This scoping review focused on mapping the existing empirical evidence on occupational exposure to healthcare providers and ancillary staff in Ghana. Inclusive of forty-three (43) articles, this review was quite extensive and comprised of studies relating to exposures to both biological and non-biological hazards, alongside their risk factors, availability and utilization of control/preventive measures, and knowledge on control and preventive measures. Nonetheless, a greater proportion of these studies were conducted on exposures to non-biological hazards compared to biological hazards; this was contrary to a recent review by Rai et al. (21), where more studies were rather on exposure to biological hazards.
The past 3 years of this review witnessed quite a greater number of researches on occupational health and safety but the evidence is weak since more rigorous study designs were not employed in almost all articles. Yet, this still indicates an increase in the recognition of subject areas in Ghana’s health care industry and can serve as a precursor to the production of a higher form of evidence in the field (19). According to this review, most studies were conducted among the general health workers, which may include ancillary staff but no study employing ancillary staff only as participants was done in the years considered for this review. This calls for alarm since these groups of workers (ancillary staff) may be more exposed than the healthcare providers. Subsequently, it suggests that we have to take a closer look at this category of workers.
Exposure to biological hazards
Sharp-related injuries
Many pieces of literature according to this review, investigated sharp-related injuries as a route of exposure to biological hazards. Sharp-related or needle-stick injury is highly recognized as one of the most serious occupational health hazards among health workers (27). And it is ranked as a high-risk route of acquiring and transmitting biological hazards such as Hepatitis B Virus (HBV), Hepatitis C Virus (HBV) and Human Immunodeficiency Virus (HBV) (27,28). The high prevalence of these blood borne pathogens in low-middle-income countries including Ghana, and the lack of safety measures to reduce their risks accounts for the increased risk of transmission among healthcare providers and ancillary staff in developing countries (29,30).
The studies included in this review reported variable prevalence of sharp-related injuries, needlestick injuries and cuts. The prevalence was reported in the past 12 months for most studies with a study reporting a lifetime prevalence. The prevalence of sharp injuries and needlestick injuries was reported in four (4) studies while cuts were reported in two (3) studies. The prevalence of sharps-related injuries over one year ranged from 15.13% in a study conducted in the Brong Ahafo region to 53.7% in a study done in the Greater Accra region (31–34). Also, needlestick prevalence over a 12 months duration ranged from 34.5% in a study done in the Ashanti region to 66.0% in a study conducted in the Northern region (31,34–36). A lifetime prevalence of needlestick injuries was reported as 54.6% in a study conducted in the Northern region (35). Also, a year prevalence of cuts was reported as 34.6%, 62.1% and 70.5% in studies conducted in Ashanti, Greater Accra and Northern regions, respectively (31,34,37).
Lack of workplace supervision, health and safety training, alcohol consumption, job stress, sleeping difficulties, failure to use PPE and type of facilities were predisposing factors associated with sharp-related injuries (33,36). Gender, age category, training in infection prevention and control, working experience, type of facility were factors associated with needlestick injuries (35,36). Preventive measures such as proper disposal of sharps, usage of PPE and training in occupational safety were highly utilized as reported in a study (34) included in the review while the system of reporting sharp injuries was not utilized, which ended up in some injuries not reported and subsequently not treated (35). Knowledge on the protocol to report a sharp-related injury, needlestick injuries and associated diseases acquisition, and appropriate quarters to assess PEP and other occupational safety issues were reported (32,34,36).
To sum up, the occurrence of sharp-related injuries through needlestick injuries and cuts is still common in Ghana. Though individual-related factors have been associated with these exposures, facility-related factors have also been mentioned.
Blood and Body fluids
The exposure to blood and body fluids among healthcare professionals has become the most prevalent means of exposure to blood-borne pathogens; hence, making it a major problem of great concern in the health care industry (23,38). Blood and body fluid exposure has been reported as a major predisposing factor to the transmission of common blood-borne infections including HIV (39). The accidental contact of a patient’s blood and body fluids during a medical procedure does not only affects the safety and wellbeing of the healthcare provider or ancillary staff but also disrupts the delivery of quality health care (40,41).
Two studies included in this review investigated exposure to blood and body fluids. Both studies reported a 12-month prevalence of 50.6% (42) and 67.5% (43). One of the studies (43) reported that 25% of the participants who were exposed to blood and body fluids tested positive for HIV; however, all of them utilized the post-exposure prophylaxis (PEP) for HIV. Also, other studies in this review reported a pathogen infection prevalence of 13.8% and 33.0% (37,44). The most prevalent ways of exposure were torn gloves, a splash of blood and body fluids, sharp injury and needle pricks (42). PPE availability, risk perception, exposure reporting, infection prevention training, being a midwife, attending to more patients per shift and work experience were associated with exposure to blood and body fluids.
