湖南省基层医护人员安全注射现状及实验性干预研究
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摘要
背景安全注射是指对接受注射者无害,对实施注射操作的医疗卫生人员无害,使用过的废弃物不对社会和公众造成危害的注射。不安全注射是指任何对接受注射者、提供注射者或环境造成危害的注射相关行为,包括滥用注射。目前在全球范围内普遍存在注射滥用和不安全注射的问题,发展中国家尤为突出。据WHO报道,发展中国家儿童30%的免疫注射以及50%的非免疫注射是不安全的。不安全注射是乙型肝炎病毒(Hepatitis B virus, HBV)和丙型肝炎病毒(Hepatitis C virus, HCV)传播的主要途径,还可导致艾滋病病毒(Human Immunodeficiency Virus, HIV)、脓肿、败血病、疟疾和病毒性出血热的传播,同时滥用注射可造成药物毒、副作用与医疗卫生资源的浪费。目前,安全注射问题已经成为二十一世纪全球公共卫生领域关注的焦点。
如何减少不安全注射现象,各国学者开展了很多研究,多认为注射提供者的关于注射的知识、态度与行为是造成目前不安全注射现状的重要原因。目前的研究多数集中于预防接种领域,关注注射提供者的知识、态度,且研究对象没有包括所有与注射有关的人群,评价指标局限于目标人群知识的改变。如何全面客观评价目前的安全注射现状,采取有效措施降低不安全注射行为,成为一项亟待解决的重大公共卫生课题。
目的从医护人员及医院管理两方面研究湖南省基层医疗机构的安全注射现状及其影响因素；对医护人员进行以安全注射知识讲座、发放安全注射指南以及现场指导等方式相结合的综合性实验性干预,评价干预后的近期效果及远期效果,降低不安全注射行为,为我国安全注射政策制定提供依据,为改善不安全注射现状提供切实可行的措施。
方法本课题分为两个部分：第一部分为安全注射现状的抽样调查；第二部分为安全注射的实验性干预研究。
一安全注射现状的抽样调查
1研究样本与抽样两阶段分层随机整群抽样。
第一阶段的目标是抽取基层医疗单位。首先按照人均GDP、人均能源消费、农村人口比重、人口预期寿命、新生婴儿死亡率、识字率等标准将湖南省所有市(州)分为四个不同等级,在每个等级中随机抽取一个市(州),分别是长沙市、益阳市、衡阳市、湘西自治州；然后从抽取的市州中随机抽取两个县,共8个县；最后从每个县随机抽取1所县级医院,4所乡镇卫生院,共8个县级医院,32个乡镇卫生院,共40个基层医疗单位为研究单位样本。
第二阶段的目标是从已抽取的基层医疗单位中抽取医生、护士和安全注射管理人员。通过预调查发现医护人员不安全注射行为发生率为29.3%,干预后拟降低10%,根据流行病学公式,结合干预研究过程中可能的失访等因素,本研究最后确定医护人员总样本量为664人。根据样本量的需要,确定从每个已抽取的县级医院中随机抽取医生17名,护士34名；每个已抽取的乡镇卫生院随机抽取医生4名,护士4名。另外从每个基层医疗单位抽取1名安全注射相关负责管理人员。合计共抽取执业医生264名,注册护士400名,医院管理人员40名(因问卷不同,管理人员不纳入医护人员样本量计算)。
2研究内容
(1)基层医护人员不安全注射行为的发生率及其分布；
(2)基层医护人员安全注射的知识和态度；
(3)基层医疗机构的安全注射管理现状：与安全注射的相关规章制度、安全注射用具的供应情况、医疗用品的消毒流程及注射废弃物处理流程等；
(4)分析医护人员安全注射知识、态度与行为之间的关系；
(5)探索医护人员安全注射的影响因素。
3研究工具
(1)医护人员安全注射问卷根据7位专家的意见,结合安徽王藩设计的问卷修订而成,重测信度为0.895(p<0.01)。包括四个部分：①一般资料；②安全注射知识,共13个条目,重测信度为0.811(P<0.01)；③安全注射态度,共8个条目,重测信度为0.692(P<0.01)；④安全注射行为,共13个条目,重测信度为0.925(P<0.01)。
(2)安全注射现场观察调查问卷根据世界卫生组织安全注射现场观察问卷翻译,并结合我国具体国情修订形成。主要包括以下内容：医疗机构的相关设备与供应情况,注射现场是否有锐器盒及锐器盒的使用与处理,医疗机构是否有随意丢弃的用过的锐器,处理大部分锐器垃圾的方式；注射场景观察：如注射环境,使用注射器的类型,注射流程是否规范,注射结束后医疗废弃物的处置情况等。
(3)医院安全注射管理调查问卷包括注射器具及防护器具的供应情况,医疗废弃物处理等安全注射相关政策、制度等。
4研究过程2008年11月,由8名调查员分为四组到各抽样医院发放问卷并进行现场调查与观察,在获得被调查人员口头知情同意后,共发放医护人员安全注射问卷664份,回收有效问卷610份(回收率为91.9%)；发放医院安全注射管理调查问卷40份,回收有效问卷36份(回收率为90.0%)。
5统计方法应用SPSS统计软件包对基层医护人员安全注射现状进行统计描述、卡方检验、方差分析、直线相关分析以及多元线性回归等。
二安全注射的实验性干预研究
1样本根据安全注射现状调查研究结果,为避免交叉影响,将基层医疗单位随机分为实验组与对照组,每组有4家县级医院及16家乡镇卫生院。
2干预方法干预分四个部分进行,包括安全注射知识与技能的培训、安全注射指南的发放、注射现场的实践指导以及与管理者的访谈。
(1)安全注射培训①湖南省安全注射普及性培训：组织专家编写安全注射知识课件、聘请专家讲授医院感染、医疗废弃物的处理、滥用注射、如何处理针刺伤及预防因注射导致的血源性传染疾病及相关法律法规。于2008年10月份举办,为期3天,参加人员为湖南省内多家医院的医院感染负责人员,抽样医院的全部安全注射负责人及湖南省内其他部分非样本医院的负责人。②干预单位安全注射专题培训：委派经统一安全注射培训的8名调查员到实验组医院进行知识讲座,参加人员只有实验组样本人员。方式为多媒体课件集中授课,每次授课时间2小时,于2008年11月10日-17日进行。
(2)安全注射指南根据湖南省安全注射培训班的授课内容编制成指南,在实验组医院的安全注射讲座后即发放,确保实验组医护人员每人一份。要求医院安全注射相关管理部门组织集中学习指南1次,然后再由实验组医护人员自行学习,并根据指南指导实践操作,工作中遇到安全注射的疑问时及时查看指南,研究人员在现场观察时予以提问考核。
(3)注射现场实践指导集中授课后,调查员即到临床科室对注射现场及与注射有关的场所进行现场观察和现场指导,指导前采用单盲法对样本医护人员在值班期间进行的各项注射相关操作进行仔细观察,然后再对现场观察到的各种不安全注射行为予以及时纠正,并进行针对性的正确操作示范,确认对样本人员都进行过一次观察与指导后结束再离开医院,共到样本医院进行过3次观察与指导,每次指导时,均询问其对安全注射指南的学习情况,告知实践操作有疑问时及时查看指南或者电话咨询研究人员。
(4)管理者访谈研究人员到达样本医院后,先与医院安全注射管理人员访谈,仔细询问了解该医院安全注射相关制度的制定与落实情况,是否组织过相关知识的培训,对安全注射的认知,对本院安全注射现状的评价,以及安全注射用具的供应与医疗废弃物的处置流程等,并就我国安全注射相关法律、法规进行讨论。在注射现场及医疗废弃物现场观察后,将观察结果反馈至管理人员,并提出改进建议。
3干预评估分别于干预后1个月和6个月对干预效果进行评估。采取问卷调查、现场观察及访谈等方式综合评估。主要从以下几个方面评价：
(1)医护人员安全注射问卷评价应用医护人员安全注射自填式问卷,由医护人员自行填写问卷,根据问卷结果分析评价医护人员的安全注射相关知识、态度及行为；
(2)医护人员安全注射行为现场评价根据安全注射现场观察调查问卷,由调查员到医疗机构的注射现场进行观察评价；
(3)医疗机构安全注射管理现场评价根据安全注射管理调查问卷,由调查员对医疗机构的安全注射用具供应情况、注射废物处置现场等情况进行现场观察评价,并查看医疗机构相关政策。
4统计方法应用统计软件包SPSS对实验组与对照组之间、实验组自身前后的安全注射知识与行为进行两样本t检验、卡方检验及非参数检验。
结果
1安全注射抽样调查现状
1.1基层医护人员安全注射现状
1.1.1基层医护人员不安全注射行为率为26.94%。不同医院级别医护人员不安全注射行为率之间有差异(P<0.01),县级医院医护人员(22.77%)不安全注射行为发生率低于乡镇卫生院医护人员(33.63%),不同职业医护人员不安全注射行为率之间无差异；医护人员安全注射行为得分为9.50±1.987分,不同医院级别的医护人员安全注射行为得分差异有统计学意义(P<0.01),县级医院医护人员的安全注射行为得分(10.10±1.799)高于乡镇卫生院医护人员得分(8.62±1.922),不同职业医护人员间的安全注射行为得分差异没有统计学意义。不安全注射行为发生率由高到低依次为：58.2%的医护人员不能正确处理针头,57.7%的医护人员在静脉采血及输液时不能检查戴手套；46.9%的医护人员不能坚持在提供注射前检查注射用具的消毒灭菌情况；11.8%(现场观察为17.1%)的医护人员在提供注射时有共用注射器或共用针头现象。
1.1.2基层医护人员安全注射基本知识总正确率为73.62%,安全注射基本知识为9.57±1.63分,不同医院级别的医护人员其知识得分差异有统计学意义(P<0.01),县级医院医护人员的安全注射基本知识(9.89±1.57)知晓情况好于乡镇卫生院医护人员(9.24±1.66)。医护人员间的安全注射基本知识得分差异亦有统计学意义(P<0.01),护士的安全注射基本知识(9.79±1.54)知晓情况优于医生(9.23±1.71)。安全注射知识正确率低于60%的依次是：安全注射的范围(21.0%),能否双手分离注射器(36.6%),不安全注射的后果(54.3%),能否双手回套针帽(55.4%)。
1.1.3基层医护人员安全注射相关态度98.5%的医护人员认为安全注射对患者和医护人员都非常重要。医护人员的标准防护意识较差。16.4%的医护人员认为普通感冒需要打针或输液。
1.1.4医护人员安全注射知识、态度、行为相关分析医护人员安全注射知识分别与态度及行为呈正相关,相关系数分别为0.200(P<0.01)及0.195(P<0.01),但医护人员安全注射态度与行为的相关系数不具有统计学意义。
1.1.5以医护人员注射行为安全性总分为因变量,以医护人员基本资料、知识总分、态度等为自变量,进行逐步引入法多元线性回归分析。最终进入逐步回归模型的有统计意义影响因子有11个,分别是医院级别、经常开展培训、认为滥用注射少见、对艾滋病患者的注射防护态度、科室业务学习、工作类别、知识总分、培训班、五官科、感染病科及提供注射服务时,是否在意患者所患疾病。
