Introduction

The COVID-19 pandemic has been one of the biggest public health crises in recent years, impacting life of millions of people worldwide. Amongst this, healthcare systems and their frontline workers, including primary healthcare professionals, have borne a significant burden in the fight against the spread of COVID-19 1,2,3,4.

The Coronavirus pandemic underscored the increased susceptibility of healthcare workers to biological hazards owing to occupational exposure5,6. Healthcare workers are at high risk of contracting COVID-19 due to their occupational exposure7. Non-adherence to IPC protocols by HCWs due to the inadequacy of IPC logistics in healthcare facilities in COVID-19 puts HCWs, patients, and communities at risk8. Healthcare workers who move between teams and workplaces are at a higher risk of contracting and spreading COVID-19. The COVID-19 pandemic has had a devastating impact on healthcare workers. Many HCWs have contracted the virus, and a significant number have died. Those who survive may face long-term health consequences, potentially limiting their ability to return to work. The pandemic has also disrupted healthcare delivery, strained mental health, and may lead to workforce shortages due to attrition and reduced international recruitment9.Primary healthcare professionals have played an important role during COVID-19 by providing basic healthcare services to individuals and communities. They are the first point of contact for individuals seeking primary care services, and are also responsible for identifying and controlling the spread of the infection within the community2. Primary Health Care Workers (PHCWs) comprise different professional groups tasked with different roles and responsibilities such as health promotion, disease prevention, treatment, rehabilitation, and palliative care10.

It has been shown that the risk of COVID-19 hospitalization was increased in the majority of healthcare professions, including nurses, physicians, healthcare assistants and medical laboratory technicians11. Some studies showed nursing assistants and nurses had the highest risk of COVID-19 among the different groups of healthcare professionals11,12,13. Previous studies in Iran (2021) examined the incidence of COVID-19 infection among HCWs and reported the majority of infected cases were among nurses14,15 and their assistants14, while the highest infection rate was among physicians15. Harith et al. examined the prevalence, trends, characteristics, and sources of COVID-19 infection among healthcare workers in Malaysia and demons treated nursing professionals, medical doctors, specialists, and healthcare assistants were the most highly infected occupational groups16.

Health workers assigned to primary healthcare centers are classified into three groups based on their roles and responsibilities: primary care professionals (clinical), public health professionals (community), and administrative staff (support). PHCWs are responsible for a wide range of activities, including contact tracing, vaccination, health education, and patient support, especially for vulnerable individuals and underserved communities who face numerous health challenges1,3,17. Therefore, owing to the nature of their work and direct contact with patients and individuals suspected of the disease, Frontline Health Workers (FHWs) are at higher risk of occupational exposure18. Recent studies conducted in various countries have shown different rates of occupational exposure, highlighting the risk of COVID-19 transmission among primary healthcare professionals. For instance, the level of occupational exposure to the disease among FHWs in Ghana, India, and Ethiopia were found to be 80%, 75%, and 66%, respectively8,19,20. Previous studies have emphasized the elevated risk of COVID-19 exposure among PHCWs. A study by Nguyen et al. (2020), showed that community health workers are at a higher risk of COVID-19 compared to other professionals4. Moreover, Dzinamarira et al. (2022) demonstrated that the likelihood of COVID-19 infection in PHC Workers is 10 times higher than in the general population21.

The risk factors for COVID-19 infection among PHCWs depend on several factors, including the level of exposure, the type of healthcare facility, the prevalence of the disease in the community, and the status of Infection Prevention and Control (IPC) measures1,2,22. Non-adherence to IPC measures among PHCWs is a leading issue that increases the risk of exposure to COVID-19. This can be attributed to insufficient training on the proper use of Personal Protective Equipment (PPE), poor working conditions, and inadequate facilities such as appropriate ventilation and isolation rooms, and low-quality PPE23,24. In many countries, the public health system has experienced significant shortages and challenges in providing adequate PPE and other necessary supplies to HCWs during the COVID-19 pandemic21,25.

