None of the 16 studies examined elimination or substitution (e.g., substituting an oral medication for an intravenous medication to reduce the risk of exposure via needlestick) as a way of managing exposure to biological hazards. Four examined facilities’ engineering-based controls (Adinma et al., 2009; Enwere & Diwe, 2014; Kingham et al., 2009; Yawson & Hesse, 2013). Two of these examined the infrastructure needed for proper hand hygiene. Yawson and Hesse’s (2013) survey of hand hygiene practices found that of the 15 Ghanaian units surveyed, all had running water, although other controls, such as alcohol gel and single-use towels, were frequently missing (Yawson and Hesse, 2013). By contrast, Adinma et al. (2009) in Nigeria found that 46.4% of nurses reported that insufficient water supply was a factor affecting their use of universal precautions.

Two other studies examined engineering controls outside the context of hand hygiene. Enwere and Diwe (2014) noted that although the teaching hospital they were studying had color-coded bins for needle disposal, only 54% of nurses were aware of them. Kingham et al.’s (2009) survey reviewed the availability of equipment needed for safe surgery in Sierra Leone. It found that only 50% of government hospitals had functioning sterilizers and sharps containers available for use. By contrast, all of the faith-based and nongovernmental hospitals previously surveyed had these controls available (Kingham et al., 2009).

Administrative, or behavioral, controls was the topic examined most often in this literature. Fifteen of the 16 papers addressed these controls, with the only exception being Kingham et al. (2009). The most common topics were vaccination, universal or standard precautions, and injection safety. Although each paper had an overarching research topic (e.g., universal precautions, injection safety), they often explored more than one occupational health behavior.

HBV vaccination was the focus of in three studies (Abiola et al., 2016; Konlan et al., 2017; Ogoina et al., 2014). Two of these were conducted in Nigeria (Abiola et al., 2016; Ogoina et al., 2014) one in Ghana (Konlan et al., 2017). All identified serious gaps in knowledge, attitudes, or practice pertinent to HBV vaccination. All three found low rates of HBV vaccination: Abiola et al. (2016) reported the highest rate of vaccination at 48.5% of HCWs receiving the necessary three doses; Konlan et al. (2017) found the lowest at 33.3%. Ogoina et al. (2014), who found 36.2% of HCWs had received three doses, also reported that 32.5% of HCWs had received zero doses. Abiola et al. (2016) found a statistically significant relationship between professional cohort and HBV vaccine practice; nurses were more likely to have good vaccine practice than physicians (p = .05). By contrast, Ogoina et al., (2014) found that while nurses were more likely to be vaccinated than house officers, there was no statistically significant difference between nurses’ vaccination rates and those of resident or consulting physicians. Abiola et al. (2016) found only 56.3% of nurses had good knowledge of HBV infection and appropriate vaccination practices, although the exact knowledge tested was not clear. Konlan et al. (2017), in Ghana, found that only 12.1% of nurses had adequate knowledge of postexposure prophylaxis (PEP) for HBV.

Six studies focused explicitly on knowledge, attitudes, or practices pertinent to universal or standard precautions (Adinma et al., 2009; Arinze-Onyia et al., 2018; Egwuenu & Okanlawon, 2014; Iliyasu et al., 2016; Isara & Ofili, 2010; Olatunji et al., 2009). All were conducted in Nigeria. The term “standard precautions” covers a wide range of behaviors (CDC, 2011); these studies tended to focus on four topics: hand washing, use of protective barriers, and safe use and disposal of sharps. High levels of awareness of standard precautions were reported consistently, with a range of 94.4% (Arinze-Onyia et al., 2018) to 82% (Isara & Ofili, 2010) of HCWs reporting they had ever heard of standard precautions. Isara and Ofili (2010) reported no statistically significant difference in knowledge of standard precautions between different health professions (p = .129); Adinma et al. (2009) found that both 97% of physicians and 92% of nurses had a high level of awareness of standard precautions and did not test to see if the difference was statistically significant. Iliyasu et al. (2016), by contrast, reported that nurses were significantly more likely to have good knowledge of infection transmission than physicians (p = .001). Only one study (Arinze-Onyia et al., 2018) surveyed attitudes to standard precautions, and found them to be generally positive: 94.5% of HCWs either agreed or strongly agreed that standard precautions were useful for protecting against hazards.

