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Infection prevention and control, knowledge, training, compliance
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Amanya SB, Nyeko R, Obura B et al. Knowledge and compliance with Covid-19 infection prevention and control measures among health workers in regional referral hospitals in northern Uganda: a cross-sectional online survey [version 1; peer review: 1 approved with reservations]. F1000Research 2021, 10:136 (https://doi.org/10.12688/f1000research.51333.1)
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Research Article
Knowledge and compliance with Covid-19 infection prevention and control measures among health workers in regional referral hospitals in northern Uganda: a cross-sectional online survey
[version 1; peer review: 1 approved with reservations]
PUBLISHED 22 Feb 2021
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Abstract
Corresponding author:
Sharon Bright Amanya
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No competing interests were disclosed.
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The author(s) declared that no grants were involved in supporting this work.
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© 2021 Amanya SB et al.
This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
How to cite: Amanya SB, Nyeko R, Obura B et al. Knowledge and compliance with Covid-19 infection prevention and control measures among health workers in regional referral hospitals in northern Uganda: a cross-sectional online survey [version 1; peer review: 1 approved with reservations]. F1000Research 2021, 10:136 (https://doi.org/10.12688/f1000research.51333.1)
First published: 22 Feb 2021, 10:136 (https://doi.org/10.12688/f1000research.51333.1)
Latest published: 12 Apr 2021, 10:136 (https://doi.org/10.12688/f1000research.51333.2)
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Introduction
Coronavirus disease 2019 (Covid-19) is arguably the greatest global health threat of our time. As of January 24, 2021, 19,462,112 people were infected globally, with 2,112,759 deaths1. In Uganda, the cases are on the rise, with 39,044 cases as of January 24, 20211. As the case numbers grow, health workers are increasingly at risk of infection as they care for the ever -growing number of Covid-19 patients. Because the safety of health workers is key to winning the fight against the virus, infection prevention and control (IPC) measures remain critical tools.
The World Health Organization (WHO) issued interim guidance on Covid-19 IPC that emphasized several measures, including applying standard precautions to all patients, ensuring early triage and case recognition, and applying additional precautions such as wearing masks2. As the Covid-19 pandemic grows, countries have further stepped up IPC measures, including mandatory wearing of face masks and hand washing in all public places3,4. Without compliance, however, these measures will not help in achieving the intended goal, and the health workers will increasingly be at risk of Covid-19 infection, a fact becoming evident in Uganda where health workers have been infected5.
Uganda has designated treatment sites for Covid-19 patients at regional referral hospitals6 where rigorous IPC standards are implemented. However, some asymptomatic Covid-19 patients are likely to seek care from non-designated hospital departments where IPC measures might be inadequate. We believe that health workers in these departments are much more at risk of Covid-19 as they could be managing undiagnosed Covid-19 patients and therefore may not feel compelled to practice strict Covid-19 IPC measures. In this study, we evaluated the knowledge and compliance with Covid-19 IPC measures among health workers in regional referral hospitals in northern Uganda.
Methods
Study setting and design
A descriptive cross-sectional online study was conducted among health workers at regional referral hospitals (RRHs) in northern Uganda. The RRHs include: Lira RRH, Arua RRH, and Gulu RRH, which serve as referral centers for the 30 districts in northern Uganda. The health workers who participated in the study were those assigned to hospital departments other than the treatment center. Data collection took place between July and August 2020.
Study population
The study targeted health workers whose work involves primary contact with patients, including doctors, nurses, midwives, clinical officers, and laboratory officers. All health workers present at the health facility within the data collection period were included in the study. We exclude health workers who were on study leave and those who were working in designated Covid-19 treatment centers during the data collection period.
Study size
The sample size was determined using the single population proportion formula7 based on assumed probability of good knowledge regarding Covid-19 IPC of 69%8, with a marginal error of 5%, and a standard normal value corresponding to 95% certainty, and a non-response rate of 15%. This yielded a sample size of 213 health workers. Of the 213 health workers approached, only 75 responded within the 1 month period for data collection giving a response rate of 35%.
