Investigation and Analysis of Biosafety Awareness Among Hospital Laboratory Staff in Seven Provinces of China

Background: To understand the biosafety awareness of hospital laboratory staff in seven provinces of China, and to provide a basis for medical staff to carry out laboratory biosafety education. Methods: By using a stratied random sampling method, 188 laboratory staff from 41 hospitals in seven provinces were selected for a face-to-face questionnaire survey. In this survey, the biosafety awareness of the respondents was scored, and the biosafety awareness among hospital laboratory staff were evaluated based on the score. Results: The overall average score of laboratory staff in the surveyed hospitals was 81.64 points, and the average score of the biosafety awareness in the laboratory was 95.57 points, while the average score of biosafety awareness in risk assessment and control was only 44.68 points. Among the respondents, 57.22% of the staff identied a lack of special funds relating to biosafety activities. Conclusion: Biosafety awareness of laboratory staff is low, with laboratory funding, education level and years of laboratory work affecting the biosafety awareness of hospital laboratory staff. Biosafety training needs to be improved by paying attention to the biosafety training content, plus adding training effect evaluation and feedback loops, as well as exploring new training modes and increasing the support through special hospital biosafety funds. biosafety between level and biosafety awareness (P 0.05), of laboratory and biosafety awareness 0.05).


Background
Laboratory biosafety assessment is a comprehensive preventive measure to establish laboratory risk factors, to prevent laboratory personnel from being exposed to these risks [1], and to prevent any biohazards from spreading outside the laboratory and causing public endangerment [2]. Laboratory biosafety is not only important in scienti c research institutions, but also in medical institutions [3]. Its successful implementation includes adequate system documentation, personnel training, sample transportation, waste disposal, and emergency treatment [4]. The biosafety awareness of laboratory staff re ects the comprehensive ability of laboratory staff to identify and effectively deal with any potential risks that may compromise the safety of the laboratory workplace. If biosafety awareness is weak, there may be risks in all the previously mentioned areas [5]. Facing numerous and frequent patient encounters, the hospital is an important place for the spread of infectious diseases and the occurrence of crossinfection. The clinical laboratory staff of a hospital gets in contact with a patient's blood, body uids, feces and other samples that may carry infectious pathogens at any time. It is a high-risk area for biohazards [6]. The incidence of the nosocomial infection rate was signi cantly higher in microbiological laboratories than other departments [7], which suggests that attention needs to be paid to the selfprotection awareness of medical staff to reduce the risk of nosocomial infections. Laboratory testing is a key technology in the response to emerging infectious diseases, particularly considering the current global pandemic of COVID-19. Biosafety awareness is crucial to the accuracy and safety of laboratory testing, and it is an important guarantee for laboratory testing.
In order to understand the biosafety knowledge of hospital laboratory staff in several provinces of China, this study aimed to carry out a survey of laboratory staff in 41 hospitals in Shanghai, Zhejiang, Hunan, Guangdong, Guangxi Zhuang Autonomous region, Guizhou and Yunnan province from 2014 to 2015 to assess the knowledge of hospital laboratory staff on biosafety and provide data support for laboratory biosafety training.

Survey methods
The questionnaire on biosafety awareness and knowledge of laboratory staff was generated by collecting and reading the literature on the topic. It included questions relating to demographic characteristics and laboratory biosafety knowledge. The nal questionnaire consisted of 26 questions that were distributed as follows: risk assessment and control, safety of laboratory facilities & equipment, individual protection, health monitoring, laboratory activities, transportation of infectious substances, collection and disposal of medical waste, and emergency management.

Data Collection
The information was collected from July 2014 to December 2015. The survey was strati ed by provincial, municipal and county regions, and hospitals were selected from each province. The object of the investigation was the hospital laboratory staff which was mainly concerned with patient sample testing.
All respondents were interviewed face-to-face, the researcher asked the respondent all questions and notes their responses. The response rate is 100%.

Statistical analysis
A database was created using the Statistical Package for the Social Sciences (SPSS) software, version 22 (IBM SPSS Inc.). The eligible participants totaled 188. Descriptive analysis was used to analyze baseline characteristics and scores, variance analysis was used for personnel strati cation comparison.
To evaluate which characteristics were associated with average scores of the participants, in uencing factors analysis were performed using rank correlation. The statistical signi cance level was set at p ≤ 0.05.