1.2基层医疗机构安全注射管理现状通过对36家医疗机构的管理人员进行调查,一次性注射器使用率达100%。医院有安全注射指南和安全注射协议的占41.7%和19.4%。6家(16.7%)医疗机构管理人员反映所在医院出现过因安全注射问题引起纠纷,4家(11.1%)表示对该情况并不清楚,其余大部分(26家)医院未出现过。75.0%的医疗机构无库存耐刺锐器盒,19.4%医疗机构的注射现场有满溢的、被刺穿的或敞开的锐器盒；83.3%有放在塑料瓶或敞开容器的锐器；22.2%医疗机构有随意丢弃的使用过的锐器。80.6%的医疗机构将大部分锐器垃圾转运至集中处理处,但存在一次性注射器具焚烧不彻底或者掩埋深度不够的问题。
2干预后结果
2.1不安全注射行为干预后1个月实验组不安全注射行为率为21.7%,与干预前(26.94%)有明显下降(P<0.01),低于对照组(27.9%)(P<0.01)。干预后6个月实验组不安全注射行为率为18.4%,低于干预后一个月(21.7%)(P<0.01),也低于同期的对照组(22.4%)(P<0.01)。干预后1个月,实验组行为得分为10.17±1.66,与干预前(9.39±1.84)及对照组(9.37±2.13)比较具有统计学差异,实验组得分高于干预前及对照组。实验组在处理使用后的注射器和针头、锐器盒的使用方面明显好于对照组。6个月后的调查结果表明,实验组的行为得分为10.61±1.80,与对照组(10.08±1.78)比较具有统计学差异(P<0.01),实验组的得分明显高于对照组。实验组在“处理使用后的注射器针头、锐器盒的使用、抽血带手套”等方面明显好于对照组。干预后现场观察仍发现各种不安全注射现象,较自我报告的不安全注射情况严重。
2.2安全注射知识干预后1个月,实验组知识总分为(10.18±1.46),与干预前(9.66±1.56)及对照组(9.26±1.80)比较具有统计学差异(P<0.01),得分高于干预前及对照组；干预后6个月实验组知识得分为10.32±1.49,与干预前(9.66±1.56)比较有统计学差异(P<0.01),与对照组(10.09±1.42)无差异。
2.3安全注射态度干预后1个月,实验组有99.3%的人认为安全注射对患者和医护人员都是非常重要的,当遇到艾滋病患者时,实验组有93.0%的人会选择继续提供注射服务,但会加强自我保护,这些与对照组(96.4%,85.1%)比较均具有统计学差异,对于普通感冒患者使用注射的态度,实验组明显好于对照组；干预后6个月,对于普通感冒患者使用注射的态度,实验组仍明显好于对照组。
结论
1.基层医护人员不安全注射行为率为26.94%,主要不安全注射行为表现为：不同患者共用注射器或针头、不能正确应用防护措施、职业暴露多、不正确处置注射废弃物等。
2.基层医护人员安全注射知识掌握不全面,掌握较差的条目表现为：安全注射的范围,能否徒手分离注射器,不安全注射的后果,能否双手回套针帽。
3.基层医护人员普遍对安全注射表示重视,认为安全注射重要,但存在依赖注射的态度,表现为支持普通感冒进行注射治疗。
4.基层医护人员的安全注射行为受以下因素的影响：医院级别、经常开展培训、认为滥用注射少见、对艾滋病患者的注射防护态度、科室业务学习、工作类别、知识总分、培训班、五官科、感染病科及提供注射服务时,是否在意患者所患疾病。
5.基层医院安全注射管理存在较大缺陷,主要表现为：对注射废弃物等医疗垃圾的处置不规范、安全注射用具供应不足。
6.干预后基层医院医护人员不安全注射行为率下降,其安全注射行为与知识得分均有显著提高。知识与技能培训、现场实践指导与管理者访谈相结合的综合干预模式对改变基层医护人员不安全注射的行为效果显著,对提高基层医护人员的安全注射知识也是有效的。
Background Safe injection refers to the injection that is harmless to the recipient, protects the health workers from any avoidable risks and does not result in waste which is dangerous for the comunity. In contrast, unsafe injection practices are detrimental not only to patients, but also to health workers and environment. At present, injection abuse and unsafe injection practices occur routinely all over the world, especially in developing countries. According to WHO reports, in developing countries, 30%of immunization injections and 50%of non-immunization injections given to children were unsafe. Unsafe injection is the main way of transmitting Hepatitis B virus (HBV) and Hepatitis C virus (HCV), which can also lead to the spreading of human immunodeficiency virus (HIV), abscesses, septicemia, malaria and viral hemorrhagic fever. Furthermore, injection abuse can result in toxic and side effects of drugs and waste of health care resources. Currently, injection safety has become the focus of global public health in the 21st century.
In order to reduce unsafe injection practices, a lot of researches have been implemented all over the world. The level of knowledge, attitude and practices of injection provider are the key reasons for current status of unsafe injection. However, most of the current studies focused on the areas of vaccination, the knowledge and attitude of injection providers. Furthermore, not all injection-related groups were included, and the evaluation index was limited to the knowledge difference of the target population. It is becoming an urgent need to evaluate the current status of safe injection comprehensively and objectively so as to take effective measures to reduce unsafe injection behaviors.
Objectives To investigate the status quo of safe injection in primary medical institutions of Hunan province, from both the medical staff and the hospital managers; To give the experimental intervention through lectures, brochures and guidance, evaluate the immediate and long-term effects of the intervention, so as to provide evidences for developing safe injection policies and effective strategies for reducing unsafe injection practices.
Methods The project consists of two parts. The first part is a sample survey of the status of safe injection; the second is the experimental intervention.
Part One Sample survey of the status of safe injection
1 The sample and sampling It has two phases.
The first phase aimed to select primary health care units. The cities and states of Hunan province were divided into four different levels according to the Gross Domestic Product (GDP) per capita, per capita energy consumption, and proportion of rural population, life expectancy, neonatal mortality and literacy. Changsha, Yiyang, Hengyang and Western Hunan Autonomous Prefecture were randomly selected from each level and 8 counties were selected from the 4 cities. Lastly,1 county hospital and 4 rural health centers were selected from every county. Totally,8 county hospitals and 32 township hospitals were chosen as samples of this study.