Exposure to COVID-19 virus
The occupational contact of healthcare workers makes them the highest population at risk of exposure to the COVID-19 disease (45). This risk of exposure has resulted in numerous COVID-19 infections reported across the globe (46). Healthcare providers and ancillary workers are at the forefront of the fight against the pandemic and play critical roles such as clinical management of COVID-19 patients (45,47). Our review included only a study that involved the risk of exposure to COVID-19 assessment among healthcare professionals. About 80.4% of these professionals were at a high level of occupational exposure to the COVID-19 virus. Furthermore, approximately 14.0% were at a high risk of COVID-19 virus infection. Workers who performed aerosol-generating procedures held a Master’s degree and were registered were associated with the risk of exposure to COVID-19 virus infection.
In another study in this review, clinical staff, poor maintenance of hospital items and victims of verbal assault were related to biological hazards, marital status was associated with non-biological hazards (37).
Exposure to non-biological hazards
Burnout
The incidence of burnout among healthcare providers, particularly, physicians have increased over time and one in every three physicians is at risk of occupational burnout (48). Low remuneration, imbalance work-life, postgraduate training challenges are prevailing risk factors to burnout (49). Again, burnout has an immense effect on the healthcare system such as absenteeism, decreased commitment and job satisfaction, lower effectiveness and productivity, workforce turnover, risks to patient safety and ultimately poor quality care (50–52).
In this present review, seven studies that made the inclusion criteria investigated burnout. While some of the studies reported general burnout, others reported the component of burnouts – depersonalization, personal achievement and emotional exhaustion. General burnout was reported from a range of 9.90 to 47.0% (53–56). Emotional burnout was reported from a minimum of 10.8% to a maximum of 62.5% (56–59), depersonalization burnout was reported from 5.5% to 55.0% (56–59) and personal achievement burnout was reported from 7.8% to 58.4% (56–59).
Age, gender, educational qualification, occupation, years of work experience, marital status, parenthood, COVID-19 preparedness, fear of infection, appreciation from management and family support were associated with burnout (55,56). Also, work-to-family conflict, career satisfaction, extra work hours, night shifts were related to burnout (53,54,57). Problem-focused copying strategy, emotional support from family/friends coping strategy, using humour and listening to music were suggested ways of preventing burnout (58).
In summary, burnout was prevalent in Ghana; however, emotional burnout is on the rise compared to the other forms of burnout. Support from family and management was fundamental in coping with burnout.
Stress
The workers of health care industries are highlighted as one of the occupational groups that experienced elevated stress levels in their line of work and are at risk of developing several occupational stress symptoms (60,61). Understaffing, high job demands, insufficient resources and compassion fatigue, risk of infection are among the prevailing reasons that lead to increased job strain and occupational stress and finally poor service delivery (62).
This review included seven articles that studied work-related stress among healthcare workers. Stress levels were reported within the range of 4.0 – 89.8% (55,56,63–66). However, a study reported stress reported as 10% above the Weiman occupational stress scale (67). Work-related stress was associated with hypertension, age, marital status, work overload and educational background, manual lifting of patients and equipment, risk of acquiring infection, receipt of feedback on unsatisfactory performance and inadequate opportunities for continuous professional development (55,63,65,66). Appreciation from management, family support, being prepared for the COVID-19 pandemic was associated with lower stress levels (56) whilst fear of infection and absence due to sickness was related to higher stress levels (56). There was adequate knowledge of hypertension as a risk factor of stress (65).
Taken all together, stress was high among the healthcare providers and ancillary staff in Ghana. Also, work load related factors like moving equipment or patients, and fear of receiving unsatisfactory feedback from supervisors were prevalent risk factors.
Musculoskeletal injuries and violence
Health care workers are most vulnerable to work-related musculoskeletal injuries due to their line of work routine (68,69). About a third of all sick leave among healthcare personnel are attributed to musculoskeletal disorders or injuries (70). However, these injuries are underreported, even in developed countries (71). The issues of violence in the healthcare sector are extensively documented both in developing and developed countries (72–74). Also, healthcare professionals are 16 times more exposed to workplace-related violence (75). The huge cost and poor healthcare services, low knowledge of the healthcare system, no or lack of faith in the judicial system and vulnerability of healthcare facilities are factors that trigger the menace of violence (76). A single study on musculoskeletal injuries and another on violence satisfied the inclusion criteria for this current review. A one year and a week musculoskeletal injuries prevalence of 70.1% and 44.6%, were reported, respectively (77). The occurrence of sexual harassment was 12.0% and verbal assault was documented as 52.2% (78). Violence was related to gender and intention to quit the job. Whereas frequent verbal abusers were relatives of patients, sexual perpetuators were doctors (78).