Study procedure and tool
Convenience sampling was used to identify and select WhatsApp groups with the health workers of interest from the respective RRHs. The researchers obtained verbal consent from the group administrators and requested their help in mobilizing members on the WhatsApp platforms. A link to the questionnaire on Google forms (Alphabet Inc., California, USA) was shared with the potential respondents via WhatsApp messenger (Facebook, Inc., California, USA). Participants were invited to voluntarily participate in the study by following the link shared.
Data was collected from 75 health workers using an anonymous, self-administered, online, structured questionnaire adapted from the literature. Knowledge and institutional support were assessed using an eight-item questionnaire adapted from Haridi et al.9 and modified to assess Covid-19 IPC knowledge among health care workers. Compliance was assessed using an eight-item questionnaire from the WHO protocol for the assessment of potential risk factors for Covid-19 infection among health care workers10. The data collection tool consisted of four sections. The first section captured the demographic characteristics of the participants. The second section comprised eight questions ascertaining the level of knowledge and understanding of the concepts of Covid-19 IPC and was scored as follows: one (1) point was awarded for each correct response and zero (0) for an incorrect response, and a correct response score of ≥80% was considered sufficient knowledge. The third section comprised eight questions to ascertain the level of compliance with IPC measures and scored as follows: 1, for ‘never’; 2, for ‘rarely’; 3, for ‘sometimes’; and 4 for ‘always’, giving a possible score of 32 points. Adequate compliance was set at ≥75% (24) of the maximum score. The fourth section comprised three questions concerned with the perception of institutional commitment to IPC and was rated on a Likert scale (never, rarely, sometimes, and always). A scoring system was assigned as follows: 1, for ‘never’; 2, for ‘rarely’; 3, for ‘sometimes’; and 4 for ‘always’, giving a total score of 12. Strong institutional support was considered with a score of ≥75% (9).
Ethical considerations
Ethical approval for this study was obtained from St. Mary’s Hospital Lacor Research and Ethics Committee [Ref. No. LHIREC 0168/06/2020]. The study participants were availed with adequate information regarding the study purpose and procedures and thereafter invited to sign an online informed consent.
Data management and analysis
The responses from Google forms were downloaded in an Excel sheet (Microsoft Inc. Albuquerque, New Mexico, United States) and then exported to Statistical Package for the Social Sciences (SPSS) software, version 21.0 (SPSS, Chicago, IL, USA) for analysis. Frequencies and percentages were used to summarize knowledge and compliance with IPC among health care workers, while means and standard deviations were used to summarize data on age, work experience, and other numerical variables. The chi-square test was performed to determine the relationship between categorical variables, while the Pearson correlation test was used to determine the association between continuous variables. A variable was considered significant in this analysis if it had a p-value <0.05.
Results
Demographic characteristics of respondents
A total of 75 health care workers responded, and the majority were female (52%). More than half of the respondents (60%) belonged to the age group of 20–39 years with a mean age of 36.92 (SD ±9.39). The majority of the health workers interviewed had a bachelor’s degree as their highest level of education and had a mean work experience of 10.4 years (SD ± 8.79). Of all the participants, only 50.7% reported to have received training in Covid-19 IPC, and 66.7% reported having Covid-19 IPC guidelines at their workstations. A significant number of respondents (94.7%) perceived themselves as being at risk of Covid-19 (Table 1).
Table 1. Demographic characteristics of respondents.
Knowledge of Covid-19 infection prevention and control
The majority of the respondents (69.3%) had sufficient knowledge, with a mean knowledge score of 5.88/8 (SD ±1.05) (Table 2). Knowledge varied by item assessed. The vast majority of health care workers provided correct responses to items concerning the cleaning of frequently touched surfaces (97.3%), use of contact precautions (94.7%), screening for Covid-19 signs and symptoms (94.3%), applicability of standard precautions (92%), and cleaning of shared equipment (89%). Few correct responses were obtained for items regarding airborne precautions (41.3%) and applicability of hand hygiene (57.4%) (Underlying data file 1). There was no statistically significant relationship between knowledge and socio-demographic variables of respondents (Table 3).