The second phase aimed at selecting the doctors, nurses and managers of safe injection form the sampling primary health units. The pre-survey revealed that rate of unsafe injection practices of medical staff was 29.3%, which was expected to reduce by 10%with intervention. According to epidemiological formula, combined with other factors, such as the possibility of attrition, the total sample size of medical staff was 664.17 doctors and 34 nurses were selected form each county hospital,4 doctors and 4 nurses were selected from each township hospital respectively, additionally,1 manager of safe injection was selected from each primary health care unit. Totally,264 doctors,400 nurses and 40 managers participated the survey. (Due to the different questionnaires, the managers were not included in calculation of sample size).
2 Contents
(1) The incidence and distribution of unsafe injection among primary medical staff;
(2) The knowledge level of safe injection and attitude of primary medical staff;
(3) The reality of management of safe injection in primary health care units:the relevant rules and regulations of safe injection, the supply of injection equipments, the disposal process of medical waste and so on;
(4) The impact factors of safe injection.
3 Instruments
(1) Medical staff safe injection questionnaire The questionnaire was developed based on Wang fan's original questionnaire and modified by 7 experts, the test-retest reliability of the questionnaire was 0.895 (P <0.01). It included four sub-scales:①general information;②safe injection knowledge, consisting of 13 items, the test-retest reliability was 0.811 (P<0.01);③safe injection attitude, including 8 items, the test-retest reliability was 0.692 (P<0.01);④safe injection behavior, including 13 items, test-retest reliability was 0.925 (P<0.01).
(2) Safe injection field observation questionnaire The questionnaire was translated from WHO safe injection field observations questionnaire, and modified according to the national conditions in China. It included the following:the supply of related equipments, sharp boxes available in injection site and disposal of sharp boxes; used sharps; the way of handling most of the sharps waste. We also observed the injection scenery, such as environment, the type of syringes, the process of injection and the management of medical waste.
(3) The safe injection questionnaire for hospital managers It aimed to investigate the supply of injection and protective equipments, the policies of medical waste collection and management.
4 Procedures In November 2008,8 investigators divided into 4 groups went to all the selected hospitals to observe and investigate the status of safe injection. Informed verbal consent was taken from each eligible participant before administration.664 medical staff safe injection questionnaires were administered and 610 were valid (response rate was 91.9%),40 safe injection questionnaires for hospital managers were handed and 36 were valid (response rate was 90.0%).
5 Statistical methods SPSS statistical package was used in the analysis of safe injection of primary medical staff, including statistical description, chi-square test, analysis of variance, linear correlation analysis, and multiple linear regression.
Part two The experimental intervention of safe injection
1 Sample According to the results of the survey and in order to avoid cross-effects, the primary health care units were randomly divided into experimental and control groups, each group has four county hospitals and 16 rural hospitals.
2 Intervention methods The intervention included safe injection knowledge and skills training, injection safety guidline, the guidance of injection fields and practices, and the interviews of managers.
(1) Injection safety training①Safe injection training for the medical staff in Hunan Province:we invited experts to compile the curriculum of injection safety, and give lectures on management of hospital infection and medical waste, injection overuse, how to deal with needle injection injuries and prevent blood born diseases, related policies and laws. The course was held in October 2008 and lasted 3 days. The participants were managers from sampled and non-sampled hospitals.②Special training for intervention units:8 trained investigators went to the intervention hospitals and trained the staff. Only the staffs of intervention groups were trained. The workshop was held from November 10 to 17 in 2008. Multimedia was used to give lesson, and each module lasted 2 hours.
