Infection prevention and control compliance of healthcare workers towards COVID-19 in conflict-affected public hospitals of Ethiopia

STRENGTHS AND LIMITATIONS OF THIS STUDY

  • Diverse professionals of healthcare workers were included.

  • Observational checklist and questionnaire were used to collect data.

  • Even though the healthcare staff members were not conscious of being under observation, some individuals may have suspected it and consequently adjusted their behaviour.

  • This cross-sectional study may not entirely capture infection prevention and control compliance practices consistently throughout the entire year, especially during periods of fluctuating workloads.

Introduction

Globally, COVID-19 continues to pose a substantial public health challenge, troubling all aspects of human life.1 According to the Worldometer report, more than 513.6 million cases of COVID-19 and 6.2 million deaths have been reported globally until 2 May 2022.2 In the African region, over 11.4 million confirmed COVID-19 cases and 252 157 deaths from COVID-19 pandemic were reported until 1 May 2022.3 Similarly in Ethiopia, during the same period, the confirmed coronavirus cases rose up to 470 581 resulting in 7510 deaths.4

Healthcare workers are playing a significant role in the fight against COVID-19 infection.5 6 Consequently, they are frequently exposed to COVID-19 and become at greater risk of infection than the general community, which may directly contribute to the spread of infection.6–8 This is particularly true as the virus is known to continuously undergo unprecedented mutations, and evolve to exhibit high infectivity and transmissibility.9 According to the United Nations health and labour agency, approximately 115 000 healthcare workers died in the first 18 months of the COVID-19 pandemic.10 Evidence from the UK and the USA indicated that the odds of COVID-19 infection were 3.4 times higher among frontline healthcare workers than people living in the general community.11 Similarly, up to 10% of the reported COVID-19 cases in China have been accounted for healthcare workers.12

The burden of COVID-19 is expected to be high among healthcare workers who do not comply with infection prevention and control (IPC) strategies.13 14 This is particularly the case in countries where all healthcare facilities are overloaded by routine activities before the onset of the pandemic.15 A cross-sectional study conducted in Ethiopia showed that the adherence to COVID-19 IPC among healthcare workers is low (22%).16 Reports indicated that lack of COVID-19 IPC training, absence of hand washing, gender, lack of personal protective equipment (PPE), absence of support from hospital management and work overload were determinant factors for non-compliance with COVID-19 IPC.16–21

As protective behaviours including IPC are significant weapons for protecting healthcare providers,6 22 compliance with IPC practices is critical at minimising their exposure to COVID-19. Although few studies are conducted in Ethiopia on adherence to COVID-19 IPC practice,16 there are no detailed investigations on COVID-19 IPC among healthcare workers deployed at conflict-affected areas. Moreover, while observation is acknowledged as a better tool for assessing compliance with IPC protocols23 24 earlier studies predominantly used self-administered questionnaires and/or face-to-face interviews8 17 18 as modes of data collection. Therefore, there is an urgent need to investigate the actual compliance of healthcare workers towards COVID-19 infection prevention measures while treating their patients.

Hence, the objective of this study was to assess healthcare workers’ compliance with the COVID-19 IPC protocol and identify the factors associated with it in three public hospitals in northeastern Ethiopia. The results of this study could be valuable in pinpointing deficiencies in the efforts to curb the transmission of the virus among healthcare workers. This, in turn, could play a crucial role in implementing essential measures to reduce the transmission of COVID-19 within the community.

Methods and materials

Study setting

The research was carried out in three public hospitals affected by conflict, situated in the Oromia special zone and North Shoa zone of the Amhara regional state in Ethiopia (online supplemental file 1). Two of the study hospitals are in Oromia special zone and the other in North Shoa zone. Oromia special zone has seven districts with a total population of 457 278. Similarly, North Shoa zone has 23 districts with a total population of 1 837 490. These two neighbouring zones are experiencing unpredictable and frequent internal conflicts, which is likely to impact the health system delivery in the area.

Supplemental material

Study design and period

A cross-sectional study was conducted within institutional settings aimed to evaluate compliance with IPC practices among healthcare providers from March to April 2022.

Source population

The source populations were all 459 healthcare providers who have direct contact with patients (midwives, nurses, public health officers, medical laboratory technicians, medical doctors, dentists, ophthalmologists and anaesthetists).

Study population

Randomly selected 325 healthcare providers who have direct contact with patients (midwives, nurses, public health officers, medical laboratory technicians, medical doctors, dentists, ophthalmologists and anaesthetists) from the three public hospitals were the study population.

Inclusion and exclusion criteria

The study excluded healthcare providers who do not have direct contact with patients, those who were seriously ill and those not present during the data collection. In addition, administrative staff and cleaners were not included as the focus of the paper is limited to healthcare providers.