Physical hazards, irritation from disinfectants, lower back pain, slips, trips and falls were reported in other studies included in this review (37,44,79). Also, extreme pressure from work was related to both exposure to biological and non-biological hazards (37).
Exposure to general occupational health hazards
A single study included in this current review reported a collective exposure to occupational health hazards among healthcare personnel as 44.0% (79). Again, more years on the ward was associated with exposure while the frequency of exposure was related to healthcare personnel on the routine day and those that alternate day and night (79).
Control/preventive measures regarding exposures to occupational hazards
Hand hygiene and face mask compliance
Hand hygiene continuously proves to be an effective way of preventing or reducing the transmission of healthcare-associated pathogens in the health care industry, where transmission of infection from patient to patient is mostly transferred through the hands of healthcare workers (80,81). However, low compliance of hand hygiene are reported all over the world (82). The combination of universal face masking and comprehensive infection prevention programme has proven to reduce healthcare-associated cases of infectious diseases including COVID-19 (83,84). Nonetheless, compliance to face masking among healthcare providers remains suboptimal irrespective of the recent call for universal face masking (85).
Hand hygiene compliance was investigated in four of the studies included in this review and one of the studies considered hand and face mask compliance. Compliance with hand hygiene ranged from 9.2 – 88.4% (86–89). Perceived risk, occupational category, educational level, IPC in-service training, hospital monitoring, staff adherence to IPC, ward of a health care worker, duty shift, occupation and type of hand hygiene indication were associated with hand hygiene compliance (86–88). Alcohol hand rub and liquid soap dispensers were found to be readily available at facilities for hand hygiene compliance (86). Face mask compliance level was reported as 73.7% (87). Also, occupation, age group, educational level and hospital monitoring of adherence to IPC were related to face mask compliance (87).
Hepatitis B vaccine uptake
Though hepatitis B infection is vaccine-preventable, low uptake has been reported among healthcare workers in developing countries (90). Studies conducted among healthcare professionals in sub-Saharan Africa have reported between 35 to 65% (90–92), which is below the World Health Organization recommended 100% coverage of hepatitis B vaccination. The uptake of the hepatitis B vaccine among healthcare providers and the ancillary staff was explored in three studies included in this present review. The prevalence of hepatitis B vaccination was reported within a range of 44.8-90.4% (93–96). Nonetheless, the full vaccination status of health personnel ranged from 49.4 to 80.0% (93–96). Again, working more than sixteen years, daily exposure to blood, body fluids, sharp instruments, stained linens and waste, performing invasive procedures daily, a program of study, year of study, knowledge on hepatitis B, and hepatitis B vaccine effectiveness was associated with vaccination status (93–95).
Adherence to HIV post-exposure prophylaxis protocol
The prevention of a possible seroconversion of HIV after an exposure dwells on a timely uptake of post-exposure prophylaxis; unfortunately, health care workers hardly adhere to the post-exposure prophylaxis protocol (97,98). A single study included in this review ascertained the adherence of HIV post-exposure prophylaxis protocol. The adherence to HIV post-exposure prophylaxis protocol among healthcare providers was 17.9% (98). While the risk of occupational exposure was 91.5%, exposure in the past year was 51.3%, out of those exposed only 44.4% received HIV PEP. Also, adherence to HIV PEP protocol was associated with the risk of assessment of participants and training on HIV PEP. Again, only 16.6% had adequate knowledge of PEP.
Compliance with infection prevention and control guidelines
Compliance with IPC precautions, methods and strategies are significant in the reduction of healthcare-associated infections (99). Yet, varied compliance to IPC practices such as the use of PPE and hand hygiene has been published (99,100). Also, training and education improves IPC practices and ultimately its compliance (101,102). Three studies in this review investigated compliance with infection prevention and control guidelines. These IPC compliance studies were conducted concerning hand hygiene and PPE usage, hepatitis B infection preventive measures, and general IPC compliance measures. A general IPC compliance was reported as 54.9% (103), IPC compliance for hand hygiene was 88.4% while that for PPE usage was 90.6% (89). Compliance with hand hygiene was associated with a category of staff, educational level while PPE usage was related to marital status, educational level, type of staff and category of staff (89). Also, compliance to hepatitis B infection preventive measures was 16.1% (104). Again, the type of department and availability of dustbins were associated with adherence to HBV infection preventive measures (104), and there was high knowledge of hepatitis B infection and general infection control preventive guidelines (103,104). There was high availability and access to IPC materials including PPE, handwashing facilities and dustbin liners (103,104).