(2) Injection safety guideline We compiled the guideline based on the curriculum of the workshop, and the guideline were designed as portable booklet. All the staff of intervention group got the guideline to guide their practices. The hospital organized them to study the guideline. The researchers assessed their knowledge during field observation.
(3) Injection-site practice guidance After class teaching, the investigators went to the injection sites to observe and guide the practices of injection. They observed the procedures of injection, corrected the unsafe injection practices and demonstrated the right procedure. They observed and guided every participant. They had been to the hospitals for 3 times. Each time, they assessed participants'understanding of guideline and told them to refer to the guideline or consult researchers by telephone when they were confused.
(4) Managers interview It aimed to know about the establishment and implementation of the policies, the training of injection safety, the awareness of safe injection, the evaluation of safe injection, as well as the supply of safe injection equipments and medical waste disposal process, etc, and discuss the related laws and regulations. After injection field observation, the researchers gave the managers feedback and recommendations for improvement.
3 Evaluation The performance evaluation was given respectively after 1 month and 6 months. The evaluation methods included questionnaire, field observation and interview. The following aspects were evaluated:
(1) The safe injection knowledge, attitude and practices of medical staff:it was evaluated by self-administered questionnaire.
(2) The on-site evaluation of safe injection practices:it was evaluated by the field observation questionnaire and the Observation results from the investigators who went to the hospitals.
(3) The management of safe injection sites:based on the questionnaire, and the observation results from the investigators who evaluated the supply of the safe injection devices and the disposal of injection waste and the relevant policies.
4 Statistics methods Statistical package SPSS was to collect and analyze data. Two sample t test, chi-square test and nonparametric test were used to compare the safe injection knowledge and behavior of intervention and control group. The same test were used to compare the difference between pre-and post intervention (intervention group).
Results
1 The status of safe injection
1.1 Safe injection status of primary medical staff
1.1.1 The incidence of unsafe injection practices was 26.94%. There were differences between different levels of hospitals, the county medical staff had the lower incidence of unsafe injection practices(22.7%) than that of township hospitals(33.63%); there were no differences between different kinds of medical workers; the score of safe injection practices were 9.50±1.987, and there were statistical differences between different hospitals. The medical staff of county had the higher score (10.10±1.799) than those of township hospitals (8.62±1.922), and there were no statistical differences between different occupations. The incidence of unsafe injection behavior in order were:59.2%of the medical staff did not dispose needles correctly,57.7%of the medical staff did not wear gloves when drawing blood and giving intravenous infusion,46.9%of the medical staff did not check the disinfection and sterilization of the equipments before injection,11.8%(17.1%field observation) of the medical staff shared needles or syringes.
1.1.2 The accuracy rate of safe injection knowledge was 73.62%. The knowledge score was 9.57±1.63. There were significantly differences between different levels of hospitals, the medical staff of county hospitals were better than those of rural township hospitals. There were differences between different occupations, the nurses were better than doctors. The accuracy rate of safe injection less than 60%were:the range of safe injection (21.0%), whether to separate syringes with hands (36.6%), the consequences of unsafe injections (54.3%), and whether to recap the needles (55.4%).
1.1.3 The attitude of safe injection 98.5%of medical staff agreed that safe injection was very important to patients and medical staff, 16.4%believed that injection or infusion was necessary for ordinary cold, and the conception of standard precaution was not optimistic.
1.1.4 The correlation analysis of safe injection knowledge, attitude, and behavior The safe injection knowledge showed a low positive correlation to attitude and behaviors, the correlation coefficient was 0.200 and 0.195 respectively and there were significances in statistics; but the correlation coefficient of safe injection attitudes and behaviors did not have statistical sense.
1.1.5 Using total score of safe injection behaviors as dependent variable, the basic information, knowledge scores and attitudes as independent variables, stepwise multiple linear regression analysis was used to determine the impact factors. Eventually 11 statistically significant factors entered the stepwise regression model:hospital type, regular training, thinking of rare injection abuse, the protective attitude towards AIDS patients, continuous education, occupations, knowledge score, training courses, providing injections in ENT and epidemiology department, and whether minding what diseases patients got.
1.2 The status of management of safe injection The interview with managers from 36 hospitals suggested that all the hospitals used disposable syringes.41.7% had the guideline of safe injection and 19.4% had safe injection protocol.6 hospitals(16.7%) reported disputes caused by safe injection,4 hospitals (11.1%) were not clear, and the others(26) never had such issues.75.0% of the medical institutions did not have spare puncture-resistant sharps boxes,19.4% of the medical institutions' sharps boxes were overfull, broken or open; 83.3% of medical institutions disposed sharp waste in plastic bottles or open containers; used sharps were found around the medical institutions(22.2%),80.6% of medical institutions collected and destroyed most sharp waste centrally, but some disposable syringes were not completely burned or buried deep enough.
2 The results of intervention
2.1 Unsafe injection practices One month later, the incidence of unsafe injection practices was 21.7%, significantly lower than pre-intervention(26.94%) and control group (27.9%) (P<0.01). Six month later, the incidence of unsafe injection practices was 18.4%, significantly lower than itself(one month later) and control group(P< 0.01). One month later, the practices score of intervention group was 10.17±1.66; there were significantly differences between pre-intervention and control group. The intervention group was better than control group in disposing used syringes and needles, using sharp boxes. Six month later, the intervention group got higher practices score(10.61±1.80), compared with control group. The intervention group was better than control group in disposing used syringes and needles, using sharp boxes and wearing gloves when drawing blood. But we also observed a lot of unsafe injection behavior, which was-worse than self-administered questionnaire.
2.2 The score of safe injection knowledge One month later, the knowledge score of intervention group was 10.18±1.46. There were significantly differences compared with control group and pre-intervention; Six month later, the knowledge score of intervention group was 10.32±1.49, which was significantly different from pre-intervention. However, there was no significantly difference between intervention group and control group.
2.3 Safe injection attitudes One month later,99.3%of intervention group believed that safe injection was very important to patients and health care workers.93.0%would give injection for people with AIDS, but they would enhance self-protection. Compared with control group, these differences were statistically significant. Intervention group had better attitude on common cold both 1 month and 6 month later.
Conclusions
1 The incidence of unsafe injection practices of primary medical staff were 26.94%, the main unsafe injection practices included different patients sharing needles or syringes, protective measures applied incorrectly, excessive occupational exposure and incorrect disposal of injection waste.
2 The primary medical staff did not fully grasp the knowledge of safe injection, the weakness were:the range of safe injection, separating syringes by hand, the consequences of unsafe injections, and recap the needle.
3 The primary medical staff agreed the importance of safe injection, but the safe injection attitude was somewhat dependent on injection by supporting that injection was necessary for common cold.
4 The safe injection practices of primary medical staff were influenced by following factors:hospital type, regular training, thinking of rare injection abuse, the protective attitude towards AIDS patients, continuous education, occupations, knowledge score, training courses, providing injections in ENT and epidemiology department, and whether minding patients'disease.
