key: cord-0737515-d79iqlkv
authors: Abed Alah, Muna; Abdeen, Sami; Selim, Nagah; Hamdani, Dhouha; Radwan, Eman; Sharaf, Nahla; Al‐Katheeri, Huda; Bougmiza, Iheb
title: Compliance and barriers to the use of infection prevention and control measures among health care workers during COVID‐19 pandemic in Qatar: A national survey
date: 2021-08-05
journal: J Nurs Manag
DOI: 10.1111/jonm.13440
sha: 690782e66b97b11d472e16abbf0299cf41100241
doc_id: 737515
cord_uid: d79iqlkv

AIM: To assess health care workers’ compliance with infection prevention and control measures in different health care sectors in Qatar during COVID‐19 pandemic. BACKGROUND: Being the first line of defense against COVID‐19 infection, health care workers are particularly at increased risk of getting infected. Compliance with infection prevention and control measures is essential for their safety and the safety of patients. METHODS: A web‐based national survey was conducted between November 2020 and January 2021 targeting all health care workers in governmental, semi‐governmental, and private health care sectors. RESULTS: Of 1757 health care workers, 49.9% were between 30‐39 years of age, majority (47.5%) were nurses. Participants reported a significant increase in the median self‐rated compliance scores during the pandemic compared to before it (p<0.001). During the pandemic, 49.7% of health care workers were fully compliant with personal protective equipment (PPE) use, 83.1% were fully compliant with hand hygiene. Overall, 44.1% were fully compliant with infection prevention and control measures (PPE and hand hygiene). Nationality, health sector, profession, and frequency of interactions with suspected or confirmed COVID‐19 cases were significantly associated with compliance with overall infection prevention and control measures. The most reported barriers were work overload, and shortages of PPE and handwashing agents. CONCLUSIONS: Compliance of health care workers with infection prevention and control measures needs further improvement. IMPLICATIONS FOR NURSING MANAGEMENT: Frequent quality checks, provision of adequate supplies, and behavior change interventions are recommended strategies for hospital and nursing administrators to improve health care workers’ compliance.

and capacities worldwide become overwhelmed dealing with the rising numbers of infected persons. Health care workers-the first line of defense in the fight against COVID-19are particularly at risk of getting infected while taking care of infected patients (Gholami et al., 2021) . A recent systematic review and metanalysis showed that the percentage of health care workers who tested positive for COVID-19 among 28 studies was 51.7%, with 15% rate of hospitalization and 1.5% death rate (Gholami et al., 2021) . In Qatar, the rates of infection and hospitalization among health care workers are 10.6%, and 11.6% respectively (Alajmi et al., 2020) . Standard precautions such as proper use of personal protective equipment (PPE), proper hand hygiene and respiratory hygiene practices are essential preventive measures against the spread of the infection in health care facilities. The large number of COVID-19 infected cases among health care workers was attributed to inadequate personal protection of health care workers at the beginning of the pandemic, shortage of PPE, and inadequate training of health care workers on the appropriate infection prevention and control measures (Rational, scientific and standardized protection is the core of infection prevention and control in medical institutions, 2020).

Low compliance with infection prevention and control measures may have negative consequences for workers, patients and institutions such as the occurrence of occupational accidents, health care associated infections and institutional damage (Askarian et al., 2004; I. Jeong et al., 2008; Oliveira et al., 2009; World Health Organization (WHO), n.d.) . Health care associated infections can result in prolonged hospital stays, long-term disability, massive additional costs for health systems and organizations, and unnecessary deaths (World Health Organization (WHO), n.d.). Compliance with PPE among health care workers during COVID-19 pandemic varied among different studies, ranging from 54% to over 95% (Ashinyo et al., 2021; Darwish et al., 2021; Michel-Kabamba et al., 2020; Neuwirth et al., 2020 ).

According to current evidence, SARS-CoV 2 virus is transmitted between people through respiratory droplets and contact routes. Transmission can occur by direct contact with infected people and indirect contact with surfaces in the immediate environment Huang et al., 2020; Li et al., 2020; Liu et al., 2020) . The World Health Organization (WHO) recommends droplet and contact precautions (including the use of a medical mask, eye protection (goggles) or facial protection (face shield), a clean, non-sterile, long-sleeved gown and gloves) for health care workers caring for suspected or confirmed COVID-19 patients, and airborne precautions using N95 respirator or equivalent in addition to contact precautions for settings in which aerosol generating procedures (AGP) are performed. It also emphasized the importance of practicing hand hygiene (World Health Organization (WHO), 2020a). Qatar formulated national infection prevention and control guidelines for in accordance with the WHO and Centers for Disease Control (CDC) recommendations.