Table 2. Knowledge and compliance with Covid-19 infection, prevention, and control (IPC) among health care workers in regional referral hospitals in northern Uganda.
| IPC Score | Frequency (n) | Percentage (%) |
|---|---|---|
| Knowledge Sufficient knowledge (80–100%) Insufficient knowledge (≥79%) | 52 23 | 69.3 30.7 |
| Compliance Adequate compliance (75–100%) Inadequate compliance (≥74%) | 51 24 | 68 32 |
Table 3. Factors associated with knowledge and compliance with Covid-19 IPC.
| Variable | Knowledge status | Odds ratio (95% CI) | P value | Compliance status | Odds ratio (95% CI) | P value | ||
|---|---|---|---|---|---|---|---|---|
| Adequate n = 52 | Inadequate n = 23 | Sufficient | Insufficient | |||||
| Sex • Female • Male | 27 25 | 12 11 | 0.99 (0.371-2.644) | 0.984 | 27 24 | 12 12 | 1.125 (0.426-2.970) | 0.812 |
| Age (mean and SD) • 18 to 39 • ≥40 | 34 18 | 11 12 | 2.06 (0.760-5.589) | 0.152 | 28 23 | 17 7 | 0.501 (0.177-1.416) | 0.189 |
| Health worker cadre • Doctor • Nurse • Midwife • Clinical Officer • Laboratory Officer | 13 15 13 9 2 | 4 4 9 3 3 | 0.304 | 11 15 14 8 3 | 6 4 8 4 2 | 0.830 | ||
| Level of education • Certificate • Diploma • Bachelor’s Degree • Master’s Degree | 4 13 34 1 | 2 8 13 0 | 0.751 | 4 13 34 0 | 2 8 13 1 | 0.408 | ||
| Work experience • 1–9 years • ≥10 years | 35 17 | 10 13 | 2.672 (0.977-7.33) | 0.052 | 29 22 | 16 8 | 0.659 (0.239-1.816) | 0.419 |
| Working hours a week • ≤40 hours • >40 hours | 33 18 | 17 6 | 0.674 (0.217-1.932) | 0.434 | 35 16 | 15 8 | 1.167 (0.411-3.308) | 0.772 |
| IPC training for Covid-19 • Trained • Not trained | 29 23 | 9 14 | 1.96 (0.721-5.33) | 0.184 | 30 21 | 8 16 | 2.857 (1.035-7.88) | 0.039* |
| Have Covid-19 IPC guidelines at workstation • Have • Do not have | 34 18 | 16 7 | 0.826 (0.287-2.37) | 0.723 | 38 13 | 12 12 | 2.9 (1.056 - 8.092) | 0.036* |
| Institutional support • Strong support (70.7%) • Weak support (29.3%) | 34 18 | 0.398 (0.117 -1.347) | 0.13 | 40 11 | 13 11 | 3.077(1.08 – 8.74) | 0.031* | |
Compliance with Covid-19 infection prevention and control
Majority of the respondents (68%) had adequate compliance, with a mean score of 27.35/32 (SD±3.3) (Table 2) and varied by item assessed (Underlying data file 2). Compliance was associated with having received training in Covid-19 IPC (p=0.039), having Covid-19 IPC guidelines at workstations (p=0.036), and sufficient institutional support (p=0.031). There was no statistically significant relationship seen between compliance and sociodemographic characteristics of participants such as age, level of education, working hours, work experience and health worker cadre (Table 3).
Institutional support for Covid-19 infection prevention and control
Generally, there was strong perceived institutional support, with the majority of participants (70.7%) feeling adequately supported by their respective institutions. Moreover, strong institutional support was associated with Covid-19 IPC compliance (p=0.031) (Table 3). Just as knowledge and compliance, institutional support score varied by item assessed (Underlying data file 3). For example, only 18.7% of the participants reported always being availed with adequate personal protective equipment (PPE) by their hospitals, while 50.5% reported always having access to handwashing facilities and products, and 49.3% reported always being availed sufficient supplies for the collection of medical waste (Underlying data file 3).