To further protect the HCWs, the World Health Organization (WHO) issued interim guidance to guide HCWs on IPC protocols during the management of COVID-19 cases22,26. The risk of exposure to COVID-19 infection among HCWs can be minimized by adherence to IPC practices (e.g. sufficient education, provision of necessary equipment, and supplies). Non-adherence to IPC protocols by HCWs in managing COVID-19 can put HCWs at risk8,24.

Although some studies have addressed the risk of occupational exposure to COVID-19 among healthcare workers, very few studies have examined the extent of occupational risk among FHWs and practical strategies to address this issue. Moreover, since the precise nature and scope of their exposure to COVID-19 have not yet been fully distinguished, few studies have investigated the correlation between the type of healthcare worker and the degree of occupational exposure. HCWs play a critical role in providing essential healthcare services to COVID-19 patients. Given that HCWs perform clinical procedures for COVID-19 patients, they face a high risk of exposure to COVID-19. Therefore, assessing the clinical risk and exposure to the pathogen in HCWs cannot only prevent HCWs’ exposure to COVID-19 but also guide healthcare centers’ managers in better management and control to perform safe risk management. Since few studies have assessed the exposure of HCWs to COVID-19 in Iran, this study aimed to assess the level of occupational risk of COVID-19 exposure among HCWs using a standardized tool developed by the WHO.

Additionally, although previous studies8,27 have addressed occupational exposure of HCWs to the COVID-19 virus, they have not categorized the level of risk exposure in HCWs in terms of the type of profession and role of healthcare workers. Therefore, this study aimed to categorize the level of exposure risk and explore the associated factors, focusing on the type of profession and health workers’ roles among first-level health workers in primary healthcare centers in the northern region of Khuzestan province, Iran.

Methods

Study design and setting

This was a cross-sectional, descriptive-analytical study conducted in 2022, from June to October, among HCWs managing COVID-19 cases in primary healthcare centers in the north of Khuzestan province, Iran.

The province includes six counties; Dezful, Andimeshk, Shoushtar, Gotvand, Masjed Soleyman, and Lali, with a population of over 900,000 people. In terms of the organizational structure of healthcare services, these counties are affiliated with Ahvaz Jundishapur University of Medical Sciences (Andimeshk, Masjed Soleyman, Gotvand, and Lali), Dezful University of Medical Sciences (Dezful), and Shoushtar Faculty of Medical Sciences (Shoushtar).

This study was performed in primary healthcare units, including urban and rural comprehensive health services centers, health bases, health houses, 16-hour centers for COVID-19, and vaccination centers.

Study population

The study participants included three occupational groups who were categorized based on their roles and responsibilities: primary care professionals (clinical), public health professionals (community), and administrative staff (support); (1) the clinical group consisting of physicians, dentists, midwives, and laboratory personnel; (2) the community group consisting of allied health workers, urban community health workers (caregivers), and rural community health workers (Behvarz); (3) other employees such as admission clerks, drivers, cleaners, and guards were also placed in the administrative and logistics group.The number of samples for each county was as follows: Shoushtar: 211, Dezful: 111, Gotvand: 49, Masjed Soleyman: 79, Lali: 52, Andimeshk: 97.

Primary inclusion criteria were all HCWs who worked at the primary healthcare level and were in contact with suspected COVID-19 cases. HCWs who, in addition to working in primary health centers, worked overtime or part-time in hospitals and medical centers were excluded from the study.

Measurements

We used the “Risk assessment and management of exposure of healthcare workers in the context of COVID-19” tool designed by the WHO in 202028. This is one of the most widely used methods for measuring the risk of COVID-19 in healthcare settings. This questionnaire was modified and adjusted for use in community-based health centers.

In this study, first, the English version of the tool was translated into Persian. Then, face validity was conducted by asking 20 study population and a panel of 5 experts to comment on the clarity and flow of the questions in the proposed tool. The clarity of the questionnaire was evaluated using the Content Validity Index (CVI). The reliability of the tool was evaluated using test-retest reliability and was completed by 30 participants in two stages, two weeks apart. The degree of agreement (0.84) was established with the kappa coefficient. Also, the Kuder-Richardson coefficient for dichotomous variables (0.83) and Cronbach’s alpha coefficient for polychotomous variables (0.837) were used to assess the internal consistency of the questionnaire; these results indicate that the tool was reliable.

