Occupational health hazards among healthcare providers and ancillary staff in Ghana: a scoping review

Background The safety of healthcare workers is a pathway to providing safe care to patients and their relatives, and yet healthcare providers and ancillary staff in developing countries such as Ghana are continuously exposed to occupational health hazards. The strict implementation of occupational health and safety policies seeks to curb these exposures. However, empirical evidence including reviews that are needed to arm these policies is lacking in Ghana. This review primarily explored the types and prevalence of exposure to occupational health hazards among health workers in Ghana. Methods A scoping review design was employed for this study. A systematic search strategy was used to identify articles in PubMed, MEDLINE, CINAHL, Embase, PsycINFO, Scopus and Google scholar databases and search engines covering the period of 1 January 2010 to 30 November 2021. Additionally, key studies reference lists, and sources of grey literature were also searched to identify relevant articles. The articles were screened, and data of included articles were extracted and subsequently synthesized. The review considered only quantitative studies. An extensive protocol to this review has already been published elsewhere. Results Our systematic search strategy retrieved 507 publications; however, only 43 met the inclusion criteria. Healthcare professionals in Ghana were exposed to non-biological occupational hazards (stress, burnout, musculoskeletal injuries and violence), biological occupational hazards (sharp-related injuries, blood and body uids and COVID-19 infection). But studies on exposure to non-biological hazards (34.9%) were more compared to biological hazards (20.9%). Averagely, health care workers utilized and complied to control/preventive measures (compliance to hand hygiene, face mask, infection prevention and control guidelines, hepatitis B vaccine uptake, adherence to HIV post-exposure prophylaxis protocol). Further, there was suboptimal knowledge of control/preventive measures (post-exposure prophylaxis, standard precautions, tuberculosis infection prevention and control measures, risk of exposure to occupational health hazards) among the healthcare personnel. The menace of occupational health hazards in the health care sector of Ghana needs more attention. Though this review supports the existing data for occupational health and safety policy, more research is needed to understand the extent of these exposures and their effects on the health system. exposed to occupational health hazards compared to those in developed countries. Exposure to numerous forms of biological and non-biological hazards among healthcare providers and ancillary in the Ghanaian health industry has been reported in single original studies but not scoping or systematic reviews. What are the new ndings? We present the rst scoping review mapping out literature on exposure to biological and non-biological hazards, adherence and knowledge of control/preventive measures among the healthcare providers and ancillary staff in Ghana, after more than a decade of the implementation of the rst occupational health and safety policy for the health care workers of Ghana. foreseeable The development of policy centres on empirical evidence in the form of original research studies, scoping reviews, and systematic reviews and metanalysis. Since there is no form of reviews on the subject matter in Ghana, this present scoping review can serve as an empirical evidence in the creation of future policy by identifying areas that needs attention and amendment. 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). 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).


Introduction
Healthcare providers and ancillary staff continuously experience exposures to several types of biological and non-biological hazards owing to their occupational surroundings, which is documented as one of the unsafe working environments (1)(2)(3). Undeniably, it is counter-intuitive that the health workers that care for the sick work in an industry whose setting is labelled as 'high-hazard'. The infection and reinfection of healthcare workers in the ongoing Coronavirus disease 2019 (COVID-19) pandemic expose the aws in the health care industry (4).
Besides, the exposure to biological and non-biological occupational hazards has been well established in a plethora of empirical evidence. Even so, exposure to biological hazards such as hepatitis B virus (HBV), Human Immunode ciency Virus (HIV), in uenza and tuberculosis (TB) has gained more attention in terms of interventions such as safety programmes, personal protective equipment and research works (5). Nonbiological hazard exposures emanating from formaldehyde, antineoplastic drugs, latex, ethylene oxide, cleaning and disinfecting chemicals have been linked to asthma, unfavourable procreative outcomes and cancers (6-10). Again, many studies have established varying incidences of burnout, stress, violence, injuries and musculoskeletal disorders in the health care industry (11)(12)(13).
Further, the issue of occupational injuries and exposures in the health care sector is a threat to both the high-income and low-middle-income countries. However, there has been much reduction in the occurrence of exposure and improvement in ways of mitigating the burden of the exposure in developed countries compared to developing countries such as Ghana, where occupational health and safety is not on the priority list (14)(15)(16). Lack of data and inadequate policies implementation are among the main reasons why the subject of occupational health and safety have not been given much attention in the third world countries, apart from insu cient data collection systems, poor application of safety rules and regulations, political negligence, and healthcare personnel's not adhering to universal safety precautions (17,18).
A data-driven approach is imperative in addressing the problem of occupational health and safety in health care industries especially in Ghana, where inadequate data and data collection systems is a fundamental challenge (16). In a quest to solve this problem in Ghana, the Ghana Health Service (GHS) and the Ministry of Health (MoH) implemented an Occupational Health and Safety Policy in 2010 and an updated one in 2021, which was solely in the context of COVID- 19 (16, 19). The earlier policy details the lack of data and poor data collection systems on occupational exposures and lack of sensitization on occupational health and safety issues among the workers of the health service, which have improved over the period. Therefore, this scoping review based on knowledge from Arksey and O'Malley methodology (20) was conducted to scope the body of literature on occupational exposures among health personnel in Ghana.
Although some studies have employed scoping reviews methodology on the subject matter, most of these were done in developed countries. The few conducted in developing countries were for low-middle-income and sub-Saharan African countries while the others considered only exposure to biological hazards and not non-biological hazards (21)(22)(23). Again, those reviews which were done in developing countries did not include primary studies that had among only ancillary staff as study participants; workers in the elementary occupations category of the WHO health worker classi cation.
This scoping review summarized the type and prevalence of exposure to occupational health hazards, described health workers' knowledge on occupational exposures and available preventive measures, explored predisposing factors of exposure to occupational health hazards and utilization of occupational health hazards control/preventative measures.

