Knowledge and associated factors towards cytotoxic drug handling among University of Gondar Comprehensive Specialized Hospital health professionals, institutional-based cross-sectional study

Currently, cancer is among the leading causes of morbidity and mortality in the world. Chemotherapeutic agents are cytotoxic drugs (CDs) which are extensively practiced in health care facilities to treat cancer [1]. Their pharmacological property to kill tumor cells is by interfering with cell division. However, their action is not specific to cancerous cells, and non-cancerous cells may also get damaged [2].

Exposure to CDs may occur during drug preparation and mixing [1, 3], during drug administration [4], during transport, and cleaning spills and waste disposal [5]. Significant amounts of CDs can be absorbed via inhalation of the powder and liquid aerosols, unprotected skin, and mucous membranes; oral exposure may occur from hand-to-mouth contact or ingestion of or drinks and (iv) needle stick injury [6‐8].

Healthcare workers who prepare or administer antineoplastic drugs, or who work in areas where these drugs are used, can be exposed to these agents when they are present on contaminated work surfaces, drug vials and containers, contaminated clothing and medical equipment, and patient excreta and secretions such as urine, feces, and sweat [9]. Several studies reported increased risks of leukemia and breast cancer among nurses handling CDs and not following safety guidelines [10].

Several studies revealed that CDs are hazardous to healthcare workers particularly nurses, pharmacists, and cleaners who may come in contact with these CDs during their daily work activities [11]. The number of healthcare workers who are in contact with cytotoxic drugs is expected to increase due to the increase in the number of new cancer cases requiring chemotherapy [12].

Cytotoxicity can be due to direct contact with CDs without personal protective equipment, needle stick injury, spills, and other unintended exposures which can be contributed by lack of training, inadequate controls, and poor communication [13]. Although guidelines for safe handling of CDs were introduced more than 20 years ago, contamination of both the working environment as well as the healthcare workers is still reported in several recent studies mainly in developing countries [9, 14]. Chronic health effects of cytotoxicity include mutation, carcinogenicity, and adverse reproductive outcomes like infertility, abortion, and poor neonatal outcomes [15‐17].

The cytotoxicity of antineoplastic drugs is preventable using different mechanisms including the use of personal protective equipment and understanding safety guidelines. Acquiring such ways is through the acquisition of knowledge in training or taking the course [18]. Previous studies regarding knowledge revealed a need for training and delivering protective equipment to those working in oncology units [19, 20]. Knowledge about cytotoxic drug handing can help professionals in reducing cytotoxicity of CDs which is associated with the job rank of professionals [21]. Antineoplastic drugs (CDS) are known to cause problems to health workers, the environment, and the general public [22]. CDS can induce significant side effects in patients or any other person exposed to them [23]. CDS, if not properly handled, may end up in the drinking water and put the general public to several health consequences [24]. The characteristic feature of each health-care waste is to pose risk to patients, staff, and the environment [25]. Although guidelines for safe handling of CDs were introduced earlier, contamination of both the working environment as well as the healthcare workers is still reported in previous studies particularly in developing countries [9, 14]. Lack of knowledge among other factors was a major determinant of unsafe behavior related to handling of CDs by healthcare workers [9, 26].

Medical staff and administration have to be more attentive and responsible in the collection and disposal of waste. The knowledge regarding CDs among health professionals is important to safeguard themselves, the patients, and the general public through safe operating procedures and public education about safe disposal of unused drugs.

Because of the aforementioned problems related to cytotoxic drugs, the relevance of healthcare professional’s knowledge about CD handling and absence of studies in Ethiopia, the authors conducted this study to put baseline results for patients, health sector stakeholders, health professionals, and public health safety. The current study assessed the level of knowledge of health professionals who were working in the University of Gondar Comprehensive Specialized Hospital.

Four hundred and twelve health professionals participated in the study with a response rate of 97.4%. Two hundred and twenty (53.4%) participants were males with a mean age of 29.9 years ranging from 20 to 60 years old. Three hundred and thirty-nine (82.3%) participants attain an educational level of bachelor’s degree, 142 (36.5%) had 2 years work experiences, and only 27 (6.6%) individuals had working experiences in oncology unit with 13 (3.2%) workers working in cancer center currently (Table 1).

This study aimed at assessing the knowledge and contributing factors of health professionals about CD handling. Long-term occupational exposure to cytotoxic drugs is associated with various carcinogenic, teratogenic, and mutagenic effects [17, 28, 29]. High levels of knowledge on cytotoxic drugs and their adverse health effects are essential to improving adherence by health professionals with safety measures [9]. Health professionals’ knowledge of CDs is vital for safeguarding themselves, the patients, and the general public through safe operating procedures and public education about proper disposal of unused medications. Lack of knowledge was one of the major determinants of unsafe behavior related to handling of CDs by healthcare workers as evidenced from previous studies [9, 26].

In the current study, 52.7% (47.8–57.8%) of the health professionals had good knowledge about cytotoxic drug handling. The proportion of health professionals with good knowledge about CDs handling in the current study was lower than previous reports among healthcare professionals in Kenya [27], nurses in Turkey [30], nurses and pharmacists in Italy [31], and oncology nurses in Egypt [23]. The lower proportion of knowledge about CDs in the current study might be because cancer treatment units are recently established in the university. The other reason might be the difference between the study setting and the study participants included.

In this study, sociodemographic factors such as male sex, age of 29 to 31 years, having information about CD and attending training or courses related to CDs handling, and good CD handling practice were associated with knowledge about CDs handling.

Male health workers had better odds of knowledge as compared to females. This is in line with a few previous studies [20, 32]. However, a study in Saudi Arabia revealed significantly higher knowledge among females [33]. These discrepancies might be due to other latent factors that mediate the knowledge than sex disparity.

Respondents aged 29–31 years were more likely to have better knowledge regarding cytotoxic drug handling. However, age was not significantly associated with knowledge of CDs handling in previous studies [34]. Study participants who ever heard about proper CD handling were more likely to have better CDs handling knowledge. This is not surprising as knowledge is acquired through information. Health professionals who received training about CD handling were more likely to have better CD handling knowledge as compared to those who did not attend training. Several previous studies supported that training improves knowledge about cytotoxic drug handling [9, 23, 29, 35‐38].

Finally, participants who had taken courses directly related to CDs handling were more likely to have better knowledge regarding CDs, and those with good self-reported CDs handling practice were more than 3 times more likely to have good knowledge. This might be because a high level of knowledge will enable for safe CDs handling compliance, and the practice leads to the acquisition of knowledge. The association of practice with knowledge was in line with a previous study [9]. Nonetheless, the practice has no association with knowledge in other studies [23, 27].

Some of the limitations of this study include social desirability bias and recall bias. The use of relative scale than global sum score in analyzing the response variable in the current study made the comparison with earlier studies difficult. The generalizability of the result to other countries or regions might not be possible as the socio-cultural context, and the health service delivery is different from country to country. It is not known whether similar results will be obtained in other countries and/or regions. Researchers might be expected to adapt the scale used to assess the cytotoxic drug handling knowledge to their own context. Besides, the cause-effect relationship cannot be established as this is a cross-sectional study conducted at a medical hospital in Ethiopia.

Above half of the study participants scored higher than the median of the cytotoxic drug handling knowledge questions. Sex, age, information about cytotoxic drug handling, training, taking courses related to cytotoxic drugs, and good practice were significantly associated with knowledge towards cytotoxic drugs handling. It is therefore imperative to train health professionals and to incorporate CDs handling related course contents while revising curricula to raise the knowledge of health professionals about appropriate cytotoxic drug handling.