5 There was a big flaw on the management of safe injection in primary hospitals:causally disposal of medical waste and inadequate supply of safe injection equipments.
6 The incidence of unsafe injection practices reduced after intervention, their safe injection practices and the score of safe injection knowledge improved greatly. The intervention consisting of combination of the knowledge with skills training, practices guidance and managers interview can significantly change the unsafe injection practices and improve the safe injection knowledge.
如何减少不安全注射现象,各国学者开展了很多研究,多认为注射提供者的关于注射的知识、态度与行为是造成目前不安全注射现状的重要原因。目前的研究多数集中于预防接种领域,关注注射提供者的知识、态度,且研究对象没有包括所有与注射有关的人群,评价指标局限于目标人群知识的改变。如何全面客观评价目前的安全注射现状,采取有效措施降低不安全注射行为,成为一项亟待解决的重大公共卫生课题。
目的从医护人员及医院管理两方面研究湖南省基层医疗机构的安全注射现状及其影响因素；对医护人员进行以安全注射知识讲座、发放安全注射指南以及现场指导等方式相结合的综合性实验性干预,评价干预后的近期效果及远期效果,降低不安全注射行为,为我国安全注射政策制定提供依据,为改善不安全注射现状提供切实可行的措施。
方法本课题分为两个部分：第一部分为安全注射现状的抽样调查；第二部分为安全注射的实验性干预研究。
一安全注射现状的抽样调查
1研究样本与抽样两阶段分层随机整群抽样。
第一阶段的目标是抽取基层医疗单位。首先按照人均GDP、人均能源消费、农村人口比重、人口预期寿命、新生婴儿死亡率、识字率等标准将湖南省所有市(州)分为四个不同等级,在每个等级中随机抽取一个市(州),分别是长沙市、益阳市、衡阳市、湘西自治州；然后从抽取的市州中随机抽取两个县,共8个县；最后从每个县随机抽取1所县级医院,4所乡镇卫生院,共8个县级医院,32个乡镇卫生院,共40个基层医疗单位为研究单位样本。
第二阶段的目标是从已抽取的基层医疗单位中抽取医生、护士和安全注射管理人员。通过预调查发现医护人员不安全注射行为发生率为29.3%,干预后拟降低10%,根据流行病学公式,结合干预研究过程中可能的失访等因素,本研究最后确定医护人员总样本量为664人。根据样本量的需要,确定从每个已抽取的县级医院中随机抽取医生17名,护士34名；每个已抽取的乡镇卫生院随机抽取医生4名,护士4名。另外从每个基层医疗单位抽取1名安全注射相关负责管理人员。合计共抽取执业医生264名,注册护士400名,医院管理人员40名(因问卷不同,管理人员不纳入医护人员样本量计算)。
2研究内容
(1)基层医护人员不安全注射行为的发生率及其分布；
(2)基层医护人员安全注射的知识和态度；
(3)基层医疗机构的安全注射管理现状：与安全注射的相关规章制度、安全注射用具的供应情况、医疗用品的消毒流程及注射废弃物处理流程等；
(4)分析医护人员安全注射知识、态度与行为之间的关系；
(5)探索医护人员安全注射的影响因素。
3研究工具
(1)医护人员安全注射问卷根据7位专家的意见,结合安徽王藩设计的问卷修订而成,重测信度为0.895(p<0.01)。包括四个部分：①一般资料；②安全注射知识,共13个条目,重测信度为0.811(P<0.01)；③安全注射态度,共8个条目,重测信度为0.692(P<0.01)；④安全注射行为,共13个条目,重测信度为0.925(P<0.01)。
(2)安全注射现场观察调查问卷根据世界卫生组织安全注射现场观察问卷翻译,并结合我国具体国情修订形成。主要包括以下内容：医疗机构的相关设备与供应情况,注射现场是否有锐器盒及锐器盒的使用与处理,医疗机构是否有随意丢弃的用过的锐器,处理大部分锐器垃圾的方式；注射场景观察：如注射环境,使用注射器的类型,注射流程是否规范,注射结束后医疗废弃物的处置情况等。
(3)医院安全注射管理调查问卷包括注射器具及防护器具的供应情况,医疗废弃物处理等安全注射相关政策、制度等。
4研究过程2008年11月,由8名调查员分为四组到各抽样医院发放问卷并进行现场调查与观察,在获得被调查人员口头知情同意后,共发放医护人员安全注射问卷664份,回收有效问卷610份(回收率为91.9%)；发放医院安全注射管理调查问卷40份,回收有效问卷36份(回收率为90.0%)。
5统计方法应用SPSS统计软件包对基层医护人员安全注射现状进行统计描述、卡方检验、方差分析、直线相关分析以及多元线性回归等。
二安全注射的实验性干预研究
1样本根据安全注射现状调查研究结果,为避免交叉影响,将基层医疗单位随机分为实验组与对照组,每组有4家县级医院及16家乡镇卫生院。
2干预方法干预分四个部分进行,包括安全注射知识与技能的培训、安全注射指南的发放、注射现场的实践指导以及与管理者的访谈。
(1)安全注射培训①湖南省安全注射普及性培训：组织专家编写安全注射知识课件、聘请专家讲授医院感染、医疗废弃物的处理、滥用注射、如何处理针刺伤及预防因注射导致的血源性传染疾病及相关法律法规。于2008年10月份举办,为期3天,参加人员为湖南省内多家医院的医院感染负责人员,抽样医院的全部安全注射负责人及湖南省内其他部分非样本医院的负责人。②干预单位安全注射专题培训：委派经统一安全注射培训的8名调查员到实验组医院进行知识讲座,参加人员只有实验组样本人员。方式为多媒体课件集中授课,每次授课时间2小时,于2008年11月10日-17日进行。
(2)安全注射指南根据湖南省安全注射培训班的授课内容编制成指南,在实验组医院的安全注射讲座后即发放,确保实验组医护人员每人一份。要求医院安全注射相关管理部门组织集中学习指南1次,然后再由实验组医护人员自行学习,并根据指南指导实践操作,工作中遇到安全注射的疑问时及时查看指南,研究人员在现场观察时予以提问考核。
(3)注射现场实践指导集中授课后,调查员即到临床科室对注射现场及与注射有关的场所进行现场观察和现场指导,指导前采用单盲法对样本医护人员在值班期间进行的各项注射相关操作进行仔细观察,然后再对现场观察到的各种不安全注射行为予以及时纠正,并进行针对性的正确操作示范,确认对样本人员都进行过一次观察与指导后结束再离开医院,共到样本医院进行过3次观察与指导,每次指导时,均询问其对安全注射指南的学习情况,告知实践操作有疑问时及时查看指南或者电话咨询研究人员。
(4)管理者访谈研究人员到达样本医院后,先与医院安全注射管理人员访谈,仔细询问了解该医院安全注射相关制度的制定与落实情况,是否组织过相关知识的培训,对安全注射的认知,对本院安全注射现状的评价,以及安全注射用具的供应与医疗废弃物的处置流程等,并就我国安全注射相关法律、法规进行讨论。在注射现场及医疗废弃物现场观察后,将观察结果反馈至管理人员,并提出改进建议。
3干预评估分别于干预后1个月和6个月对干预效果进行评估。采取问卷调查、现场观察及访谈等方式综合评估。主要从以下几个方面评价：
(1)医护人员安全注射问卷评价应用医护人员安全注射自填式问卷,由医护人员自行填写问卷,根据问卷结果分析评价医护人员的安全注射相关知识、态度及行为；
(2)医护人员安全注射行为现场评价根据安全注射现场观察调查问卷,由调查员到医疗机构的注射现场进行观察评价；
(3)医疗机构安全注射管理现场评价根据安全注射管理调查问卷,由调查员对医疗机构的安全注射用具供应情况、注射废物处置现场等情况进行现场观察评价,并查看医疗机构相关政策。
4统计方法应用统计软件包SPSS对实验组与对照组之间、实验组自身前后的安全注射知识与行为进行两样本t检验、卡方检验及非参数检验。
结果
1安全注射抽样调查现状
1.1基层医护人员安全注射现状