The questionnaire consisted of demographic information of HCW (8 items), health worker interactions with COVID-19 patient information (6 items), HCW activities performed on COVID-19 patient in healthcare facility (5 items), adherence to IPC measures during healthcare interactions (7 items), adherence to IPC measures when performing aerosol-generating procedures (e.g. tracheal intubation, nebulizer treatment, open airway suctioning, collection of sputum, tracheotomy, bronchoscopy, cardiopulmonary resuscitation (CPR), etc.) (6 items), and accidents with biological materials (2 items).

Community exposure to the COVID-19 virus: HCWs were considered “community exposure to COVID-19 virus” if they responded “yes” to having a history of contact with a confirmed COVID-19 patient in their family or classroom environment (if they were studying) or a history of traveling together nearby (within 1 m) with a confirmed COVID-19 patient in any kind of conveyance.

Occupational exposure to COVID-19 virus: HCWs were considered “occupational exposure to COVID-19 virus” if they responded “yes” to one of the following activities on a COVID-19 patient: providing direct care to a confirmed COVID-19 patient, face-to-face contact (within 1 m) with a confirmed COVID-19 patient in a health care facility, performed/present when aerosol-generating procedures were performed on COVID-19 patients, and had direct contact with the environment where the confirmed COVID-19 patient was cared for (e.g., bed, linen, medical equipment, bathroom, etc.).

The risk of exposure to COVID-19 infection was classified into two categories: high-risk and low-risk for COVID-19 virus infection. HCWs were considered at high risk for COVID-19 infection if their response was not “always” during healthcare interaction with a confirmed patient with COVID-19 to any of the following IPC measures: wearing and replacing PPE according to protocol, performing hand hygiene (before and after touching a COVID-19 patient, the patient surroundings, and after touching contaminated surfaces), decontaminating surfaces frequently, receiving sufficient training on personal hygiene and decontamination practices, having accident with body fluids or respiratory secretions during interactions with a confirmed or suspected COVID-19 patient, removing and replacing PPE (e.g., single-use gloves, medical mask, face shield or goggles /protective glasses, disposable gown) during interaction with a COVID-19 patient28.

Prior to commencing the study, ethical clearance and proposal approval were granted by the Research and Health Deputies of the universities in Ahvaz, Dezful, and Shoushtar. After receiving permission, two briefing sessions were first held for the study participants. Then, based on the research information sheet, necessary training and guidance were provided regarding the purpose, benefits, and completing the questionnaire.

Sample size and sampling

The sample size was determined using the sample size determination formula for descriptive studies (n = (Z1−α/2)2 P (1-P)/d2). The study precision value (d) was set at 0.20, and the prevalence rate (P) was considered 0.14 8. A value of 1.96 (Z1−α/2)2 at a 95% confidence interval was used. The calculated sample size was found to be 590 + 10% (non-response) = 650. To ensure the representativeness and generalizability of the findings, a rigorous sampling method (a combination of multi-stage and mixed-method approaches) was employed. A proportional stratified random sampling method was used to select the study participants. The required sample size for each county was determined based on the ratio of HCWs in healthcare settings in each county to the total number of counties. As a result, the samples in one county were selected using a proportional stratified random sampling method according to the size of each occupational group.

Data analysis

The data were analyzed using STATAV14.2. Descriptive statistics such as frequency, mean, standard deviation, and median, as well as Poisson regression, were utilized in this study. Given that the prevalence rate of the main outcome was higher than 10% and the odds ratio (OR) value tends to overestimate the prevalence rate, the appropriate effect size index and prevalence ratio (PR) were used to examine the relationship. Also, the confidence interval for the prevalence rate was calculated using the binomial exact approximation method for prevalence rates < 10% and > 90%, as well as the normal approximation method for prevalence rates between 10% and 90%. A P value < 0.05 was considered significant.