To the best of our knowledge, studies assessing compliance with the proper use of infection prevention and control measures among health care workers during this pandemic are limited, particularly in the Middle East. This is the first national study in Qatar to address this issue. It is expected that compliance with the use of PPE and hand hygiene practices changes after an epidemic, as this was evident from previous infectious outbreaks when significant improvements in compliance were noted (G. Jeong et al., 2016; Wong & Tam, 2005) . So, addressing the changes in compliance during the current pandemic is worth investigating. We This article is protected by copyright. All rights reserved. aim to assess health care workers' compliance with the proper use of PPE and hand hygiene practices in different health care sectors in Qatar (governmental, semi-governmental, and private sectors) during COVID-19 pandemic and explore the barriers to the proper use of such infection prevention and control measures.

Study design, setting, and the target population:

A national web-based cross-sectional survey was conducted between November 2020 and January 2021. The target population included health care workers at governmental, semigovernmental and private health care sectors. In Qatar, health care services are provided by these three sectors. The governmental sector provides primary health care services at the level of Primary Health Care Corporation (PHCC) through 27 health centers distributed all over the country, and secondary and tertiary care through Hamad Medical Corporation with a number of designated hospitals. the semi-governmental sector includes six health care facilities. The private sector includes over 40 private hospitals and clinics. We included health care workers in clinical positions (physicians, nurses, dentists, pharmacists, and allied health professionals), while excluded those in administrative positions.

A web-based self-administered survey was developed using Microsoft Forms software.

Because of the low response rate generally encountered in web-based surveys and in order to improve the external validity of our study, we invited all eligible health care workers in PHCC (representing a major part of the governmental sector), semi-governmental and private facilities to take the survey. They were contacted via e-mail with an information letter and a link to the electronic version of the questionnaire. The letter stated the purpose of the study, and that the participation is voluntary. Taking the survey implied informed consent and participants were free to terminate the survey at any time they desired. The survey was anonymous, and confidentiality of information was assured. Weekly reminders were sent to maximize the response rate.

We developed a questionnaire adopted from different surveys (Chia et al., 2005; Majeed, 2018; Schwartz et al., 2014; Shimokura et al., 2006 ; World Health Organization (WHO), 2020c) in English. Face and content validities were assured by experts in the field. It consisted of three sections. The first one, addressed the socio-demographic data for the participants (age, gender, nationality, profession, clinical experience, health care facility), in addition to general COVID-19 related information such as having a friend or a relative infected with COVID-19, status of PPE and hand hygiene training, and frequency of dealing with suspected or confirmed COVID-19 cases. The second and third sections assessed health care workers' compliance with the proper use of infection prevention and control measures (PPE and hand hygiene) using a checklist adopted from WHO risk assessment tool for healthcare workers in the context of COVID-19 (World Health Organization (WHO), 2020c), and the barriers to the proper use respectively.

To assess the compliance of health care workers with infection prevention and control measures, they were asked about the frequency of using each PPE item when dealing with suspected or confirmed cases or while performing an AGP for a suspected or confirmed case using a five points-Likert scale (always as recommended, often, sometimes, seldom, never).

And asked about the frequency of performing hand hygiene (using similar Likert scale) at five moments which are: before touching a patient, before any clean or aseptic procedure is performed, after exposure to body fluid, after touching a patient, and after touching patient's surroundings. Health care workers who answered all the questions as "always as recommended" were considered as fully compliant. We also asked the participants to rate their overall perceived compliance with proper use of PPE and hand hygiene before and during the pandemic on a ten-points scale (from 0-9, where zero indicates no compliance, and 9 full compliance). Barriers to the appropriate use of infection prevention and control measures as recommended were assessed by asking health care workers to select one or more options from a list of barriers for PPE and hand hygiene separately. They were also able to specify other barriers that were not listed.

Data analysis was performed using IBM SPSS Statistics for Windows, Version 26.0.

Armonk, NY: IBM Corp. Descriptive statistics were presented as frequencies and percentages for categorical variables. Continuous not normally distributed variables were presented as medians and interquartile ranges. Chi-square test was used to determine the differences between categorical variables. The Wilcoxon Signed Rank test was used to test the differences in the self-rated compliance with infection prevention and control measures before and during COVID-19 pandemic taking into consideration the self-rated compliance on the ten-points scale as an ordinal dependent variable. Rank biserial correlation was calculated to measure the effect size for these comparisons (small 0.10−<0.30, medium 0.30−<0.50, large ≥0.50). Three Multivariable logistic regression models were executed to determine the predictors of full compliance with infection prevention and control measures, one for appropriate use of PPE, one for hand hygiene, and one for overall infection prevention and control measures (both PPE, and hand hygiene). The associations between risk factors and outcomes were presented as adjusted odds ratios (ORs) and 95% confidence intervals (95% CIs). Goodness of Fit was assessed using Hosmer Lemeshow test. P-values less than 0.05 were considered significant.