Knowledge of control/preventive measures
Post-exposure prophylaxis
A plethora of studies has published a lack of knowledge regarding post-exposure prophylaxis, which leaves an information gap in the health care system (105,106). The insufficient knowledge on PEP has been attributed to health care workers’ attitude towards PEP, fear of stigmatization and adverse side effects of the treatment using PEP (107). Two studies included in this review assessed knowledge of post-exposure prophylaxis among healthcare personnel; one was one HIV post-exposure prophylaxis and the other on HBV post-exposure prophylaxis. Relating to the study on HIV PEP, only 44.9% had good knowledge while 12.1% had adequate knowledge on HBV PEP (96,108). Though about 51.9% of the study participants were eligible for HIV PEP, only 33.8% took the PEP (108).
Standard precautions
Low knowledge of standard precautions is recorded among health care personnel in developing countries including Ghana although adequate knowledge is likely to influence compliance to standard precautions (96,109,110). The general knowledge of the basic concepts of standard precautions was low as reported in the only study in this review that investigated standard precautions and barriers to compliance to them. (111). The major barriers that hindered the compliance to these precautions included lack of time, panic to patients, demands to patient care and lack of PPE. Also, sufficient knowledge was reported on general control measures, individual protective practices and institutional culture and practices (112).
Tuberculosis infection prevention and control measures
The tuberculosis disease is well understood by healthcare providers; however, knowledge on its infection prevention and control measures are not satisfactory (113–115). Two studies in this review looked at knowledge of tuberculosis infection prevention measures. However, one of these studies partly considered tuberculosis infection prevention practices. About 59.8% adequate knowledge on tuberculosis infection preventive measures and knowledge mean percentage of 67.2% were reported among health care workers (116,117). Also, sex, current ward of work, job title, practices by health workers and use of information and communication materials were associated with knowledge on tuberculosis infection prevention measures. Again, approximately 27.1% of doctors and nurses practised effective tuberculosis infection prevention measures (116). And working years, knowledge of TBIPC, ever attending TBIPC training were key predictors of effective TBIPC practices (117).
Risk of exposure to occupational health hazards
Finally, three studies in this review considered the knowledge of the risk of occupational health hazards. Knowledge of risk of occupational health hazards and safety were reported within a range of 66.5 - 92.7% (44,79,112). There was adequate knowledge on the risk of exposure to biological, psychological, ergonomic, physical and chemical hazards (112). Also, age, educational level, income and profession had an association with knowledge of the risk of exposure to psychological, chemical and ergonomic hazards.
Implications
This scoping review has depicted that healthcare providers and ancillary staff in Ghana are invariably exposed to a wide scope of both biological and non-biological occupational health hazards. Though exposure to biological hazards is reported to occur frequently in low-middle-income countries (21), this review revealed that more studies are conducted in the area of exposure to non-biological hazards, implying that assessment of biological hazards may not have been adequately assessed in Ghana.
The risk factors of occupational exposures were mainly individual and health facility-related. This calls for government and non-government organizations to consider ways of improving the quality of services provided by healthcare facilities since factors related to health facilities have a direct bearing on the exposures to occupational hazards among workers in the health sector. The review further reveals that compliance to and utilization of control/preventive measures regarding exposure to occupational hazards was not adequate; it is necessary to provide prevention and control facilities, implement policies and increase supervisory roles to curb non-compliance to these control or precautionary measures and increase the utilization of available preventive measures. Further, low knowledge of control/preventive measures among health care workers was revealed in this review. A knowledge gap is a fundamental problem that can retard the fight against the control and prevention of occupational health hazards.
The popularity of occupational health hazards research works over the last three (3) years is highly recommended; this will in a long run bring improvement of services in the healthcare industry if their findings are adequately implemented. However, more work needs to be done since almost all studies were based on cross-sectional designs. To substantiate the current evidence available, prospective designs and other vigorous study designs are needed. Again, a wholistic occupational exposure in the health care industry of Ghana is difficult to ascertain because there was no single study that considered only ancillary staff, workers in the WHO elementary occupations category as study participants. Although this review was keen on finding studies done among only this category of workers, none was found. Nonetheless, they were considered as part of studies that considered health workers as a whole; and most studies in this review looked at study participants from this angle. Again, this review has shown that more studies have been conducted on occupational exposure to stress, burnout and sharp-related injuries. This implies that some key other exposures in the healthcare industry have not received sufficient research focus.
Strengths and Limitations of the Review
This scoping review provides comprehensive coverage of exposure to occupational health hazards among healthcare providers and ancillary staff in Ghana because it did not only consider the prevalence of these exposures but also looked at predisposing factors that are attributed to these exposures as well as knowledge and utilization of the control/preventive measures. Also, articles were searched in seven (7) broad databases through a systematic approach.
The main limitation to this review was that quality assessment of articles was not done and it even included unpublished thesis and dissertations. Another limitation is that the review was restricted to articles published in the English Language and within a review period. Although a search strategy was developed and used for the review, all eligible data may not have been captured by it. The review was comprehensive enough irrespective of these limitations.