Sample size determination

The sample size was calculated using a formula for a single population proportion: n=(Zα/2)2 p (1-p)/d2.

The assumptions included a 95% confidence level (Zα/2=1.96), a proportion (p) of 24% non-compliance with COVID-19 IPC obtained from a similar study conducted in Uganda25 and margin of error (d=5.0%). The calculated sample size becomes 296. Taking into account a 10% non-response rate, the final sample size amounted to 325.

Sampling technique and procedure

The study participants were allocated proportionally among the three hospitals (online supplemental file 2), based on the respective numbers of healthcare workers in each hospital. Stratified sampling technique was employed to choose healthcare workers representative of various wards, including emergency, radiology, laboratory, delivery, outpatient department and intensive care unit. Allocation among the wards was done in proportion. The study participants were chosen using the simple random sampling technique.

Supplemental material

Data collection method and quality control

The data were collected using structured questionnaire (online supplemental appendix 1) and observational checklist (online supplemental appendix 2) which were adapted from WHO COVID-19 IPC protocol and other published articles.8 17 18 23 The questionnaire consisted of three main sections: sociodemographic characteristics of healthcare workers; knowledge-related questions; and behavioural and institutional factors. The questionnaire and observational checklist were drafted in English, translated into the local language (Amharic) and subsequently retranslated into English to verify consistency. Prior to the actual observation, seven BSc nurses (data collectors) and two BSc health officers (supervisors) underwent a 2-day training session following the COVID-19 IPC observation technique outlined by WHO. Subsequently, a pretest was carried out involving 25 healthcare workers at Dessie Comprehensive Specialized Hospital. The Cronbach’s alpha method was used to check the reliability, and showed satisfactory internal consistency and high reliability of the questionnaire. Throughout the observational study, the data collectors closely observed the participants directly as they performed patient examinations. To minimise bias, the healthcare workers were unaware of the ongoing research. After completion of the observational data collection, a questionnaire designed for self-administration was given to the healthcare workers to collect additional necessary data. Supervisors conducted daily checks to ensure the completeness and consistency of the questionnaire. To enhance data accuracy, 5% of the entered data were subjected to double entry.

Supplemental material

Supplemental material

Statistical analysis

Data were checked, coded and entered into EpiData V.3.1 before being exported to SPSS V.25.0 for data cleaning and analysis. To pinpoint factors associated with non-compliance with IPC, an initial step involved conducting bivariate logistic regression analysis with a significance level set at p<0.25 to screen the most significant candidate variables.26 Afterwards, a multivariable analysis was used to address potential confounding variables. To determine the association between variables (dependent and independent), adjusted ORs (AOR) and their corresponding 95% CI were used. A significance level of p<0.05 was employed to determine the statistical significance of associations. A check for multicollinearity among the independent variables was conducted using SE. As the maximum SE was 1.95, it indicates no multicollinearity. The fitness of the model was assessed through the Hosmer-Lemeshow test, with a p value of 0.44, signifying that the model was fit.

Patient and public involvement

Patients or the general public did not participate in the design, implementation, reporting or dissemination plans of this research.

Operational definitions

In order to identify the compliance towards COVID-19 IPC (good or poor), the response from 12 working practice questions was computed. Each item’s correct practice received a score of ‘1’, while an incorrect answer was assigned a score of ‘0’. Consequently, healthcare workers scoring above the mean were classified as having good COVID-19 IPC practice, and vice versa (refer to online supplemental appendix 2).27

Similarly, good knowledge of COVID-19 IPC was defined as study participants achieving a score equal to or higher than the mean score on the 10 knowledge questions. In this study, a healthcare provider is defined as an individual actively engaged in clinical services with a regular schedule for direct patient care.23

When a healthcare worker chews khat and drinks alcohol at least once a week, it is considered as khat and alcohol user, respectively.28

Results

In this study, a complete response was obtained from all 325 participants, resulting in a response rate of 100%. Of all the participants, 199 (61.2%) were males. Nurses accounted for 123 (37.8%) of the study participants. About three-fourths (250, 76.9%) of the study participants had work experience of less than 5 years (table 1).

Table 1

Sociodemographic profile of healthcare providers (n=325) in three government hospitals in northeastern Ethiopia

Knowledge of healthcare workers towards COVID-19 infection

This study indicated that 128 (39.4%) of the healthcare workers had poor knowledge towards COVID-19 infection. From the respondents, 198 (60.9%) reported that COVID-19 is a viral infection. Similarly, 110 (33.8%) of the healthcare workers reported that regular hand washing with soap is an effective way to prevent COVID-19 infection (table 2).

