key: cord-0711015-udo1r14s authors: Agarwal, Ayush; Ranjan, Piyush; Saikaustubh, Yellamraju; Rohilla, Priyanka; Kumari, Archana; Prasad, Indrashekhar; Baitha, Upendra; Dwivedi, Sada Nand title: Development and validation of a questionnaire for assessing preventive practices and barriers among health care workers in COVID-19 pandemic date: 2021-04-23 journal: Indian J Med Microbiol DOI: 10.1016/j.ijmmb.2021.03.006 sha: 8c873eba3436f10a0b6a698ec66ef4f2734681c3 doc_id: 711015 cord_uid: udo1r14s OBJECTIVES: COVID-19 has affected thousands of health care workers worldwide. Suboptimal infection control practices have been identified as important risk factors. The objective of this study was to develop and validate a questionnaire to holistically assess the preventive practices of health care workers related to COVID-19 and identify the reasons for shortcomings therein. METHODS: The development of the questionnaire involved item generation through literature review, focus group discussions and in-depth interviews with health care workers and experts, followed by validation through expert opinion, pilot testing and survey. A cross-sectional survey on 147 healthcare workers was done using an online platform and/or interviews in August 2020 in New Delhi, India. Exploratory factor analysis using principal component extraction with varimax rotation was performed to establish construct validity. Internal consistency of the tool was tested using Cronbach's alpha coefficient. RESULTS: The developed questionnaire consists of two sections: Section A contains 29 items rated on a five-point Likert scale to assess preventive practices and Section B contains 27 semi-structured items to assess reasons for suboptimal practices. The first section has good validity (CVR = 0.87, S-CVI/Av = 0.978) and internal consistency (Cronbach's alpha coefficient = 0.85) CONCLUSIONS: This questionnaire is a valid and reliable tool for holistic assessment of preventive practices and barriers to it among health care workers. It will be useful to identify vulnerable practices and sections in health care settings which would assist policymakers in designing appropriate interventions for infection prevention and control. This will also be useful in future pandemics of similar nature. Suboptimal preventive practices are an important risk factor for getting COVID-19 infection. This questionnaire evaluates preventive practices in health care workers holistically and identifies reasons for suboptimal compliance in these practices. It will help in identifying loopholes in the healthcare system and formulating corrective interventions and policies for infection prevention and control. Being at the front line of the outbreak response, millions of healthcare workers (HCWs) have been infected in the Coronavirus Disease 2019 (COVID-19) pandemic [1] . There is around 11 fold increased risk of infection in HCWs compared to the general population and the incidence of COVID-19 infection in HCWs is reported up to 38.9% in various studies [2, 3] . HCWs have an increased risk of acquiring COVID-19 compared to the general population due to interaction with sick patients and/or potentially infected co-workers and hospital environment [4] . Suboptimal preventive practices like improper personal protective equipment(PPE) and handwashing have been identified as important risk factors in HCWs, thus highlighting the importance of proper preventive practices in reducing the spread of COVID-19 [2, 5] . Several studies have been done to assess knowledge, attitude and practices among HCWs regarding COVID-19 but few of them have focused on preventive practices of HCWs in detail. Also, there is a dearth of studies that have utilised scientifically designed and validated questionnaires to explore the reasons for suboptimal practices. Therefore, we undertook this study to design and validate a standardized questionnaire that can holistically assess the preventive practices by HCWs related to COVID-19 and identify the reasons for shortcomings therein. Such a tool can help in assessing the lapses and formulating appropriate strategies for infection prevention and control in healthcare settings during the COVID-19 pandemic as well as future pandemics of similar nature. The development and validation of the questionnaire were done following a standard methodology which included literature review, indepth-interviews and Focussed Group Discussions (FGDs) to generate items followed by expert validation, pilot testing and a cross-sectional survey to establish validity and reliability ( Fig. 1) [6, 7] . The study was approved by the Institutional Ethics Committee of the institute. Appropriate consent was obtained from all the participants before their enrolment in the study. The study was conducted in two phases: It involved the following three steps: In the first step, an extensive review of existing literature was done using medical search engines like PubMed and Google Scholar. Keywords "COVID-19 or Coronavirus", "Risk factors or Prevention or preventive practices", for "Health care workers" and MeSH terms like "Coronavirus Infections/prevention