Methods
This scoping review was conducted based on guidance from the Arksey and O'Malley methodology framework (20) and Levac et al. (24) methodology enhancement. Six steps were followed in conducting this review: 1) Identifying the research question, 2) Identifying relevant studies, 3) Selecting studies, 4) charting the data, 5) collating, summarising and reporting of ndings and 6) consulting with relevant stakeholders.
However, the Joana Briggs Institute (JBI) elements for scoping reviews, namely: Participants, Concepts and Context (PCC) was used to de ne the core concept, focus participants, setting of studies and inclusion criteria of the scoping review. Subsequently, it guided in the formulation of research questions and title of the review. The ndings of this review were reported using Preferred Items for Systematic reviews and Metaanalyses extension for Scoping Reviews (PRISMA-ScR) guidelines (25). A detailed protocol for this scoping review has been published elsewhere (26).

Research questions
To achieve a wholistic view of the exposure to occupational health hazards among healthcare providers and ancillary staff in Ghana, and based on the expertise of the research team and some stakeholders in the healthcare industry, the following research questions were developed, and they subsequently guided the conduct of this scoping review; 1. What are the types and prevalence of exposure to occupational health hazards among healthcare providers and ancillary staff in Ghana? 2. What are the predisposing factors of exposure to occupational health hazards?
3. What are the available control/preventive measures for the health workers to use? 4. What is the level of knowledge relating to the risk of exposure and control/preventive measures of occupational health hazards among health care workers? 5. What is the level of adherence to these control/preventive measures?
And it was limited to articles published in the English Language. Additional articles were included by a hand-screening reference list of relevant articles and non-electronic materials. Grey publications, speci cally dissertations/thesis were retrieved through a search on tertiary institutions' websites.

Study selection
Studies included in the scoping review were 1) conducted among healthcare providers, healthcare students, ancillary staff or general health workers, 2) done on occupational exposures to biological and non-biological hazards, 3) conducted in health care facilities in Ghana, 4) based on quantitative; cross-sectional, case-control, prospective and retrospective cohort study designs and 5) studies published from 1 January 2010 until 30 November 2021 and in English Language. Also, studies 1) conducted among participants not working in health care facilities, 2) based on qualitative study approach were excluded from the review.
After the removal of duplicates from extracted articles, title and abstract screening was carried out independently by two reviewers (PAT and AB-A) against a group of minimum inclusion and exclusion criteria including participants' characteristics, the concept of the study, context or setting of the study. Any article adjudged as relevant by any of these reviewers were subjected to full-text review. The full-text review was subsequently carried out. Any discrepancies and disagreement in selecting a particular article was subjected to a second review and further discussed with two reviewers (EA-B and EA-G) to achieve consensus and control reviewer bias.

Data extraction
For every article included in this scoping review, descriptive characteristics comprising of authors, year of publication, the title of study, region of study, study design, study population and sample size, methodology and instrument used, and key ndings were extracted. Furthermore, key outcomes were charted based on the review questions. A nal extraction form is shown in online supplementary Appendix II).

Synthesizing Review Results
The study characteristics of articles covering the study population, year of publication, number of studies published in peer-reviewed journals, and region of the study were presented in graphs. The number of studies based on occupational exposures and preventive measures was tabulated.
Included studies were then summarized according to study characteristics; authors, year of publication, topic, region of study, study design, study population, sample size, methodology/instrument(s) used and key ndings. Finally, the outcome of the studies was summarized along with review research questions.

