 0.004 0.071
c2/df 1.783 2.164 1.585 2.855
RMSEA 0.041 0.035 0.058 0.034
GFI 0.930 0.959 0.854 0.981

BBFE, blood and body fluid exposure; GFI, goodness-of-fit index; HCW, health care worker; RMSEA, root mean square error of approximation.

resources and improved working conditions in hospitals may comprehensive intervention strategies to improve work safety in
reduce the incidence of occupational BFFEs in HCWs.12 HCWs. These measures may reduce the incidence of occupational
BBFEs in HCWs.
Study limitations
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