Baseline characteristics
A total of 188 laboratory staff from 41 hospitals in seven provinces were surveyed. The majority of the respondents were female (61.17%), half of the respondents had a bachelor's degree, most had intermediate or junior professional titles, and 51.06% of the respondents were from municipal hospitals (Table 1).  Biosafety awareness of laboratory staff in provincial, municipal and county hospitals The average score of laboratory staff in provincial, municipal and county hospitals was similar, with the highest score at the municipal hospitals (82.96 points). The result of variance analysis was F = 1.343, and there was no statistical difference between the three groups (P > 0.05) ( Table 3).  In uencing factors of biosafety awareness Rank correlation was used to analyze the in uencing factors of biosafety awareness of hospital laboratory staff, including gender, professional title, educational level, age, and years of laboratory experience. There was a positive correlation between education level and biosafety awareness (P < 0.05), and a negative correlation between years of laboratory work and biosafety awareness (P < 0.05). The results indicate that gender, professional title and age did not correlate with biosafety awareness (P > 0.05) ( Table 5). Laboratory biosafety management The survey on the management of laboratory biosafety found that only 11.76% of respondents thought there was no problem in any aspect of the laboratory, 60.96% of respondents thought that the laboratory staff lacked biosafety awareness, 57.22% of respondents identi ed a lack of special funds for laboratory operation and maintenance, 48.66% of respondents indicated a shortage of full-time staff in laboratory biosafety management, and 44.39% of respondents thought that the laboratory equipment was outdated (Fig. 1).

Discussion
Biosafety awareness of hospital laboratory workers with low educational background It has been reported that educational level is one of the factors that affect the biosafety awareness of laboratory staff [8]. In this survey, the education level of the respondents was mainly at bachelor's degree and below. The study also found that education level was positively correlated with biosafety awareness (P < 0.05). At present, most of the colleges and vocational schools in China lack laboratory biosafety knowledge courses [9], and medical students' cognition of laboratory biosafety was not encouraging [10,11]. It has been suggested to set up biosafety courses from junior college majors, to train the students who were ready to engage in biosafety work as soon as possible [12], which has been shown to be bene cial to the cultivation of biosafety awareness and formation of good habits at work, as well as having signi cance to practical work [13].
This study showed that years of experience in laboratory work also was a factor affecting biosafety awareness. The biosafety awareness average score of those who had worked for more than 30 years was only 69.92 points, lower than the average score of those who had worked for less than 30 years. By working in a safe environment for a long time, people tend to pay less attention to detail, which may pose a higher risk of accidents [14]. Therefore, attention to the training of long-term laboratory testing staff should be paid by regularly monitoring and updating the standard operating procedures, and cultivate the ability of risk identi cation and control, so as to improve the biosafety awareness.

Training of risk assessment and control ability
In this survey, hospital laboratory staff had the lowest score (44.68 points) for risk assessment and control, with risk management being shown to reduce the incidence of hospital infections [15]. It is necessary for hospital testing staff to train comprehensively on biosafety knowledge, with emphasis on risk assessment, i.e. identifying and assessing risks and proposing measures to control risks.

Biosafety training of laboratory testing staff in hospitals
Biosafety training of laboratory personnel is an internationally recognized strategy for improving the ability to handle potentially infectious samples [16]. In this survey, 60.96% of participants believed that laboratory staff lacked safety awareness. It was noted that there was little training on biosafety in the hospitals or less time for the staff to participate in training, so the staff was unable to develop a high biosafety awareness, which can only be gained through continuous training at work.
Special funds for hospital biosafety The clinical laboratory of a hospital is responsible for the detection of many pathogens potentially risky to human health, which need to be managed in a Biosafety Level 2 laboratory [17]. The facilities and equipment of a biosafety laboratory and the personal protective equipment are different from an ordinary laboratory. Regular testing and maintenance of equipment, as well as the collection, transportation and disposal of medical waste need special funds to support these actions. At the same time, with the improvement of medical and detection technologies, the technology and components of biosafety facilities & equipment should be constantly updated. Modern instruments and equipment can provide more effective, convenient and accurate biosafety detection abilities for personnel and patients. Therefore, it is suggested that the hospital or the relevant department grants special funds to the biosafety laboratory to ensure that the laboratory testing can be carried out more e ciently.

Training effect evaluation and new training modes
This study revealed that the laboratory staff identi ed the training as not su cient in terms of frequency and content, leading to low biosafety awareness. In the future, biosafety training courses should include a training feedback and evaluation loop, which can assess whether the trainees understand the content, but also whether the training has achieved the set goal. The received feedback can also provide ideas for new training content and methods. By exploring online training delivery and optimizing the training method, the e ciency of the biosafety training can effectively be improved [18][19][20].

Conclusions
Enhancing biosafety awareness among hospital laboratory staff is a long-term and complex task. It requires staff and managers to recognize the importance of biosafety assessment and risk aversion. By using new training modes and focusing on the training of key staff and key contents, staff should be encouraged to participate in the training, so as to effectively improve the biosafety awareness. Future research may expand on the investigation scope, increase the sample size and improve the accuracy of the analysis.

Declarations
Ethics approval and consent to participate The study received approval from Chinese Center for Disease Control and Prevention. All interviews were conducted with the participants' written informed consent. Each participant in the study was clearly explained of the study objectives, informed of their rights to deny participation and assured for the con dentiality of the information provided.

Consent for publication
Not applicable. Problems identi ed in laboratory biosafety management.

Supplementary Files
This is a list of supplementary les associated with this preprint. Click to download. Questionnaire.doc