Results
Four hundred and ninety-four (494) publications were identi ed from a search involving seven databases (Fig. 1). An additional thirteen (13) were retrieved from government and university websites; thus, the total number of articles retrieved was 507. After removal of duplicates, two hundred and seventy (270) were subjected to screening by title, followed by an abstract screening of seventy-eight (78) articles.
Fifty-three (53) articles were appropriate for full-text examination; yet, forty-three (43) were eligible for the scoping review ( Fig. 1). Most of the eligible articles (n = 27, 62.8%) were published within the past three years (2018-2021) of the review (Fig. 2). However, twelve (n = 12, 28.0%) studies included in this review are thesis work and were not published in peer-reviewed journals (Fig. 5). Almost all studies included in this review were conducted using a cross-sectional study design with a relatively larger number of them (n = 15, 34.9%) conducted in the Greater Accra region (Fig. 3). More than half (n = 24, 55.8%) of these studies employed the general health workers group as study participants (Fig. 4), followed by nurses (n = 11, 25.6%).
Relating to the occupational exposures and preventive measures, a greater number (n = 15) of the eligible studies (n = 43) were done on exposure to non-biological hazards, followed by control/preventive measures to occupational health hazards (n = 10), exposure to biological hazards (n = 9), knowledge on control/preventive measures (n = 5), and exposure to both biological and non-biological hazards (n = 4) ( Table 1).
Among the studies on exposure to non-biological hazards, the majority of them, two-fth (2/5) each examined stress and burnout (Table 3). Also, relating to studies on exposure to biological hazards, the majority, two-thirds (2/3) investigated sharps-related injuries (Table 2). Again, with regards to research works on control/preventive measures, one-third (1/3) each inquired into hand hygiene, hepatitis B vaccine uptake, and infection prevention and control (Table 5). Additionally, concerning studies on knowledge on control/preventive measures, two-fth (2/5) each explored post-exposure prophylaxis and tuberculosis infection and prevention (Table 6).

Discussion
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 eld (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 Immunode ciency 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)(32)(33)(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)(35)(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 di culties, 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 uids
The exposure to blood and body uids 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 uid 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 uids 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 uids. 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 uids 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 uids, 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 uids.

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 ght 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)(51)(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 quali cation, 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 con ict, 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). Understa ng, high job demands, insu cient resources and compassion fatigue, risk of infection are among the prevailing reasons that lead to increased job strain and occupational stress and nally 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)(73)(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 satis ed 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). 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 inservice 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)(91)(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)(94)(95)(96). Nonetheless, the full vaccination status of health personnel ranged from 49.4 to 80.0% (93)(94)(95)(96). Again, working more than sixteen years, daily exposure to blood, body uids, 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)(94)(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 signi cant 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).

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 insu cient 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 in uence 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, su cient 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)(114)(115). 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 ght 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 ndings 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 di cult 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 nding 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 su cient 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.

Conclusion
Quite a considerable number of healthcare providers and ancillary staff are exposed to both biological and non-biological occupational health hazards. The predisposing factors of these exposures are primarily healthcare providers and facility-related. The compliance and utilization of control/preventive were not desirable. The knowledge level of control/preventive measures relating to occupational hazards exposure was also suboptimal. Though research that examined occupational health hazards has increased over the last three years, there is still a lack of recognition and knowledge gap of the exposures in the Ghana health care system. Apart from sharps-related injuries, stress and burnout which have received some research attention, all the other exposures have not been extensively studied. An urgent call is required to wholistically research the exposures in the Ghana health system using rigorous study designs including prospective studies.

Declarations Patient and public involvement
No patient was involved.

Ethics and Dissemination
The study is geared towards providing an overview of occupational health hazards among healthcare providers and ancillary staff in Ghana.
Again, it is aimed at providing relevant inputs in the modi cation of the existing occupational health and safety policy and guidelines for the health sector in Ghana. Therefore, the ndings of the study will be shared among key stakeholders like the Ghana Health Service and Ministry of Health. It will also be made public to the Universities that are into the training of public health, occupational and environmental health specialists.
The study will also be published in a peer-reviewed journal, presented at conferences and stakeholders meetings. Since the methodology of scoping reviews involves the collection and reviewing of already available materials in the public space, the study does not require ethical approval. However, this study will involve a consultative approach of key stakeholders that will guide the research objectives and facilitate the knowledge transition and translation process.   A selfadministered questionnaire was designed for the study.
More than half (50.6%) of participants experienced at least one exposure to blood and body fluids. Work experience increased the odds of being exposed to BBF while adequate PPE reduced the odds of being exposed. Torn gloves were experienced most, followed by a splash of blood and body fluids, needlestick and sharp injury.
Apetorgbor (43)  A close-ended questionnaire was used to gather data.
All study participants were aware of NSI and its associated infectious diseases acquisition. However, the prevalence of NSI was 47%. NSI occurrence was high at bedside (28.5%) and clinical laboratories (26.4%). Working more than 5 years and above, being 30 years and above and working in a District Hospital were associated with increased events of NSI.
Hippolyt (33) Figure 1 Flow chart illustrating the scoping review study selection process Number of studies and the regions they were conducted Figure 4