and control", "Health Knowledge, Attitudes, Practice" and "Surveys and Questionnaires" were used to search for articles which led to shortlisting of 506 related articles. After screening titles, abstracts and full texts, 76 articles were found to be relevant. These articles were thoroughly read and twenty-eight items were generated at the end of this stage. In the second step, FGDs and in-depth interviews were conducted. Five FGDs were done on an online platform-three with HCWs and two with experts. The FGDs with HCWs included 6-7 participants in each session including faculty, residents, nurses, lab technicians and other paramedical staff. This was followed by FGDs with six experts from fields of infectious diseases, medicine, nutrition and clinical psychology. Each session lasted around 60-70 minutes in which sequential open-ended questions were asked to understand the various aspects of preventive practices related to HCWs. The discussions were analysed qualitatively to generate a comprehensive list of items. This led to the addition of 48 items. In-depth interviews were conducted with experts and HCWs to gain insight into practical issues which led to the further addition of 11 items. In the third step, relevant items were generated with specific attention to the proper framing of questions in a lucid language, using expressions in the first person. Each item was carefully framed to refer to a single concept, avoiding ambiguity and double negatives. Thus, a total of 87 items were generated and grouped into two sections. It involved the following steps: In the first step, the developed questionnaire was evaluated by six experts from diverse fields including infectious diseases, medicine and surgical disciplines for critical appraisal and content validation. For qualitative content validity, each expert was asked to comment on the relevance and lucidity of individual items. For quantitative content validity, each expert was asked to rate the items on necessity, clarity and relevance. Necessities of items were evaluated by using a 3-point scale: 1 (not necessary), 0 (useful but not essential), 1 (essential). The formula of content validity ratio (CVR) is CVR¼ (Ne-N/2)/(N/2) where Ne is the number of experts indicating items as essential and N is the total number of experts. According to Lawshe scores, the acceptable CVR values were determined and items with CVR less than the acceptable score were discarded or modified [8] . The clarity and relevance of items were evaluated by using Content Validity Index (CVI) [9] . Each item was rated on a 4-point Likert scale: 1 (not relevant/clear), 2 (slightly relevant/clear and needs revision), 3 (relevant/clear and needs minor revision), and 4 (very relevant/clear). Items with scoring less than acceptable CVI scores were discarded or modified. On this basis, 31 items were deleted. There was a satisfactory level of agreement between experts on the revised draft of the questionnaire suggesting good content validity (CVR ¼ 0.87 and CVI/Av ¼ 0.978). In the second step, the revised draft of the questionnaire was pretested on 9 HCWs to evaluate acceptance, relevance and lucidity. Based on the feedback, relevant modifications were done in consultation with experts. Kindly give answers to the following questions based on your routine in the last 2 weeks. You can mark more than one option and provide other reasons. No. Hand Hygiene In the third step, a cross-sectional survey was conducted on HCWs working in the institute. HCWs from diverse socio-cultural backgrounds including faculty, resident doctors, nurses, health assistants, sanitation assistants, security guards, lab technicians, OT technicians, pharmacists and data entry operators were recruited. The data collection was done in August 2020 using Google forms as an online platform. Thus, content and face validity of the questionnaire was established through FGDs, interviews, expert evaluation and pilot testing. For construct validity, exploratory factor analysis with principal component extraction and varimax rotation was done to evaluate the domain structure. This technique is used for estimating the number of factors and/or item reduction. KMO test and Bartlett's test of sphericity were done before exploratory factor analysis to determine the suitability of data for analysis. Cronbach's alpha coefficient was analysed to measure the internal consistency of the questionnaire. Descriptive statistics were used to analyse the results of the questionnaire. The final questionnaire consisting of 56 items in two sections is enclosed in box 1. The scoring instructions of the questionnaire are enclosed in box 2. Section A comprised 29 questions on preventive practices covering aspects like hand hygiene, PPE, social distancing, lifestyle, fomites, exposure and quarantine. Section B comprised 27 semi-structured questions to assess barriers to the adoption of preventive practices. It took approximately 20-25 min to complete the questionnaire. A total of 152 participants participated in the study out of which five responses were excluded as they were incomplete. The sociodemographic