1.1.1基层医护人员不安全注射行为率为26.94%。不同医院级别医护人员不安全注射行为率之间有差异(P<0.01),县级医院医护人员(22.77%)不安全注射行为发生率低于乡镇卫生院医护人员(33.63%),不同职业医护人员不安全注射行为率之间无差异；医护人员安全注射行为得分为9.50±1.987分,不同医院级别的医护人员安全注射行为得分差异有统计学意义(P<0.01),县级医院医护人员的安全注射行为得分(10.10±1.799)高于乡镇卫生院医护人员得分(8.62±1.922),不同职业医护人员间的安全注射行为得分差异没有统计学意义。不安全注射行为发生率由高到低依次为：58.2%的医护人员不能正确处理针头,57.7%的医护人员在静脉采血及输液时不能检查戴手套；46.9%的医护人员不能坚持在提供注射前检查注射用具的消毒灭菌情况；11.8%(现场观察为17.1%)的医护人员在提供注射时有共用注射器或共用针头现象。
1.1.2基层医护人员安全注射基本知识总正确率为73.62%,安全注射基本知识为9.57±1.63分,不同医院级别的医护人员其知识得分差异有统计学意义(P<0.01),县级医院医护人员的安全注射基本知识(9.89±1.57)知晓情况好于乡镇卫生院医护人员(9.24±1.66)。医护人员间的安全注射基本知识得分差异亦有统计学意义(P<0.01),护士的安全注射基本知识(9.79±1.54)知晓情况优于医生(9.23±1.71)。安全注射知识正确率低于60%的依次是：安全注射的范围(21.0%),能否双手分离注射器(36.6%),不安全注射的后果(54.3%),能否双手回套针帽(55.4%)。
1.1.3基层医护人员安全注射相关态度98.5%的医护人员认为安全注射对患者和医护人员都非常重要。医护人员的标准防护意识较差。16.4%的医护人员认为普通感冒需要打针或输液。
1.1.4医护人员安全注射知识、态度、行为相关分析医护人员安全注射知识分别与态度及行为呈正相关,相关系数分别为0.200(P<0.01)及0.195(P<0.01),但医护人员安全注射态度与行为的相关系数不具有统计学意义。
1.1.5以医护人员注射行为安全性总分为因变量,以医护人员基本资料、知识总分、态度等为自变量,进行逐步引入法多元线性回归分析。最终进入逐步回归模型的有统计意义影响因子有11个,分别是医院级别、经常开展培训、认为滥用注射少见、对艾滋病患者的注射防护态度、科室业务学习、工作类别、知识总分、培训班、五官科、感染病科及提供注射服务时,是否在意患者所患疾病。
1.2基层医疗机构安全注射管理现状通过对36家医疗机构的管理人员进行调查,一次性注射器使用率达100%。医院有安全注射指南和安全注射协议的占41.7%和19.4%。6家(16.7%)医疗机构管理人员反映所在医院出现过因安全注射问题引起纠纷,4家(11.1%)表示对该情况并不清楚,其余大部分(26家)医院未出现过。75.0%的医疗机构无库存耐刺锐器盒,19.4%医疗机构的注射现场有满溢的、被刺穿的或敞开的锐器盒；83.3%有放在塑料瓶或敞开容器的锐器；22.2%医疗机构有随意丢弃的使用过的锐器。80.6%的医疗机构将大部分锐器垃圾转运至集中处理处,但存在一次性注射器具焚烧不彻底或者掩埋深度不够的问题。
2干预后结果
2.1不安全注射行为干预后1个月实验组不安全注射行为率为21.7%,与干预前(26.94%)有明显下降(P<0.01),低于对照组(27.9%)(P<0.01)。干预后6个月实验组不安全注射行为率为18.4%,低于干预后一个月(21.7%)(P<0.01),也低于同期的对照组(22.4%)(P<0.01)。干预后1个月,实验组行为得分为10.17±1.66,与干预前(9.39±1.84)及对照组(9.37±2.13)比较具有统计学差异,实验组得分高于干预前及对照组。实验组在处理使用后的注射器和针头、锐器盒的使用方面明显好于对照组。6个月后的调查结果表明,实验组的行为得分为10.61±1.80,与对照组(10.08±1.78)比较具有统计学差异(P<0.01),实验组的得分明显高于对照组。实验组在“处理使用后的注射器针头、锐器盒的使用、抽血带手套”等方面明显好于对照组。干预后现场观察仍发现各种不安全注射现象,较自我报告的不安全注射情况严重。
2.2安全注射知识干预后1个月,实验组知识总分为(10.18±1.46),与干预前(9.66±1.56)及对照组(9.26±1.80)比较具有统计学差异(P<0.01),得分高于干预前及对照组；干预后6个月实验组知识得分为10.32±1.49,与干预前(9.66±1.56)比较有统计学差异(P<0.01),与对照组(10.09±1.42)无差异。
2.3安全注射态度干预后1个月,实验组有99.3%的人认为安全注射对患者和医护人员都是非常重要的,当遇到艾滋病患者时,实验组有93.0%的人会选择继续提供注射服务,但会加强自我保护,这些与对照组(96.4%,85.1%)比较均具有统计学差异,对于普通感冒患者使用注射的态度,实验组明显好于对照组；干预后6个月,对于普通感冒患者使用注射的态度,实验组仍明显好于对照组。
结论
1.基层医护人员不安全注射行为率为26.94%,主要不安全注射行为表现为：不同患者共用注射器或针头、不能正确应用防护措施、职业暴露多、不正确处置注射废弃物等。
2.基层医护人员安全注射知识掌握不全面,掌握较差的条目表现为：安全注射的范围,能否徒手分离注射器,不安全注射的后果,能否双手回套针帽。
3.基层医护人员普遍对安全注射表示重视,认为安全注射重要,但存在依赖注射的态度,表现为支持普通感冒进行注射治疗。
4.基层医护人员的安全注射行为受以下因素的影响：医院级别、经常开展培训、认为滥用注射少见、对艾滋病患者的注射防护态度、科室业务学习、工作类别、知识总分、培训班、五官科、感染病科及提供注射服务时,是否在意患者所患疾病。
5.基层医院安全注射管理存在较大缺陷,主要表现为：对注射废弃物等医疗垃圾的处置不规范、安全注射用具供应不足。
6.干预后基层医院医护人员不安全注射行为率下降,其安全注射行为与知识得分均有显著提高。知识与技能培训、现场实践指导与管理者访谈相结合的综合干预模式对改变基层医护人员不安全注射的行为效果显著,对提高基层医护人员的安全注射知识也是有效的。
Background Safe injection refers to the injection that is harmless to the recipient, protects the health workers from any avoidable risks and does not result in waste which is dangerous for the comunity. In contrast, unsafe injection practices are detrimental not only to patients, but also to health workers and environment. At present, injection abuse and unsafe injection practices occur routinely all over the world, especially in developing countries. According to WHO reports, in developing countries, 30%of immunization injections and 50%of non-immunization injections given to children were unsafe. Unsafe injection is the main way of transmitting Hepatitis B virus (HBV) and Hepatitis C virus (HCV), which can also lead to the spreading of human immunodeficiency virus (HIV), abscesses, septicemia, malaria and viral hemorrhagic fever. Furthermore, injection abuse can result in toxic and side effects of drugs and waste of health care resources. Currently, injection safety has become the focus of global public health in the 21st century.