Ethical statement

This study was approved by the Institutional Review Board (IRB) of the Shoushtar Faculty of Medical Sciences and registered under number 98,000,038. Additionally, the proposal of this study was also approved by the Ethics Committee of the Shoushtar Faculty of Medical Sciences (Reference No: IR.SHOUSHTAR.REC.1401.003). All methods were performed following the guidelines and recommendations of the Declaration of Helsinki for research involving human subjects. The study was performed and reported under the strengthening the reporting of observational studies in epidemiology (STROBE) guidelines. The informed consent form was obtained from the participants, and if they agreed to participate in the study, the questionnaire was provided to them to complete. It should be noted that for those who did not attend the meetings, the researcher visited their workplace to explain the study and provide them with the questionnaire. After completing the questionnaires, the researcher visited the participants’ workplace again to collect the questionnaires.

Results

A total of 599 HCWs with a response rate of 92.2% were included. The mean (SD) age of participants was 37.1 (8.4) years. The majority of participants (73%) were female and had a bachelor’s degree (41.4%). Almost half of the participants (~ 52%) had ten or more years of working experience and worked in urban areas (~ 56%). In terms of profession and health worker roles, the majority of participants (76.5%) were community health workers. Clinical staff made up 13.5% of the workforce, and the remaining 10% held other positions (administrative and support staff). In terms of the type of health facility, the majority of HCWs were placed in comprehensive health services centers, with the minority working in health bases. Finally, roughly one-third of individuals had 18 to 27 months of working experience during the COVID-19 pandemic (Table 1).

Table 1 Distribution of study participants characteristics by risk for COVID-19 virus infection.
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The prevalence of occupational and community exposure of HCWs was 95.7% (95% CI 93.7 to 97.1) and 89.6% (95% CI 87.0 to 92.1), respectively. Among HCWs with occupational exposure, 92.7% (95% CI 90.1 to 94.6) were at high risk of exposure. Moreover, 12.4% (95% CI 10.0 to 15.2) of HCWs had a history of contact with biological materials, and all of them were at high-risk exposure. Almost 90% (95% CI 87.2 to 92.2) of HCWs did not adhere to IPC measures, and all of them were at high-risk exposure. The study assessed adherence to infection prevention and control (IPC) measures among healthcare workers (HCWs) during interactions with COVID-19 patients. Results revealed that only 48.1% (95% CI 44.0–52.2) of HCWs consistently used single-use gloves, while 88.8% (95% CI 85.9–91.1) wore medical masks. Adherence to wearing face shields or goggles/protective glasses was notably low at 17.1% (95% CI 14.8–21.1), and the use of disposable gowns was reported by 22.5% (95% CI 19.2–26.1). While 61.2% (95% CI 57.2–65.2) replaced personal protective equipment (PPE) as required, 83.9% (95% CI 80.6–86.7) practiced hand hygiene before and after patient contact, and 71.0% (95% CI 67.0–74.0) did so after touching contaminated surfaces. However, only 36.0% (95% CI 33.0–41.0) adhered to frequent decontamination of surfaces, indicating gaps in comprehensive IPC compliance.

Additionally, 75.6% (95% CI 72.0 to 79.0) of HCWs had a history of COVID-19 infection, and 92.5% (95% CI 90.1 to 95.0) of them were at high-risk exposure. The study also examined the prevalence of occupational exposure to biological fluids or respiratory secretions among healthcare workers. A significant proportion, 24.3% (95% CI 15.7–35.6), reported splashes to the mucous membranes of the eyes, while 43.2% (95% CI 32.2–55.0) experienced splashes to the mucous membranes of the mouth or nose. Exposure through splashes on non-intact skin was reported by 20.3% (95% CI 12.5–31.2). Additionally, 12.2% (95% CI 0.06–22.0) of HCWs experienced puncture or sharp accidents with materials contaminated by biological fluids or respiratory secretions (Table 2).