Measures of the practice of standard precautions varied across studies. Adinma et al. (2009) found that 66.1% of nurses practiced standard precautions always. Reported rates of hand washing varied. Egwuenu and Okanlawon (2014) found that 80% of nurses reported consistently washing hands after patient care, whereas Isara and Ofili (2010) found 97%. Iliyasu et al. (2016) found that nurses were significantly more likely to wash their hands between patients than physicians (p = .02). Yawson and Hesse (2013), who directly observed nurses, found they washed their hands 60%–87% of the time after touching a patient, depending on the patient care setting. The survey also noted that nurses almost never adhered to the 40–60 second, recommended time frame for hand washing despite having access to most of the needed equipment (Yawson & Hesse, 2013).

The use of gloves was surprising: Isara and Ofili (2010) found that only 75% of nurses wear gloves when assisting with a birth, a finding consistent with Egwuenu and Okanlawon’s (2014) that only 45.9% of nurses wear gloves when they expect to come in contact with blood or body fluids. Olatunji et al. (2009), by contrast, found that 94.2% of nurses always used a protective barrier when providing care, but the difference can perhaps be explained by the fact that Olatunji et al. (2009) focused specifically on nurses providing care to people living with HIV. Isara and Ofili (2010) also reported 62% of nurses used double gloves at least some of the time. Omorogbe el al. (2012) also found that only 3.3% of nurses use gloves regularly when administering an injection; 68.9% do so sometimes.

Four studies focused on knowledge, attitudes, or practices pertinent to injection safety (Amira & Awobusuyi, 2014; Enwere & Diwe, 2014; Lori et al., 2016; Omorogbe et al., 2012); all but Lori et al. (2016) were conducted in Nigeria. These studies examined the frequency of needle stick injuries among HCWs in the past 12 months with very similar findings: 24.5% (Amira & Awobusuyi, 2014), 24.6% (Omorogbe et al., 2012), and 28.9% (Lori et al., 2016). Lori et al. (2016) also found that 36.3% of the nurses who experienced a needle stick injury in the past 12 months had experienced four or more such injuries in that period. Needle recapping, a fairly common behavior, had reported rates between 44.8% (Enwere & Diwe, 2014) and 75% (Arinze-Onyia et al., 2018). Amira and Awobusuyi (2014) found that needle recapping was the behavior leading to 45% of needle stick injuries.

Four studies discussed the amount of PPE available to HCWs by their employers and whether or not it was adequate for care (Adinma et al., 2009; Arinze-Onyia et al., 2018; Kingham et al., 2009; Konlan et al., 2017). All found a dearth of PPE supplies in practice settings. Konlan et al. (2017) found that only half of nurses (51.9%) described the glove supply as adequate; similarly, 57.7% of HCWs surveyed by Arinze-Onyia et al. (2018) reported that they did not have regular access to PPE. Similarly, Adinma et al. (2009) reported that 82.1% of nurses cited a lack of PPE supplies as a reason they sometimes did not follow standard precaution guidelines.

Kingham et al. (2009) examined the issue quantitatively in Sierra Leone by surveying government hospitals, where the majority of care is provided in that country, to assess for the presence or absence of needed surgical equipment. Only one in five of the government facilities surveyed had access to eye protection and sterile gloves, while other surveys had shown that the faith-based and nongovernmental hospitals were fully stocked (Kingham et al., 2009).

Nine studies examined how HCWs responded after an exposure to biological hazards (Amira & Awobusuyi, 2014; Enwere & Diwe, 2014; Iliyasu et al., 2016; Konlan et al., 2017; Lori et al., 2016; Olatunji et al., 2009; Omorogbe et al., 2012; Onadeko et al., 2017; Yawson & Hesse, 2013). Olatunji et al. (2009) examined PEP specifically in the context of caring for patients with HIV. Ways to mitigate risk, which were examined in this literature, were washing the exposed area, reporting the exposure to a supervisor, and, when possible and appropriate, accessing PEP.

Washing the exposed area was a surprisingly infrequent behavior: between 16.2% of nurses practicing in the surgical ward and 29.8% in the NICU washed their hands after a blood or body fluid exposure (Yawson & Hesse, 2013). Amira and Awobusuyi (2014) found that only 37% of HCWs reported their needle stick injuries to a supervisor; Konlan et al. (2017) found that 64.8% of nurses reported. Lori et al. (2016) found that while their facility protocol recommended testing nurses for HIV postexposure, the protocol did not mention HBV testing. Reported knowledge rates of PEP were low, and ranged from 58% of nurses reporting that PEP must begin with 72 hours (Iliyasu et al., 2016) to 69.4% of nurses reporting that PEP should be taken as early as possible to maximize effectiveness (Konlan et al., 2017).