Table 2

Understanding of COVID-19 infection among healthcare providers (n=325) in three government hospitals in northeastern Ethiopia

Behavioural and institutional factors

Out of all the participants, 155 (47.7%) have a daily work duration exceeding 8 hours. A majority of the study subjects (190, 58.5%) encountered disruptions in piped water supply. Furthermore, 205 (63.1%) of the healthcare workers in this study did not undergo COVID-19 IPC training. Similarly, 282 (86.7%) of healthcare workers did not have COVID-19 IPC guidelines per ward. In addition, 248 (76.3%) of healthcare workers had the habit of chewing khat (table 3).

Table 3

Behavioural and institutional factors examining compliance with COVID-19 infection prevention measures among healthcare workers (n=325) in three public hospitals in northeast Ethiopia

COVID-19 IPC compliance among healthcare workers

The overall proportion of observed non-compliance with COVID-19 IPC was 46.2%. About 225 (69.2%) of healthcare workers washed their hands prior to making contact with patients. Conversely, over two-thirds of the participants did not engage in hand washing after coming into contact with patients or administering injections. About half (50.2%) of the healthcare workers also did not wear PPE before entering into patient area (table 4).

Table 4

Compliance with infection prevention and control practices for COVID-19 among healthcare providers (n=325) in the three government hospitals of northeastern Ethiopia

Factors associated with poor COVID-19 IPC practice

In the multivariable logistic regression analysis, chewing khat, lack of water and soap, workload, disruption in piped water supply, did not receive COVID-19 IPC training, absence of support from hospital management and absence of COVID-19 IPC guidelines showed statistically significant association with COVID-19 IPC non-compliance.

Healthcare workers who had the habit of chewing khat were 2.3 times more likely to have non-compliance with COVID-19 infection prevention measure as compared with their counterparts (AOR=2.3; 95% CI 1.32 to 3.72). Healthcare workers who lacked access to water and soap had nearly three times higher odds of poor compliance with COVID-19 IPC (AOR=2.99; 95% CI 2.46 to 5.76) compared with their counterparts. In addition, healthcare workers who did not undergo training in COVID-19 infection prevention were almost three times more likely to have poor COVID-19 infection prevention measure than others (AOR=2.85; 95% CI 1.85 to 4.84). Likewise, healthcare workers with daily work durations exceeding 8 hours were twice as likely to exhibit poor compliance with COVID-19 IPC compared with those working 8 hours or less per day (AOR=2.25; 95% CI 1.33 to 3.84). Once more, healthcare workers who worked in wards with interrupted water supply were two times more likely to have poor COVID-19 IPC measure than others (AOR=1.82; 95% CI 1.11 to 2.99). Moreover, the odds of poor COVID-19 infection prevention measure were about two times higher among healthcare workers who had no COVID-19 infection prevention guidelines in the wards than their counterparts (AOR=2.14; 95% CI 1.11 to 4.13) (table 5).

Table 5

Multivariable analysis of factors associated with non-compliance with IPC among healthcare providers (n=325) in three government hospitals in northeastern Ethiopia

Discussion

This study was conducted to assess COVID-19 IPC compliance among healthcare workers in three public hospitals located in conflict-affected area. The results showed that the overall proportion of observed poor COVID-19 IPC practice is 46.2%. This figure is greater than the reports among healthcare workers in western Ethiopia,16 Ghana (2.5%),18 Uganda (26%)25 and India (19.1%).6 These disparities might mainly be due to differences in data collection methods. In this study, compliance was assessed by observation while most others employed self-reporting technique. The high non-compliance in our study could also be due to the influence of the war that blocked access to different facilities, such as PPE and water. In addition, as the study period was towards the end of the COVID-19 pandemic, the vigilance of healthcare worker might have somehow declined. Indeed, higher non-compliances were also reported in Tanzania (up to 95.2%)29 and northwest Ethiopia (61.3%).30

Evidence from this study showed that the odds of non-compliance with COVID-19 IPC protocol were two times higher among healthcare providers facing interruptions of piped water supply than their counterparts. Destruction of infrastructures in the healthcare facilities during the conflict is believed to contribute to water supply interruptions. A study conducted in conflict-affected setting of Middle East suggested that lack of sufficient water is a concern for proper IPC measures.17

Likewise, we found that healthcare workers who did not take COVID-19 IPC training were 2.85 times more likely to have non-compliance with COVID-19 infection prevention measure than others. This finding is consistent with studies conducted in Amhara region19 and Wollega, Ethiopia.16 This indicates that healthcare workers can effectively contribute to preventing the COVID-19 pandemic by undergoing regular training on preventive measures for COVID-19.