Table 2 Distribution of study participants characteristics by risk for COVID-19 virus infection.
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Table 3 shows the results of single-variable Poisson regression analysis. There was no significant association between the profession and role of HCWs and the level of occupational exposure risk (P-value > 0.05). The association was not robust (a trivial effect size (PR = 1.00; 95% CI 0.94 to 1.07)). Furthermore, adjusting step-by-step for covariates, including the type of healthcare setting, accidents with biological materials, adherence to IPC measures, occupational, and community exposure, did not reveal a significant association. However, adjusting this association for adherence to IPC measures led to a change in the direction of the estimate (aPR = 0.97; 95% CI 0.93 to 1.02), indicating that adherence to IPC measures was a significant confounder for this association.

Table 3 The association between types of healthcare professional with risk of COVID-19 virus infection coupled with adjustment for the confounding effects of covariates factors.
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Although a significant association was found between the type of healthcare setting, history of contact with biological materials, adherence to IPC measures, and the level of occupational exposure risk in a single-variable Poisson regression test (P-value < 0.05), the multivariable analysis revealed that only the history of accident with biological materials and adherence to IPC measures were significantly associated with the level of occupational exposure risk (P-value < 0.001). The effect size of the association between accident with biological materials and the level of risk was small (aPR = 1.20; 95% CI 1.12 to 1.29), while the effect size of the association between adherence to IPC measures and the level of risk was large (aPR = 3.85; 95% CI 2.60 to 5.71). Our results showed that the risk of exposure to COVID-19 virus infection among HCWs who did not adhere to IPC measures was 3.9 times higher than those who did adhere to the measures (Table 4).

Table 4 Factors associated with risk of COVID-19 virus infection.
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The Chi-Square for the trend test showed a significant dose-response association between the duration of activity during COVID-19 and the level of occupational exposure risk among HCWs (χ2=4.25, P-value = 0.04). However, the effect size of the association was not considerable (PR = 1.10; 95% CI 1.00 to 1.12) (Table 5).

Table 5 Dose-response association between work experience for COVID−19 with risk of COVID – 19 virus infection.
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As shown in Fig. 1, exposure to the COVID-19 virus was higher among HCWs with more working experience compared to those with less working experience. HCWs with more than 18 months of work experience during the COVID-19 epidemic had a 10% higher risk of exposure to the COVID-19 virus compared to those with less working experience.

Fig. 1
figure 1

The prevalence of COVID-19 risk and confidence interval for work experience.

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Discussion

The main objectives of this study were to assess the level of occupational risk exposure among frontline healthcare service providers and to investigate the association between their professional background and the level of risk they face. Since no study has previously employed the World Health Organization’s tool in Iran, this study used this practical tool to determine the prevalence of occupational exposure and the prevalence of exposure to high-risk factors. Moreover, the factors influencing high-risk exposure were examined, with emphasis on the type of profession and roles of the personnel, which yielded interesting findings. Our study revealed a high prevalence of exposure to high-risk factors among HCWs. Accident with biological materials and non-adherence to IPC measures identified as two important factors contributing to high occupational risk.

The current study showed that the prevalence of occupational exposure among HCWs was high and higher than community exposure. Considering the high prevalence of the disease in the study area, the occupational exposure of the employees due to the nature of their work and direct contact with confirmed patients and the residential area of the patients was confirmed to be high18. Studies conducted in Ghana, India, and Ethiopia also reported a high prevalence of occupational exposure among frontline healthcare service providers8,19,20. However, studies carried out in different countries have reported varying levels of occupational exposure4,26,29,30. A previous study in Qazvin, Iran (2020) showed all HCWs (n = 243) in the study had occupational exposure to the COVID-19 virus. They also reported that 76.5% were at low risk and 23.5% at high risk of COVID-19 virus infection27. The differences between studies could be due to differences in study populations, measurements, and methods of analyzing data. In this study, we categorized HCWs based on their risk exposure level, role and type of profession.