details of the remaining 147 participants are presented in Table 1 . The participants were aged 20-54 years with a slight male predominance (62.6% males), with an acceptable representation from various occupational categories. Around 43% of participants had been posted in COVID-19 designated areas and 47% of HCWs were attending to COVID-19 positive/suspect cases at the time of the survey. The caseload was higher in non-COVID-19 areas compared to COVID-19 areas (median beds 10 compared to 4). The responses of participants to part A are given in Table 2 and those to part B are given in supplementary tables S1 and S2. The highest adherence to preventive practices was observed in the practice of wearing masks inside hospital premises but the majority of participants (75.5%) commonly touched the outer surface of masks while wearing it. This was because the majority of them (36%) felt uncomfortable while wearing it while others (32.65%) believed touching the outer surface causes no harm and few (13%) had to readjust it due to loose fit. Most of the HCWs followed hand hygiene practices properly. The reasons for suboptimal practices were a shortage of sanitizers, lack of time due to high patient load and being unable to check the time while washing hands. HCWs practised social distancing more while eating food (51.0%) compared to talking to peers in duty rooms (36.7%) and working in wards (34.7%). Most of them avoided going out unnecessarily and practised social distancing in public places. A significant proportion of HCWs (31.3%) commonly reused gowns with the majority attributing it to the shortage of PPE and long duty hours. Many participants (34.7%) commonly wore PPE to duty rooms before completely doffing as there was no separate place for rest during duty hours and they found it cumbersome to don and doff multiple times. A significant number (59.2%) also used personal mobile phones commonly during duty. The majority used them for patient management and to stay connected with colleagues and family while few cited absence of separate duty phones and the need for entertainment as additional reasons. Most of the participants (95.2%) commonly took precautions while buying things like opting for cashless payments and home delivery, going out when it's less busy and buying more groceries at a time. 14.3% of participants occasionally/rarely had adequate sleep due to the lack of time and anxiety. Most participants didn't take chemoprophylaxis against COVID-19 with only 11.6% workers taking it regularly. More than 66% of HCWs had one or more high-risk contact with COVID-19 patients. A satisfactory agreement between experts with CVR ¼ 0.87 and CVI ¼ 0.978 indicated good content validity. Face validity was established through expert opinion and pilot testing. The KMO (Kaiser-Meyer-Olkin) test measure ¼ 0.82 indicated adequacy of sampling and Bartlett's test (x2 ¼ 1658.1, d.f. ¼ 406 and p < 0.001) indicated suitability of data for factor analysis. To establish construct validity, exploratory factor analysis using principal component extraction using varimax rotation with eigenvalue cut off of 1 was done. A nine-factor solution was obtained on factor analysis ( Table 3 ). The correlation of question 9 with questions 7 and 8 was more than 0.7 but it was retained after consultation with experts as it was deemed to have an important role (Supplementary table S3 ). Cronbach's alpha coefficient was found to be 0.85. A score of more than 0.7 indicates good internal consistency of the tool. The total variance was 66.488%. COVID-19 has overwhelmed the health care systems worldwide. The rising number of infections among HCWs in this pandemic is a matter of Scoring instructions for the questionnaire to assess prevention practices against COVID-19 in the health care workers For Section A, each item has 5 options. Except for items 1, 5, 11, 17, 19, 20, 22, 23, 28, 29 , the items are scored as given below: 5 ¼ Always (more than 90% times). 4 ¼ Mostly (approx. 75% times). 3 ¼ Commonly (approx. 50% times). 2 ¼ Occasionally (approx. 25% times). 1 ¼ Rarely (less than 10% times). The items 1, 5, 17, 19, 20, 23 are scored inversely as. 1 ¼ Always, 2 ¼ Mostly, 3 ¼ Commonly, 4 ¼ Occasionally and 5 ¼ Rarely. The item 11, 28 and 29 are scored as. The item 22 is scored as. 5 ¼ Yes, taking regularly, 4 ¼ Yes, taking regularly but missed some doses, 3 ¼ Yes, took initially and then left, 2 ¼ Don't remember, 1 ¼ No. grave concern both at the individual and the societal level. With a reduction in functional staff, the remaining workers have to bear the increased workload leading to a vicious cycle of stress, lapses in preventive practices, further exposure, and infection. Several studies have identified suboptimal handwashing, improper PPE use, reuse of PPE, endotracheal intubation, working in a high-risk department, longer working hours, and COVID-19 infection among family members as important risk factors for contracting COVID-19 infections [2, 3, 5] . But a limited number of studies have been done to explore the various aspects of preventive practices of HCWs related to COVID-19. Most of the studies