Discussion/Conclusion
In this study, we evaluated COVID-19 infection prevention control knowledge and compliance among health workers at RRHs in northern Uganda. Our findings suggest that the majority of the health workers in RRHs in northern Uganda are knowledgeable and compliant with Covid-19 IPC. We have identified that 69.3% of the respondents have sufficient knowledge of Covid-19 IPC and that it varied by item assessed. Whereas limited data exist on knowledge of Covid-19 IPC among health workers in Africa, our findings are comparable to those of a similar study at a Chinese mental institution that showed a knowledge score of 63.9%11. However, pre-Covid-19 pandemic studies have shown lower knowledge scores12,13. Taken together, these findings imply that training in IPC during the Covid-19 pandemic has enhanced health workers’ IPC knowledge and therefore needs to be sustained. Moreover, similar to previous studies9,14,15, we demonstrate that knowledge on various parameters of IPC varies. In our study, we found that most health workers were less knowledgeable about parameters related to airborne precautions and hand hygiene. This limited knowledge suggests a need to focus on training, audit and feedback methods to improve knowledge in these areas, as they are central Covid-19 IPC. Furthermore, we did not find a statistically significant relationship between knowledge and participants’ sociodemographic characteristics, IPC training or presence of guidelines. However, previous studies have reported a positive association between knowledge of IPC and age, years of experience, training in IPC, and availability of guidelines14,16. One possible reason for this discrepancy is the context in which the studies were conducted. Unlike these previous studies, our study was conducted during the Covid-19 pandemic, where health workers have been exposed to various training and information sources regarding IPC in the setting of Covid-19.
We also found that the majority of the health workers (68%) had good compliance with Covid-19 IPC measures. The high score of self-reported compliance is comparable to a previous self-report study14. However, previous studies that used observation methods for data collection reported lower compliance rates; for example, a hand hygiene compliance score of 53–57%11,12,16. This discrepancy could be due to the difference in methods, as self-reported studies are likely to find more compliance with IPC. Moreover, compliance scores also varied by item assessed, as reported in previous studies17,18. In addition, compliance was found to be associated with having had training in Covid-19 IPC, having IPC guidelines, and perceived strong institutional support. Previous studies have shown that training in IPC and access to guidelines improves compliance with IPC12,13,16. Accordingly, the WHO and the Uganda Ministry of Health have emphasized training of all health care staff and developed and supplied guidelines for IPC4,19. These efforts are likely to have contributed to the high knowledge and compliance scores noted in our study. Therefore, our findings provide support for the notion that support to health care workers in terms of training, provision of guidelines and appropriate facilities and supplies for IPC increases compliance.
In the present study, we also report strong institutional support (70%) for health workers. Despite the high scores, fewer health workers reported adequate provision of PPE. Indeed, inadequate supply of PPE has been a key challenge in health care systems worldwide during this pandemic, with policy makers advocating for the provision of more PPE to protect health care workers20,21. In this regard, Uganda is not spared as the Covid-19 cases and hospital admissions continue to grow. As of January 24th, there were more than 39,000 cases of Covid-19 reported in Uganda1. More so, over 1200 health workers had been infected with the disease as of November 24th, 202022. Our findings point to the need for an adequate and consistent supply of PPE to RRHs in northern Uganda. Nonetheless, the small sample size coupled with the self-report method of measuring compliance are key limitations of this study, and we therefore suggest that further studies consider observation methods to improve the objectivity of the data.
In conclusion, there is generally good knowledge and compliance with Covid-19 IPC among health workers in regional referral hospitals within northern Uganda. Majority of the respondents (69.3%) had sufficient knowledge on Covid-19 IPC while 68% had adequate self-reported compliance with IPC. Moreover, compliance was associated with health workers having had training in IPC and having Covid-19 guidelines available at their workstations as well as institutional support. These findings suggest a need for more training on a regular basis as well as up-to-date guidelines to ensure compliance with Covid-19 IPC. This limits the spread of Covid-19 to health workers their patients.
