Compliance towards infection prevention measures among health professionals in public hospitals, southeast Ethiopia: a cross-sectional study with implications of COVID-19 prevention

Introduction The new coronavirus disease 2019 is an emerging respiratory disease caused by the highly contagious novel coronavirus which has currently overwhelmed the world. Realizing a comprehensive set of infection prevention measures is a key to minimize the spread of this virus and its impacts in all healthcare settings. Therefore, this study was aimed to assess the compliance towards COVID-19 preventive measures and associated factors among health professionals in selected public hospitals, southeast Ethiopia. Methods A descriptive hospital-based cross-sectional study was conducted among 660 health professionals in public hospitals of southeast Ethiopia from October 1 to 31, 2020. A multistage sampling technique was used to select the study participants. Data were collected by interview using structured and pretested questionnaires. Ordinary logistic regression modeling was used to estimate the crude and adjusted odds ratio. To declare the statistical significance of factors associated with the outcome variable, P-value < 0.05 and 95% confidence interval were used. Results A total of 654 health professionals were involved in the study; of whom, 313 participants were nurses. The overall good compliance and knowledge of health professionals regarding COVID-19 preventive measures were 21.6 and 25.5%, respectively. Working in the general hospital (AOR = 0.55; 95% CI 0.38, 0.79), service year (AOR = 2.10; 95% CI 1.35, 3.21), knowledge (AOR = 1.80; 95% CI 1.14, 2.89), and water availability (AOR = 3.26; 95% CI 2.25, 4.72) were some of the factors found to have a statistically significant association to compliance of health professionals regarding COVID-19 preventive measures. Conclusion In this study, nearly one fifth of health professionals had good compliance towards COVID-19 prevention practices. Thus, a consistent supply of COVID-19 prevention materials, facilities, and improving the knowledge of health professionals through on and off-job training are crucial.


Introduction
Viral diseases are persistent to emerge and denote a serious issue to public health. In the preceding centuries, numerous viral epidemics such as the severe acute respiratory syndrome coronavirus (SARS-CoV) and Middle East respiratory syndrome coronavirus (MERS-CoV) were identified in different periods [1]. In our time, the new coronavirus disease 2019 (COVID-19) caused by the highly contagious novel coronavirus (SARS-CoV 2) which has currently overwhelmed the world [2,3]. The known modes of transmissions are droplets, contact, and aerosols [4].
The healthcare systems of the countries in the world became shaken and disturbed due to the COVID-19 pandemic [5]. In Africa, the COVID-19 pandemic is uncontrollably rising and the reactions to this pandemic have been challenged by a shortage of human resources, personal protective equipment (PPE), limited infrastructure, inadequate systems for the prevention, and fragile healthcare systems [6][7][8]. Globally, there have been more than nearly 80.3 million confirmed cases, and more than 1.8 million deaths registered up to December 26, 2020. In Ethiopia, the first patient with COVID-19 was detected on March 3, 2020, in Addis Ababa. From then until December 26, 2020, 121,880 COVID-19 confirmed cases and 1897 deaths were reported [9].
Health professionals (HPs) are at the front line in fighting coronavirus spread that put them at the risk of contracting COVID-19 [10,11]. Keeping safety in the working environment for the health professionals and an operative plan is crucial in each phase of the pandemic. COVID-19 preventive measures recommended by World Health Organization (WHO) consist of regular handwashing, with soap and running water or using alcohol-based hand sanitizer; using face masks; avoid touching the eyes, nose, and mouth if hands are not clean; and avoiding close physical contact [12]. Realizing a comprehensive set of infection prevention measures in all healthcare settings is a collective responsibility and critical to protecting the health and lives of our precious healthcare workforce as well as the key to minimize the spread of the virus in both health care settings and the community [13].
Despite the greater destructive consequences of COVID-19 to individuals and public health, noncompliance to the preventive measures has been reported around the world [14][15][16]. Previous studies conducted in different countries indicated that around one-tenth of healthcare workers remove their masks while talking to the patient, four-fifths of them reused surgical masks, and 44.9% correctly dispose of the used facemask in the yellow-coded bags. Overcrowding, limited infection prevention materials/supplies, less commitment of healthcare providers to the policies and procedures, insufficient training, and lack of policy were factors affecting COVID-19 prevention practice [16][17][18].
In Ethiopia, multiple interventions were implemented to prevent the COVID-19 pandemic before it causes a substantial impairment to the community. The government declared a state of emergency, and established a COVID-19 taskforce at national who were informing disease prevention measures, deliver regular situational updates, and organize massive awareness creation efforts using diverse social and mass media stages. The COVID-19 catastrophe sends a solid message to resistant health systems that can only be realized with a committed health workforce. Protecting everyone requires urgently addressing shortages of health workers, updating infection prevention measures, investing in capacity building, and warranting safe working environments [19,20].
Currently, there are no conclusive cure and specific antiviral therapeutics that are suggested for preventing or treating the COVID-19. Thus, preventive measures ranging from individuals to large-scale societal level practices are the only available means to control the spread of the virus and minimize its impacts [13,21]. In this regard, the findings of this study are crucial to health professionals, health facilities, or higher administrators and researchers to halt the spread of COVID-19 [17,22]. Therefore, this study was aimed to assess the compliance towards COVID-19 preventive measures and associated factors among health professionals in selected public hospitals, southeast Ethiopia, 2020.