have been done in subgroups like dentists and medical students and have focussed on knowledge, attitude and risk perceptions only. Among the few studies dwelling into infection prevention and control practices, most of them have assessed adherence to hand hygiene and personal protective equipment briefly [10] [11] [12] [13] . Some questionnaires have also included questions to assess adherence to social distancing [14, 15] , use of chemoprophylaxis [15] , training of HCWs [12, 16] and reporting exposure to authorities [10] . Also, a few studies have utilised validated questionnaires [14, 17] .Compared to the above studies, this questionnaire covers various aspects of preventive practices comprehensively. Not only it is validated but also it assesses reasons for suboptimal compliance. The questionnaire consists of two parts: Part A contains 29 items for evaluating various aspects of preventive practices of participants based on their routine in the last two weeks. These items are rated on a fivepoint Likert scale and grouped under areas viz. hand hygiene, social distancing, personal protective equipment, fomites, occupational exposure, and lifestyle. Part B contains 27 items for evaluating reasons for suboptimal practices in the above areas. The options in these items reflect the common reasons for deficiency in practices identified through FGDs, interviews and expert opinion. The items are semi-structured to allow identification of distinct reasons applicable in different settings. The participants are allowed to mark multiple options and write the unique reasons applicable to them under the "other reasons'' option in each item of part B. Thus, this questionnaire identifies the specific areas in which lapses in preventive practices are present along with the reasons for these loopholes. It covers major aspects of preventive practices as recommended by the World Health Organisation (WHO), and as revealed in various studies [2, 3, 5, 18] . It holistically covers preventive practices both inside and outside hospital premises and lays adequate stress on important and frequently ignored aspects in prevention against COVID-19. It is self-administered and can be filled through an offline or online mode. The flexible nature of part B allows for its application in different socio-economic and cultural settings. The applications of the tool are manifold. It evaluates both the extent and the reasons for deficiencies in the preventive practices to identify specific loopholes in various subgroups of HCWs in various departments in a health care setting. This would facilitate policymakers to design appropriate interventions to enhance occupational environment based on the results of the survey, particularly in case of an outbreak. It can also play an important role in the surveillance of occupational practices and thus, formulation of the infection control policy of the institution. It has the potential to play an important role in future pandemics of similar nature as a readily available tool too. The application of the questionnaire in various health care settings is recommended. To holistically assess all major aspects of prevention and identify reasons for shortcomings therein, the questionnaire may take around 30 min to collect data from an individual participant. We suggest that section A may be administered independently for rapid assessment when needed. Other limitations include the inability to ensure proportional representation of various occupational categories of HCWs in the survey and inability to establish predictive or concurrent validity as it would require long-term follow-up. The addition of a question to assess formal training of HCWs in infection prevention practices would be valuable too. Based on the responses of the participants, few measures to increase adherence of HCWs to preventive practices are suggested [18, 19] . Practical and easy-to-remember methods should be devised and promoted to ensure that HCWs wash hands properly for an adequate time. There is a need for intersectoral collaboration to develop ergonomic and comfortable PPE. Adequate training of HCWs, regular monitoring and reinforcement of preventive practices should be done. Their duty rosters should be optimised and adequate psychological support should be provided to them. The sufficient availability of PPE and sanitizers should be ensured. A robust institutional framework for identifying reasons for high-risk exposure and taking corrective steps for the same is recommended. This questionnaire has been developed for a comprehensive assessment of preventive practices and associated barriers in health care workers. It has good validity and internal consistency. It will play an important role in disease prevention by empowering policymakers to identify appropriate interventions for suboptimal practices and vulnerable sections of health care workers during the COVID-19 pandemic and future pandemics of similar nature as well. None. None. Supplementary data to this article can be found online at https:// doi.org/10.1016/j.ijmmb.2021.03.006. 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