In this study, healthcare workers who had no access to soap were almost three times more likely to have poor COVID-19 IPC compliance as compared with those who had access to water and soap. In our study systems, only 33.5% of healthcare workers washed their hands after touching the patient or after injection, which is lower than that reported in hospitals of northwest Ethiopia (84%).30 According to WHO, frequent and proper hand washing is one of the significant measures to prevent COVID-19 infection.31 In point of fact, non-compliance with hand hygiene among healthcare providers has been described as a global problem.24 For instance, evidence from a systematic review study showed that only 40% of hospital healthcare workers even in developed countries adhere with hand washing practices.32 Indeed, our finding on hand hygiene was greater than the reports among healthcare workers in Tanzania (6.9%),29 but consistent with similar studies conducted in Dessie, Ethiopia (32.4%)23 and Turkey (37%).33

According to the data obtained from health information management departments of the study hospitals, besides the routine health services delivery, the study hospitals were busy treating high number of emergency cases particularly associated with conflicts. Therefore, working for more than 8 hours was common as reported by 47.7% of the study participants. In this study, the odds of not adhering to COVID-19 infection prevention measures were two times higher among healthcare workers who work for more than 8 hours/day than those who work for less than or equal to 8 hours/day. Potential reasons may include stress, diminished attention and drowsiness linked to excessive workload, which could elevate the likelihood of not adhering to COVID-19 infection prevention measures. Our finding is in line with the findings reported in China.34

As per the WHO report, a global shortage of PPE is posing a threat to the well-being of healthcare workers.35 As a consequence, healthcare workers may be forced to use face masks intermittently for 8 hours. The present study also indicated that nearly two-thirds (57.5%) of healthcare workers did not wear face mask while performing an activity. Our finding was consistent with that of the study conducted in northwestern Ethiopia.36 This low utilisation of face mask among healthcare workers might be associated with work overload. Work overload could also increase the negative effects of face mask as professionals might use it improperly.37 Shortage and non-utilisation of PPE (face masks) could therefore significantly hinder healthcare workers’ compliance with IPC protocol.

We also found that the odds of poor COVID-19 infection prevention measures were 1.5 times higher among healthcare workers who did not receive support from hospital management than others. This is in agreement with previous reports from Wollega (Ethiopia).16 This is probably associated with the political instability in the area which reduces the stability of health system management. Besides, lack of support from hospitals’ management might be related to the absence of IPC guidelines. Indeed, healthcare workers in wards without IPC guidelines were twice as likely to exhibit non-compliance with IPC practices. Once more, healthcare workers who chew khat were two times more likely to have poor COVID-19 IPC compliance as compared with their counterparts. Khat is indicated to increase the level of stress and suppress immune system and health conditions. This could intensify the susceptibility of individuals towards COVID-19 infection and its complications.38 In addition, this is possibly related to the lingering effects of addiction-associated negligence and carelessness towards COVID-19 IPC protocols.

This study has some limitations. Due to shortage of literature on IPC compliance towards COVID-19 among healthcare workers in conflict settings, the discussion was made on the basis of findings from healthcare workers in non-conflict settings. This cross-sectional study might also not establish cause–effect relationship between IPC and predictable variables. While the healthcare workers were not conscious of being under observation, it is possible that some may have suspected it and consequently adjusted their behaviour. In addition, comparative studies are helpful to assess IPC practices in conflict-affected and non-affected settings.

Conclusions

In these conflict-prone and affected hospitals, the overall percentage of observed instances of non-compliance with COVID-19 infection prevention measures was determined to be 46.2%. The main factors that significantly increased the likelihood of non-compliance were shortage of hand washing soap, interruptions of piped water supply in the health facilities and work overload. In addition, lack of COVID-19 IPC training, absence of support from hospital management, unavailability of COVID-19 IPC guidelines per ward and the habit of chewing khat influenced non-compliance. Therefore, federal ministry of health, hospital managers and the regional health bureau should work together to provide regular COVID-19 IPC trainings, continuous piped water supply and personal protective facilities for healthcare workers. Workload should be taken into account as well to mitigate non-compliance with COVID-19 IPC. Given all or at least some required support, most importantly, healthcare workers should comply with COVID-19 infection prevention measures.

Data availability statement

Data are available upon reasonable request. The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.

Ethics statements

Patient consent for publication

Ethics approval

The study was approved by the Institutional Review Board of the Wollo University, College of Medicine and Health Sciences. Informed consent for participation was taken from the study participants. All the methods were performed in accordance with relevant guidelines and regulations and the Declaration of Helsinki.

Acknowledgments

The authors acknowledge the study participants who provided essential information for the study. We are also thankful to the staff members of the hospitals and the zonal authorities for their cooperation and support.

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