In order to reduce unsafe injection practices, a lot of researches have been implemented all over the world. The level of knowledge, attitude and practices of injection provider are the key reasons for current status of unsafe injection. However, most of the current studies focused on the areas of vaccination, the knowledge and attitude of injection providers. Furthermore, not all injection-related groups were included, and the evaluation index was limited to the knowledge difference of the target population. It is becoming an urgent need to evaluate the current status of safe injection comprehensively and objectively so as to take effective measures to reduce unsafe injection behaviors.
Objectives To investigate the status quo of safe injection in primary medical institutions of Hunan province, from both the medical staff and the hospital managers; To give the experimental intervention through lectures, brochures and guidance, evaluate the immediate and long-term effects of the intervention, so as to provide evidences for developing safe injection policies and effective strategies for reducing unsafe injection practices.
Methods The project consists of two parts. The first part is a sample survey of the status of safe injection; the second is the experimental intervention.
Part One Sample survey of the status of safe injection
1 The sample and sampling It has two phases.
The first phase aimed to select primary health care units. The cities and states of Hunan province were divided into four different levels according to the Gross Domestic Product (GDP) per capita, per capita energy consumption, and proportion of rural population, life expectancy, neonatal mortality and literacy. Changsha, Yiyang, Hengyang and Western Hunan Autonomous Prefecture were randomly selected from each level and 8 counties were selected from the 4 cities. Lastly,1 county hospital and 4 rural health centers were selected from every county. Totally,8 county hospitals and 32 township hospitals were chosen as samples of this study.
The second phase aimed at selecting the doctors, nurses and managers of safe injection form the sampling primary health units. The pre-survey revealed that rate of unsafe injection practices of medical staff was 29.3%, which was expected to reduce by 10%with intervention. According to epidemiological formula, combined with other factors, such as the possibility of attrition, the total sample size of medical staff was 664.17 doctors and 34 nurses were selected form each county hospital,4 doctors and 4 nurses were selected from each township hospital respectively, additionally,1 manager of safe injection was selected from each primary health care unit. Totally,264 doctors,400 nurses and 40 managers participated the survey. (Due to the different questionnaires, the managers were not included in calculation of sample size).
2 Contents
(1) The incidence and distribution of unsafe injection among primary medical staff;
(2) The knowledge level of safe injection and attitude of primary medical staff;
(3) The reality of management of safe injection in primary health care units:the relevant rules and regulations of safe injection, the supply of injection equipments, the disposal process of medical waste and so on;
(4) The impact factors of safe injection.
3 Instruments
(1) Medical staff safe injection questionnaire The questionnaire was developed based on Wang fan's original questionnaire and modified by 7 experts, the test-retest reliability of the questionnaire was 0.895 (P <0.01). It included four sub-scales:①general information;②safe injection knowledge, consisting of 13 items, the test-retest reliability was 0.811 (P<0.01);③safe injection attitude, including 8 items, the test-retest reliability was 0.692 (P<0.01);④safe injection behavior, including 13 items, test-retest reliability was 0.925 (P<0.01).
(2) Safe injection field observation questionnaire The questionnaire was translated from WHO safe injection field observations questionnaire, and modified according to the national conditions in China. It included the following:the supply of related equipments, sharp boxes available in injection site and disposal of sharp boxes; used sharps; the way of handling most of the sharps waste. We also observed the injection scenery, such as environment, the type of syringes, the process of injection and the management of medical waste.
(3) The safe injection questionnaire for hospital managers It aimed to investigate the supply of injection and protective equipments, the policies of medical waste collection and management.
4 Procedures In November 2008,8 investigators divided into 4 groups went to all the selected hospitals to observe and investigate the status of safe injection. Informed verbal consent was taken from each eligible participant before administration.664 medical staff safe injection questionnaires were administered and 610 were valid (response rate was 91.9%),40 safe injection questionnaires for hospital managers were handed and 36 were valid (response rate was 90.0%).
5 Statistical methods SPSS statistical package was used in the analysis of safe injection of primary medical staff, including statistical description, chi-square test, analysis of variance, linear correlation analysis, and multiple linear regression.
Part two The experimental intervention of safe injection
1 Sample According to the results of the survey and in order to avoid cross-effects, the primary health care units were randomly divided into experimental and control groups, each group has four county hospitals and 16 rural hospitals.
2 Intervention methods The intervention included safe injection knowledge and skills training, injection safety guidline, the guidance of injection fields and practices, and the interviews of managers.
(1) Injection safety training①Safe injection training for the medical staff in Hunan Province:we invited experts to compile the curriculum of injection safety, and give lectures on management of hospital infection and medical waste, injection overuse, how to deal with needle injection injuries and prevent blood born diseases, related policies and laws. The course was held in October 2008 and lasted 3 days. The participants were managers from sampled and non-sampled hospitals.②Special training for intervention units:8 trained investigators went to the intervention hospitals and trained the staff. Only the staffs of intervention groups were trained. The workshop was held from November 10 to 17 in 2008. Multimedia was used to give lesson, and each module lasted 2 hours.
(2) Injection safety guideline We compiled the guideline based on the curriculum of the workshop, and the guideline were designed as portable booklet. All the staff of intervention group got the guideline to guide their practices. The hospital organized them to study the guideline. The researchers assessed their knowledge during field observation.
