One of the core elements of primary health care services is prevention of infectious diseases and its transmission, including blood borne infection. Protection of both patients and health care providers from infection transmission at any point of care is crucial. Therefore, safe injection practices and proper infection control are basic expectations at any health care sites [8].

Our study demonstrated a good level of awareness regarding the implemented policies and procedures for safe injection and post-exposure NSI (96.5%). It represents an improvement over the percentage reported (63.2%) in a similar study in Gharbia, Egypt [9]. A reasonable explanation was the lack of many important policies and procedures for safe injection at that time in the Gharbia health care facilities.

The overall awareness level based on number of correct answers was satisfactory. However, 50% of participants had good awareness level whereas one third of participants had accepted awareness level. The lower level of accepted awareness score in comparison to the good awareness score could be attributed to the physician’s low level of awareness regarding ‘supplies’ and ‘disposal items. This could be inferred as these items were outside the scope of their direct responsibility. In contrast, lab technicians, and nurses in our findings demonstrated higher awareness levels which may be explained by their direct participation in the process of injection (supply and disposal).

Our findings were in line with similar studies which reported a wide difference in the level of awareness among different categories of health care providers. One of the main factors causing these wide variations is the level of education among participants and regions assessed as shown in a study in Beni-Suef University Hospital, Egypt, in comparison to a Saudi hospital. The participants were all nurses with post-secondary education and had attended training, the reported level of “good” knowledge was higher among Egyptian nurses [1]. Whereas a lower level was reported among health care providers across different health care facilities in North-Eastern Nigeria, who had lower level of education despite attending training [10].

The participants in our study were highly aware of essential awareness items such as disease transmission risks through contaminated equipment (100%), presence of reporting system after NSI exposure (86.4%), avoidance of recapping (86.1%), and rapid disposal of used syringes in sharp boxes (84.2%). A plausible explanation is the emphasis on these items during training and in the mainstream education of health care providers. However, these percentages were still lower than the ones reported in Oman study [3], and in Fayoum University teaching hospital study where the intervention effect of training was the cause behind the improved awareness level about safe injections [11].

By observation, full implementation was done only for four items: the use of new disposable syringe for each patient, a multi-dose vial is entered every time by a new syringe, the preparation of injection in a clean area, and the aseptic non-touch technique for the vein. In practice, other steps for safe injection were fulfilled in variable percentages. Research show that implementation of safe injection varied significantly across different types of services [12]. The vaccination procedures were the most common activities observed, which are within the scope of services provided at PHC facilities as the same locations were conducted [12, 13]. Although some patients would bring with them their own new syringe especially for lab investigations, yet this is never observed at vaccination clinic. Hence, proper management of the limited resources and the shortage is crucial.

The percentage of providers who cleaned their hands before injection preparation was higher than those reported in previous studies conducted in Egypt and Saudi Arabia [1], another at PHC centers in Alexandria, Egypt [12] and a third in Gizan [13] and in Port said general hospital [14]. Only one study conducted in West Bengal reported 100% of disinfecting hands before the procedures [15]. Better compliance was observed after the injection process but still urge the need for training and regular monitoring of practice to reach a satisfactory compliance level.

Proper disposal of the used syringe in a puncture-proof container that is closed immediately after use without recapping provide the providers with significant protection and reduce the most avoidable risk [16]. Our observation showed that the sharp box/container is the most used method for syringe disposal while the needle remover was used in only one center. More than three quarters of the used needles and syringes were properly disposed of in a sharp box/container. This percentage is lower than that reported in the comparative study conducted in Egypt and Saudi Arabia [1] but still higher than that reported by a Nigerian study [17]. The differences are mainly due to the relatively high cost of these devices for PHCs, although unsecure disposal can make it easier to scavenge, repackage, and resell.

Furthermore, although 78% participants had received training on NSI policies, 73.9% implemented no recapping. This rate is higher than some results reported in the Africa and Alexandria [12, 18] but still there is room for improvement as NSI mostly happen during recapping [19]. With the high compliance observed by the trained personnel, achieving a higher rate of participant’s training would help further reduce the percentage of NSI encountered.

In our study, 15% of participants stated that they had at least one exposure to NSIs in the previous 6 months. This percentage is similar to that reported in Jazan [12] and Alexandria [13], but lower than those reported by other studies [1, 9, 14]. This could be attributed to the higher risks of exposure in hospitals due to higher rate of injections administered. Although most needlestick injuries do not lead to infection transmission, a single incident can cause a serious chronic lifelong infection such as HIV or hepatitis to develop [20]. The risk of contracting hepatitis B is the highest of all infections [21], which necessitates full immunization of providers against Hepatitis B [22,23,24].

The percentage of injection providers who received full doses of hepatitis B vaccinations was similar to the one reported in a Saudi study in Jazan Region [13] and even higher than those reported by similar studies in different Egyptian regions [11, 12, 14] and in an Indian study [23]. However, full immunization of all health workers is needed and should be considered a fundamental right as Egypt has the highest rate globally for hepatitis B and C for the last 20 decades [22] with their life-long and life-threatening complications.

One of the weak points observed in safe injection practice is the low NSI reporting (38.8%) among the exposed providers for NSIs, despite the high awareness (86.4%) of the presence of an implemented NSI reporting system. It is still low and further interviews with health care providers are recommended to find out the root causes of under-reporting, which is a universal behavior by many health care personnel [13].

Overall, the comparison of awareness versus practice scores showed a statistical difference in favor of awareness. Although most health care providers are aware of safe practices, not all of them would put it into practice. This could be attributed to factors related to work such as lack of resources, work overload [2], as well as factors related to personal beliefs. Personal health beliefs are best explained by the health belief model dimensions where a lower perception of barrier and higher perception of stimuli are needed to apply knowledge into practice [19]. Reformulation of health care providers training based on the health belief model might help in achieving higher rate of knowledge translation to practice.

Furthermore, our findings showed statistically significant difference among various categories of health care providers in their awareness and practice level with the most compliant being the lab technicians though physician by education and clinical training are expected to have high level of awareness and high degree of compliance. Since our study is one of the few studies which included all the categories of health care providers and explored the differences in awareness and practice, further studies are recommended to support the findings and explore different paths for achieving optimal compliance and preventing serious sequelae.

Some collected information, e.g., needlestick injuries and hepatitis B immunization, were based on self-reporting by the providers. Additionally, observation of the health workers after obtaining informed consent may affect the results towards best practices due to the Hawthorne effect. Finally, the study was conducted in one governate. Thus, other studies are recommended to identify disparities between different governates and health districts.