Reported rates of HCWs actually obtaining PEP were all fairly low: Enwere and Diwe (2014) found that 25.6% of HCWs with a history of needle stick injury had obtained PEP (for which illness was not specified), Amira and Awobusuyi (2014) found that only 7.3% of HCWs received PEP for HIV, and 2.4% for HBV; Omorogbe et al. (2012) found the rate was only 0.6% (again, for which illness was not specified). 58.5% of nurses taking care of HIV-positive patients reported they never obtained PEP after a needlestick or sharps injury (Olatunji et al., 2009).

This is a largely atheoretical body of literature. Some internationally recognized tools pertaining to occupational health are used, such as the World Health Organization (WHO) Hand Hygiene Observation Method and WHO Hand Hygiene Technical Reference Manual (Yawson & Hesse, 2013), and the Occupational Safety and Health Administration’s (OSHA) bloodborne exposure standards (Lori et al., 2016).

The current WAHO strategic plan states a clear goal to develop human resources for health, but the plan does not mention supporting the occupational health of HCWs in the region (WAHO, 2016). This review of the literature makes it clear these HCWs are highly vulnerable and that future plans should include goals for minimizing occupational health risk. The United Nations placed the issue of occupational health at the center of the effort to recruit and retain more nurses in 1979 (United Nations, International Labor Organization, 1979) and affirmed in 2017 that poor working conditions contribute to a shortage of HCWs (World Health Organization, 2017). Thus, improving working conditions for HCWs within ECOWAS is an integral part of meeting WAHO’s strategic goals.

To improve the occupational health of nurses, policy changes should take place at the regional, or national, level, and at the level of individual facilities. Regionally, those member states of ECOWAS which do not yet have national occupational health regulations should develop and implement them, with special attention paid to HCWs. Policies supporting HCW vaccination, such as the provision of needed vaccines through the public health system and mandatory paid time off to receive vaccination, would also support worker health. Individual facilities should formulate policies mandating regular trainings on occupational health issues (e.g., standard precautions, HBV PEP) and offer those trainings accordingly.

This review suggests that many of the nurses practicing in ECOWAS do not have adequate protection from biological hazards. For the nurses themselves, simply demanding better conditions, such as more accessible PPE, is unlikely to be fruitful, as their governments are frequently highly constrained by limited budgets. It does seem, however, that certain trainings could improve occupational health by assisting nurses in using the resources that are already available to them. These trainings might include: safer handling of sharps, proper hand washing, or orienting nurses better to the engineering controls available in their facilities.

Another approach might be to partner with local or national nursing boards to develop facilities specifically meant to improve the occupational health of nurses, as has been seen in Swaziland and Lesotho (Carrier-Walker, 2011). This has the potential to be a highly efficient use of funds as such a center could serve several facilities at once and potentially make PEP, currently utilized by a small number of nurses, more broadly accessible.

Based on the studies reviewed, there are four major avenues for occupational health research on nursing in the ECOWAS region. First, the topics in this literature (e.g., adherence to standard precautions, injection safety) should be examined in all ECOWAS countries. Except for Kingham et al. (2009), all of the studies included in this review were conducted in either Nigeria or Ghana. Thus, 12 of the 15 members states of ECOWAS are not represented in this literature, but are likely as vulnerable, or more so, to the same challenges. Second, this literature is aging rapidly; of the 16 studies included in this review, four were published in 2009 and 2010.

Third, there should be more research on the elimination and engineering levels of control. These two levels are both the most efficacious and the most cost effective, so they should be of particular interest in resource-constrained settings. However, they have received very little attention to date.

Fourth, this review has shed light on the dearth of research on occupational health interventions. Every study included was a cross-sectional look at current realities, and nearly every study found important gaps. It would be useful and informative for researchers to attempt to address these gaps by offering and evaluating some of the trainings discussed above, or other interventions they design. More interventions at the administrative level in the hierarchy of controls are of particular interest, given the spending constraints facing many of these governments.