Data availability
Underlying data
Open Science Framework: [Knowledge and compliance with Covid-19 infection prevention and control measures among health workers in regional referral hospitals in northern Uganda], DOI: 10.17605/OSF.IO/84KJG
This project contains the following underlying data:
- Underlying data file 1 (Knowledge score by item assessed to determine the knowledge of Covid-19 infection prevention and control among health workers at regional referral hospitals in Northern Uganda)
- Underlying data file 2 (Compliance score by item assessed to determine health workers’ compliance with Covid-19 infection prevention and control measures)
- Underlying data file 3 (Institutional Support for Covid-19 infection prevention and control score by item assessed)
Data are available under the terms of the Creative Commons Attribution 4.0 International license (CC-BY 4.0).
Extended data
[Open Science Framework]: [Knowledge and compliance with Covid-19 infection prevention and control measures among health workers in regional referral hospitals in northern Uganda] [DOI: 10.17605/OSF.IO/84KJG]
This project contains the following extended data:
Study data file (SPSS data file with the raw data collected from participants)
The authors confirm that they have received permission to reproduce the above questionnaire from the owner of the original questionnaire.
Data are available under the terms of the Creative Commons Attribution 4.0 International license (CC-BY 4.0).
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CITE
how to cite this article
Amanya SB, Nyeko R, Obura B et al. Knowledge and compliance with Covid-19 infection prevention and control measures among health workers in regional referral hospitals in northern Uganda: a cross-sectional online survey [version 1; peer review: 1 approved with reservations] F1000Research 2021, 10:136 (https://doi.org/10.12688/f1000research.51333.1)
NOTE: it is important to ensure the information in square brackets after the title is included in all citations of this article.
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PUBLISHED 22 Feb 2021
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How to cite this report:
Bongomin F. Reviewer Report For: Knowledge and compliance with Covid-19 infection prevention and control measures among health workers in regional referral hospitals in northern Uganda: a cross-sectional online survey [version 1; peer review: 1 approved with reservations]. F1000Research 2021, 10:136 (https://doi.org/10.5256/f1000research.54489.r80019)
The direct URL for this report is:
https://f1000research.com/articles/10-136/v1#referee-response-80019
https://f1000research.com/articles/10-136/v1#referee-response-80019
NOTE: it is important to ensure the information in square brackets after the title is included in this citation.
Reviewer Report 09 Mar 2021
Approved with Reservations
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It is my pleasure to review this work on Knowledge and Compliance with IPC with regards to COVID-19 prevention among HCWs in 3 major RRHs in Northern Uganda. Patients actively involved in COVID-19 treatment in those centers were excluded and
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HOW TO CITE THIS REPORT
Bongomin F. Reviewer Report For: Knowledge and compliance with Covid-19 infection prevention and control measures among health workers in regional referral hospitals in northern Uganda: a cross-sectional online survey [version 1; peer review: 1 approved with reservations]. F1000Research 2021, 10:136 (https://doi.org/10.5256/f1000research.54489.r80019)
The direct URL for this report is:
https://f1000research.com/articles/10-136/v1#referee-response-80019
https://f1000research.com/articles/10-136/v1#referee-response-80019
NOTE: it is important to ensure the information in square brackets after the title is included in all citations of this article.
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Author Response 12 Apr 2021Sharon Bright Amanya, Microbiology and Immunology, Lira University, Lira, Uganda12 Apr 2021Author ResponseThe reviewer makes a number of important comments and these have been addressed as follows:
Comment 1: Abstract: Please include the response rates, number of respondents, and basic demographic ... Continue reading
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Author Response 12 Apr 2021Sharon Bright Amanya, Microbiology and Immunology, Lira University, Lira, Uganda12 Apr 2021Author ResponseThe reviewer makes a number of important comments and these have been addressed as follows:
Comment 1: Abstract: Please include the response rates, number of respondents, and basic demographic ... Continue reading
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