The level of staff exposure to COVID-19 depends on various factors, including the prevalence of the disease in the community, the status of preventive and infection control measures, and the type of healthcare facilities (community-based, hospital-based, and COVID-19 centers). Consequently, health systems need to consider the impact of these factors when developing interventions aimed at reducing staff exposure.

Our findings showed that more than 90% of staff were at high risk of exposure to COVID-19. Some studies also reported a high level of exposure risk among staff, which is consistent with our findings4,31. When healthcare workers become infected with COVID-19, it not only diminishes morale but also weakens our capacity to combat the virus3. The level of staff exposure to COVID-19 is influenced by various factors such as the level of exposure and the type of healthcare facilities2. The lack of PPE and inadequate training can also increase the risk of infection18. However, a study conducted in Ghana found a much lower level of exposure to high risk8. This could be attributed to several factors, including differences in staff adherence to IPC protocols, availability of PPE, and the level of monitoring and supervision. It should be noted that the study in Ghana was limited to health workers in therapeutic centers such as hospitals, which may indicate that staff in these facilities had better access to PPE and adhered better to preventive measures. On the other hand, the study showed that more than 90% of individuals with a history of COVID-19 were at high risk of exposure. Occupational risks in the workplace must be minimized if not altogether eliminated. Additionally, an established protocol is essential for the early detection and treatment of healthcare workers suspected of having contracted COVID-19 2. Healthcare workers should be provided with flexible working hours to prevent overwork, and psychological support plans should be introduced to help them manage both physical and mental stress. Healthcare service providers should prioritize measures such as providing PPE, conducting regular testing, and vaccinating frontline personnel to protect them.

One of the factors contributing to the high level of exposure risk among HCWs is their close contact with patients and exposure to body fluids or respiratory secretions. In our study, although only a few HCWs had direct contact with patients’ bodily secretions, the association between exposure to biological materials and the level of exposure risk was significant. Previous studies have highlighted the increased risk of COVID-19 transmission was associated with exposure to biological materials and patient secretions32,33. HCWs who are exposed to biological materials should not only adhere to following health protocols but also have sufficient PPE available. Given the sensitivity and importance of disease transmission through contact with patients’ bodily secretions, not all staff members should be exposed to biological materials. In these cases, specific individuals should be selected to provide care and services to patients to ensure continuity of services in healthcare facilities during epidemics. Effective strategies to reduce occupational exposure to biological fluids or respiratory secretions among healthcare workers include conducting regular workplace risk assessments to identify and address potential health and safety hazards. Providing comprehensive training and clear instructions equips workers with the knowledge and skills needed to perform their tasks safely. Implementing health surveillance programs ensures ongoing monitoring of workers engaged in high-risk roles.

The findings of our study indicated that non-adherence to IPC measures plays a critical role in increasing the occupational exposure risk among HCWs. Therefore, the risk of exposure to COVID-19 virus infection among HCWs who did not adhere to IPC measures was 3.9 times higher than those who did adhere to the measures. The WHO also emphasizes the impact of IPC measures on the incidence of high-risk diseases among HCWs in community-based healthcare centers and believes that personnel are responsible for protecting their own health and service recipients22,26. However, the effectiveness of optimal PPE and other infection prevention and control (IPC) measures remains under debate due to the limited robust evidence linking PPE and IPC interventions to the specific risk profile of a given exposure34,35,36. Various reasons can lead to non-adherence to IPC measures such as unavailability of personal protective equipment, lack of education on the appropriate use of equipment, and insufficient control measures4,24,37. 72.2% of the participants strongly agreed that gowns, gloves, masks, and goggles are essential when caring for COVID-19 patients19. Self-monitoring and reporting are more practical but should be complemented by clear communication from occupational health officers. This ensures that healthcare workers feel supported and have a reliable point of contact to address any concerns or questions30. It should be noted that enhancing workforce skills in respecting and following ethical principles is crucial38. Timely and easily accessible COVID-19 testing, routine screening of healthcare workers, and regular symptom monitoring are crucial for sustaining a sufficient workforce. Additionally, well-defined protocols must be in place to manage potential outcomes from testing symptomatic healthcare workers. Training of personnel and supervision of healthcare facilities by higher authorities can impact adherence to IPC measures. Various interventions are essential to enhance the knowledge and attitudes of healthcare professionals, aiming to improve their practices and advance service delivery. To achieve this, higher levels should prioritize capacity-building initiatives, such as in-service training, and actively motivate and recognize staff to foster knowledge growth and positively influence their behavior and attitudes.