Study settings and design
A descriptive hospital-based cross-sectional study was conducted in selected public hospitals found in three zones (Bale, East Bale, and West Arsi) of southeast Ethiopia from October 1 to 31, 2020. The purposively selected zones consist of 164 health centers and 12 hospitals (4 primaries, 6 general, and 2 referral public hospitals); of these, 7 hospitals were included in this study. According to Zonal Health Departments data of 2020, more than 4346 health professionals are employed with around 4.5 million populations in the catchment area of selected hospitals.

Source and study population
All health professionals who were working in hospitals found in three zones (Bale, East Bale, and West Arsi) were the source population. And all health professionals who are working in selected hospitals of three zones were the study population.

Sample size and sampling procedure
The sample size was calculated using the single population proportion formula by considering a 95% confidence interval (CI), 5% margin of error (d), proportion (P) 50%, and 1.5 of design effect. Considering 10% of the nonresponse rate, the final sample size 660 was obtained. A multistage sampling technique was used to select the study participants. Initially, the hospitals were stratified into primary, general, and referral hospitals. Accordingly, from each stratum, 2 primaries, 3 general, and 2 referral hospitals were selected using a simple random sampling technique. Based on the number of health professionals in each hospital, the total sample was proportionally allocated and each study participant was selected from the sampling frame using simple random sampling (lottery method).

Data collection tool, technique, and quality control
The questionnaire was developed first in English and translated to local languages by an expert of both languages "Amharic" and "Afan Oromo" and then back to English to check for consistency of the translation. The questionnaire was adapted and modified in the local settings from formerly available studies [23][24][25], CDC [26,27], and WHO guidelines [28].
Data were collected by interviewer-administered, structured, and pretested, questionnaires containing health professionals' socio-demographic characteristics, compliance, and knowledge regarding COVID-19 preventive measures. To assure the data quality, data collection instruments were pretested on 5% of the total sample size, and to minimize over-reporting of compliance to COVID preventive measures, the questionnaire was also set in PK (practice and knowledge) order.

Data processing and analysis
Data were entered using Epi-Data version 3.1 and analyzed using STATA version 14. Descriptive statistics were used to generate frequency tables, graphs, and ordinary logistic regression modeling was used to estimate crude (p-value < 0.25) and adjusted odds ratio.
To declare the statistical significance of factors associated to outcome variables, P-values < 0.05 and 95% confidence interval were used.
Adequate natural ventilation is when working and staff room have at least two air inlets and outlet with room area 12 m 2 and below.
Functional handwashing facility is functional handwashing sink with water and soap during data collection time.

Socio-demographic characteristics of the study participants
Six hundred fifty-four health professionals were involved in the study with a 99% response rate, of which, 419 (64.1%) participants were males and 501 (76.6%) were in the age category of 25-35 years.
Regarding health professionals, about 313 (47.9%) were nurses, and 318 (48.6%) were from the general hospital. About 227 (34.7%) and 264 (40.4%) of health professionals reported that working and staff rooms have no adequate natural ventilation. Regarding the COVID-19 prevention facility, 227 (34.7%) and 279 (42.7%) of health professionals reported that there were no functional handwashing facilities and continuous water supply at their workplace respectively (Table 1).

Knowledge regarding COVID-19 preventive measures
In this study, 342 (52.3%) and 167 (25.5%) of health professionals had moderate and good knowledge regarding COVID-19 preventive measures respectively, whereas 145 (22.2%) of them had poor knowledge. The majority of the health professionals know respiratory droplets and close contact was the main transmission route of COVID-19. Concerning handwashing, only one fourth (25.9%) of health professionals correctly identify the recommended duration of handwashing by the World Health Organization (Table 4).

Factors associated with compliance towards COVID-19 prevention measures
Socio-demographic-, knowledge-, and health facilityrelated factors to compliance towards COVID-19 prevention measures were identified using an ordinary logistic regression model. Health professionals who working in general hospitals were 45% times less likely to have good compliance towards COVID-19 prevention measures than health professionals working in referral hospitals (AOR = 0.55; 95% CI 0.38, 0.79). The odds of having good compliance towards COVID-19 preventive measures were 2 times more likely among health professionals with 3-6 service years than health professionals who had ≤ 2 service years (AOR = 2.10; 95% CI 1.35, 3.21). Health professionals who have a good knowledge regarding COVID-19 preventive measures were 1.80 more likely to have good compliance regarding COVID-19 preventive measures than their counterparts (AOR = 1.80; 95% CI 1.14, 2.89). Similarly, the odds of having good compliance were nearly 3 times more likely   (Table 5).