(3) Injection-site practice guidance After class teaching, the investigators went to the injection sites to observe and guide the practices of injection. They observed the procedures of injection, corrected the unsafe injection practices and demonstrated the right procedure. They observed and guided every participant. They had been to the hospitals for 3 times. Each time, they assessed participants'understanding of guideline and told them to refer to the guideline or consult researchers by telephone when they were confused.
(4) Managers interview It aimed to know about the establishment and implementation of the policies, the training of injection safety, the awareness of safe injection, the evaluation of safe injection, as well as the supply of safe injection equipments and medical waste disposal process, etc, and discuss the related laws and regulations. After injection field observation, the researchers gave the managers feedback and recommendations for improvement.
3 Evaluation The performance evaluation was given respectively after 1 month and 6 months. The evaluation methods included questionnaire, field observation and interview. The following aspects were evaluated:
(1) The safe injection knowledge, attitude and practices of medical staff:it was evaluated by self-administered questionnaire.
(2) The on-site evaluation of safe injection practices:it was evaluated by the field observation questionnaire and the Observation results from the investigators who went to the hospitals.
(3) The management of safe injection sites:based on the questionnaire, and the observation results from the investigators who evaluated the supply of the safe injection devices and the disposal of injection waste and the relevant policies.
4 Statistics methods Statistical package SPSS was to collect and analyze data. Two sample t test, chi-square test and nonparametric test were used to compare the safe injection knowledge and behavior of intervention and control group. The same test were used to compare the difference between pre-and post intervention (intervention group).
Results
1 The status of safe injection
1.1 Safe injection status of primary medical staff
1.1.1 The incidence of unsafe injection practices was 26.94%. There were differences between different levels of hospitals, the county medical staff had the lower incidence of unsafe injection practices(22.7%) than that of township hospitals(33.63%); there were no differences between different kinds of medical workers; the score of safe injection practices were 9.50±1.987, and there were statistical differences between different hospitals. The medical staff of county had the higher score (10.10±1.799) than those of township hospitals (8.62±1.922), and there were no statistical differences between different occupations. The incidence of unsafe injection behavior in order were:59.2%of the medical staff did not dispose needles correctly,57.7%of the medical staff did not wear gloves when drawing blood and giving intravenous infusion,46.9%of the medical staff did not check the disinfection and sterilization of the equipments before injection,11.8%(17.1%field observation) of the medical staff shared needles or syringes.
1.1.2 The accuracy rate of safe injection knowledge was 73.62%. The knowledge score was 9.57±1.63. There were significantly differences between different levels of hospitals, the medical staff of county hospitals were better than those of rural township hospitals. There were differences between different occupations, the nurses were better than doctors. The accuracy rate of safe injection less than 60%were:the range of safe injection (21.0%), whether to separate syringes with hands (36.6%), the consequences of unsafe injections (54.3%), and whether to recap the needles (55.4%).
1.1.3 The attitude of safe injection 98.5%of medical staff agreed that safe injection was very important to patients and medical staff, 16.4%believed that injection or infusion was necessary for ordinary cold, and the conception of standard precaution was not optimistic.
1.1.4 The correlation analysis of safe injection knowledge, attitude, and behavior The safe injection knowledge showed a low positive correlation to attitude and behaviors, the correlation coefficient was 0.200 and 0.195 respectively and there were significances in statistics; but the correlation coefficient of safe injection attitudes and behaviors did not have statistical sense.
1.1.5 Using total score of safe injection behaviors as dependent variable, the basic information, knowledge scores and attitudes as independent variables, stepwise multiple linear regression analysis was used to determine the impact factors. Eventually 11 statistically significant factors entered the stepwise regression model:hospital type, regular training, thinking of rare injection abuse, the protective attitude towards AIDS patients, continuous education, occupations, knowledge score, training courses, providing injections in ENT and epidemiology department, and whether minding what diseases patients got.
1.2 The status of management of safe injection The interview with managers from 36 hospitals suggested that all the hospitals used disposable syringes.41.7% had the guideline of safe injection and 19.4% had safe injection protocol.6 hospitals(16.7%) reported disputes caused by safe injection,4 hospitals (11.1%) were not clear, and the others(26) never had such issues.75.0% of the medical institutions did not have spare puncture-resistant sharps boxes,19.4% of the medical institutions' sharps boxes were overfull, broken or open; 83.3% of medical institutions disposed sharp waste in plastic bottles or open containers; used sharps were found around the medical institutions(22.2%),80.6% of medical institutions collected and destroyed most sharp waste centrally, but some disposable syringes were not completely burned or buried deep enough.
2 The results of intervention
2.1 Unsafe injection practices One month later, the incidence of unsafe injection practices was 21.7%, significantly lower than pre-intervention(26.94%) and control group (27.9%) (P<0.01). Six month later, the incidence of unsafe injection practices was 18.4%, significantly lower than itself(one month later) and control group(P< 0.01). One month later, the practices score of intervention group was 10.17±1.66; there were significantly differences between pre-intervention and control group. The intervention group was better than control group in disposing used syringes and needles, using sharp boxes. Six month later, the intervention group got higher practices score(10.61±1.80), compared with control group. The intervention group was better than control group in disposing used syringes and needles, using sharp boxes and wearing gloves when drawing blood. But we also observed a lot of unsafe injection behavior, which was-worse than self-administered questionnaire.
2.2 The score of safe injection knowledge One month later, the knowledge score of intervention group was 10.18±1.46. There were significantly differences compared with control group and pre-intervention; Six month later, the knowledge score of intervention group was 10.32±1.49, which was significantly different from pre-intervention. However, there was no significantly difference between intervention group and control group.
2.3 Safe injection attitudes One month later,99.3%of intervention group believed that safe injection was very important to patients and health care workers.93.0%would give injection for people with AIDS, but they would enhance self-protection. Compared with control group, these differences were statistically significant. Intervention group had better attitude on common cold both 1 month and 6 month later.
Conclusions
1 The incidence of unsafe injection practices of primary medical staff were 26.94%, the main unsafe injection practices included different patients sharing needles or syringes, protective measures applied incorrectly, excessive occupational exposure and incorrect disposal of injection waste.
2 The primary medical staff did not fully grasp the knowledge of safe injection, the weakness were:the range of safe injection, separating syringes by hand, the consequences of unsafe injections, and recap the needle.
3 The primary medical staff agreed the importance of safe injection, but the safe injection attitude was somewhat dependent on injection by supporting that injection was necessary for common cold.
4 The safe injection practices of primary medical staff were influenced by following factors:hospital type, regular training, thinking of rare injection abuse, the protective attitude towards AIDS patients, continuous education, occupations, knowledge score, training courses, providing injections in ENT and epidemiology department, and whether minding patients'disease.
5 There was a big flaw on the management of safe injection in primary hospitals:causally disposal of medical waste and inadequate supply of safe injection equipments.
6 The incidence of unsafe injection practices reduced after intervention, their safe injection practices and the score of safe injection knowledge improved greatly. The intervention consisting of combination of the knowledge with skills training, practices guidance and managers interview can significantly change the unsafe injection practices and improve the safe injection knowledge.
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