In this study, no significant difference was observed between the level of occupational exposure risk among HCWs and different professions and roles. In previous studies, no significant difference was found between the type of profession and responsibilities of service providers and the high incidence of COVID-19 exposure risk26,39. Although HCWs had different responsibilities in healthcare facilities, factors other than the type of profession and roles, such as the level of exposure and the amount of contact with infected individuals, had a significant impact on increasing the risk of COVID-19 exposure26. Therefore, healthcare organizations need to protect all personnel against the risk of infection, regardless of their profession and roles. In our study, the IPC measures were found to be a powerful confounding factor in examining the association between the type of profession and roles with the level of exposure to COVID-19. This highlights the significance of these measures in mitigating the risk of exposure to infection. Occupational health services, mental health and psychosocial support, as well as adequate sanitation, hygiene, and rest facilities, should be made available to all healthcare workers.

Our findings showed that the risk of exposure increased with an increase in the months of work experience during the COVID-19, which is in line with the results of Nguyen et al.4. However, the effect size of this association was small, and the reason for the weak association was unclear. Since this was a post-hoc finding for this study, it is better to investigate this issue further in future research. However, it is possible that with the prolonged duration of a pandemic, the sensitivity of managers and employees towards the disease, and adherence to health protocols may have declined. Therefore, managers should hold regular training sessions for personnel and increase their supervision of adherence to preventive measures. Highly experienced staff working during a pandemic may benefit from being assigned to lower-risk roles, such as telemedicine, non-COVID-19 outpatient clinics, or administrative positions. Additionally, another reason for this issue can be attributed to the shortage of PPE, which needs to be addressed.

Strengths and limitations

Our study has strengths and limitations that deserve to be mentioned. This study utilized the appropriate effect size index of prevalence ratio (PR), which demonstrates a more accurate estimation of the prevalence of an outcome in cases with a prevalence greater than 10%. Additionally, the confidence interval for the prevalence rate was calculated using a binomial approximation for prevalence rates below 10% or above 90%, and a normal approximation for prevalence rates between 10% and 90%. Concerning limitations, this study was conducted only in first-level healthcare centers, and the results cannot be compared with higher-level services in northern Khuzestan province. Therefore, it is recommended that future studies be performed to address this issue. Another limitation was the lack of investigation into the impact of environmental factors such as the prevalence rate of COVID-19 in the community and the type of virus on the level of exposure risk among healthcare personnel, which was not examined in this study. Additionally, the generalizability of our findings may be limited by the diversity of professions represented in the study. It is important to note the context-specific nature of our results, which suggests avenues for future research. We also propose that future studies could benefit from including more diverse professional groups, such as hospital-based health workers, to better assess these associations.

Conclusion

The results of this study showed that the prevalence of occupational exposure among first-level healthcare personnel was high, and regardless of their type of profession and roles, the majority of exposures were of the high-risk type. Exposure to biological materials and non-adherence to IPC measures played a significant part in this regard. The study’s findings underscore the necessity and importance of implementing preventive measures, such as adherence to IPC measures and appropriate use of PPE by the HCWs of these centers, especially for those at high risk of exposure. Reducing the level of occupational exposure to COVID-19 among healthcare personnel is crucial for protecting their health and the community they serve. First-level service managers can make a major contribution to reducing the prevalence of occupational exposure among high-risk individuals, by providing continuous personnel training, investing in the supply chain, prioritizing regular testing and vaccination of HCWs, and ensuring supportive supervision while accurately monitoring compliance with health protocols during pandemics.