Discussion
Compliance with infection prevention practices is essential for minimizing transmission of infection, particularly crucial during the COVID-19 pandemic [19,31]. This study has assessed the compliance towards COVID-19 preventive measures among health professionals in selected public hospitals, southeast Ethiopia. In this study, the overall good compliance towards COVID-19 preventive measures among health professionals was found to be 21.6%. This finding was lower than a study conducted in northwest Ethiopia, 38.7% [32], and in China, 87% [33]. The possible explanation for the disparity of this finding might be due to the difference in the number outcome variable category (two vs. three), distribution of COVID-19 prevention supplies and facilities (at different levels of hospitals, or poor managerial attention). Moreover, the compliance disparity might be due to the duration of the study (early and late pandemic) and disease burden.
In this study, about 64.2% of health professionals reported using face masks at the workplace whenever approaching COVID-19 suspected or confirmed patients. Despite wearing the face mask is mandatory within the health facility, our findings showed that only around two thirds of health professionals (HPs) use masks, which means, about one third of HPs significantly facilitate the chance to acquire or transmit the disease. This might be because some HPs may have difficulty of using masks due to uncomfortability and shortage of masks [29]. This finding is comparable with the study conducted in eight teaching hospitals in Ethiopia, 67.3% [34]. This consistency might be due to the shortage of masks which similarly affects all healthcare facilities found in Ethiopia. In this study, around 56% and  54.9% of health professionals' practice frequent handwashing before and after patients contact respectively. Again, this finding is under expected; only half of HPs reported having compliance towards one of the critical handwashing times recommended by the World Health Organization. This might be due to 65.3 and 57.3% of health professionals reported having a functional handwashing facility and continuous water supply at their workplace, respectively. Regarding working environment disinfection, only 34.1 of HPs disinfect examination tables and beds found in working rooms before and after each procedure. This might be due to no access to disinfectants or less attention to the values of disinfection or believing as this activity belongs to cleaners or nonhealth professionals. This finding was slightly higher than the study finding, in Amhara Regional state Ethiopia, 29% [32]. This difference might be due to the inconsistency of health professional's commitments regarding disinfection. Similarly, about 28% of HPs disinfect the blood pressure apparatus or thermometer after every patient contact. This might be due to the forgetfulness of health professionals or less attention, which may trigger the transmission of COVID-19 through direct contact. This study shows that 25.5% of the health professionals have a good knowledge regarding COVID-19 prevention measures. This finding is lower than the study conducted, in Amhara Region, 70% [30]; northwest Ethiopia, 73.8% [32]; and in China, 88.4% [35]. The possible reason for this variation might be due to the study settings; participant's negligence to focus on all items listed to evaluate knowledge, and only 41.1% of HPs taken training on COVID-19 prevention measures. This study indicated that the good compliance and knowledge of HPs regarding COVID-19 preventive measures were somewhat comparable, 21.6 and 25.5%, respectively. This implied that the health professional's compliance towards COVID-19 preventive measures was not overreported when compared to their knowledge. Based on the ordinary logistic regression model; service years of health professionals, level of hospital, knowledge of health professionals, presence of the COVID-19 prevention committee, handwashing facility, and water availability were factors associated with compliance regarding COVID-19 preventive measures. The odds of having good compliance were nearly 1.8 times higher among health professionals who had good knowledge regarding COVID-19 preventive measures. This might be attributed to adequate training (duration of training), the presence of reading materials/internet services, and personal commitments. The odds of having good compliance towards COVID-19 preventive measures were 2 times more likely among health professionals with 3-6 service years than health professionals with ≤ 2 service years. This finding  was comparable with the study finding in Amhara Region, Ethiopia [30]. This could be because as the HPs service years increase, the exposure and fear for such pandemic will increase and may practice prevention measures more strictly. On the other hand, the odds of having good compliance towards COVID-19 preventive measures were nearly 3 times more likely among health professionals who know the presence COVID-19 prevention committee in hospitals than their counterparts. This might be due to the committee informing HPs of the key COVID-19 preventive measures that are to be practiced during regular internal supervision.

Limitation of the study
This study had some limitations that include hospitals currently serve as COVID-19 treatment and isolation centers were not included. As the study assessed selfreported compliance regarding COVID-19 prevention measures, it may be affected by social desirability. Despite these limitations, our findings provide valuable information about health professionals' compliance regarding COVID-19 prevention measures.

Conclusions
Regardless of the above limitation, around one fifth of health professionals in selected public hospitals of southeast Ethiopia had good compliance towards COVID-19 preventive measures. Nearly one fourth of health professionals had good knowledge of COVID-19 preventive measures. In this study, level of hospital, service years, presence of COVID-19 prevention committee, knowledge on COVID-19 preventive measures, availability of functional handwashing facility, and continuous water supply at the workplace were factors associated with compliance of health professionals towards COVID-19 preventive measures. Thus, a consistent supply of COVID-19 prevention materials, facilities, and improving knowledge of health professionals through on-and off-job training is recommended. Moreover, local health authorities should work in cooperation with fruitful stakeholders to fulfill gaps and monitor the operation of all COVID-19 preventive measures in hospitals.