This study was performed in line with the principals of Declaration of Helsinki. Approval was obtained from the relevant health institutions under protocol ID PHCC/DCR/2020/07/073.

As shown in Table 1 , the survey was completed by 1757 health care workers. Of them, 757 (43.1%) from the governmental sector (PHCC), 480 (27.3%) from the semi-governmental sector, and 520 (29.6%) from the private sector. Majority (49.9%) were between 30-39 years of age, 1192 (67.8%) were females. Over 60 nationalities were reported, with the top three being Filipino (29.8%), Indian (27.4%), and Egyptian (6.4%). Only 32 (1.8%) Qatari health care workers participated in this study. Nurses accounted for the majority of health care workers (47.5%), followed by allied health professionals (22%), and physicians (20.1%). Of all participants, 1573 (89.5%) reported five or more years of clinical experience. 91.3%, and 95.6% of health care workers admitted receiving a training for proper PPE use, and proper hand hygiene practices in the preceding year, respectively. Over one third (35.2%) of health care workers reported frequent interactions with suspected or confirmed COVID-19 cases (every work shift or most of their work shifts). And about three quarters (77.1%) were aware of a relative, friend, or colleague diagnosed with COVID-19.

When participants were asked to rate their compliance with infection prevention and control measures on a ten-points scale, before and during the pandemic, there was a significant increase in the median self-rated compliance scores during the pandemic compared to before it (median score:7 before, 9 during, for PPE), and (median score: 8 before, 9 during, for hand hygiene), with p values < 0.001 and large effect sizes (r=0.87, 0.89) respectively. We assessed compliance with infection prevention and control measures using a checklist adopted from WHO risk assessment tool for health care workers in the context of COVID-19 (World Health Organization (WHO), 2020c). According to this checklist, 52.6% (95%CI: 

Three multivariable logistic regression models were executed to determine the predictors of compliance with infection prevention and control measures. One for compliance with PPE (during both; interactions with suspected or confirmed COVID-19 cases, and while performing an AGP), one for compliance with hand hygiene at the five moments, and a third one for compliance with overall infection prevention and control measures (with both PPE and hand hygiene). All models were of good fit and were statistically significant (p values < 0.001) when compared to the null model. The selection of independent variables to be included in the models was based on clinical and statistical relevance. In the first model ( Those dealing frequently (every shift) with suspected or confirmed COVID-19 cases were about two times more likely to be fully compliant than those who never deal with such cases (adjusted OR 2.02, 95%CI: 1.19-3.42, p=0.009).

Regarding the barriers to the proper PPE use, the most reported barriers were shortage of PPE (37.7%), discomfort caused by PPE such as N95 respirators or face shields (31.3%), and work overload and lack of time (23.9%). For hand hygiene, skin irritation caused by handwashing agents was the most reported barrier (22.7%) followed by work overload and lack of time (19.1%), and shortage of handwashing agents (14.7%). On the other hand, 32.8%, and 50.6% of participants reported no barriers at all for PPE use or practicing hand hygiene respectively (Figure 1 ). Higher proportions of health care workers reported shortage of PPE and handwashing agents as barriers in the governmental sector compared to the other sectors. Proportions of health care workers who reported shortages of PPE were 42.3%, 33.7%, and 35% for governmental, private, and semi-governmental sectors respectively, while 18.4%, 12.3%, and 11.5% reported shortages of handwashing agents.

Being the first line of defense against COVID-19 infection, health care workers are particularly at increased risk of getting infected. Compliance with infection prevention and control measures is critically essential for their safety and the safety of their patients. In this study we assessed health care workers' compliance in different health care sectors with proper use of PPE and hand hygiene practices as reported by them. The majority of health care workers in this study were nurses, with nurse: physician ratio of 2.4:1 reflecting almost the same ratio in the health care workers' population in Qatar which is about 2.8:1. We found a significant improvement in health care workers' perceived compliance with infection prevention and control measures since the start of the pandemic. This might have resulted from the heightened awareness of the importance of complying with PPE and hand hygiene during COVID-19 at international and national levels, and from the greater perceived threat health care workers are experiencing during this emerging serious infection. This finding matches what was reported in a study in China (Lai et al., 2020) . Comparing our results with those of a recently published study conducted in Ghana that utilized the same assessment tool (WHO checklist), the compliance of health care workers with PPE in our study was to found to be lower during both patient interactions (52.6%), and while performing an AGP (73.2%) compared to 90.6% , and 97.5% in the other study respectively (Ashinyo et al., 2021) , while similar compliance rates were found with hand hygiene practices (Ashinyo et al., 2021). On the other hand, the compliance with PPE during patient interactions in our study was similar to what was reported in another study in the Democratic Republic of the Congo (Michel-Kabamba et al., 2020), and was much higher while performing AGP than the one reported in a study in the United States (Darwish et al., 2021) . In this study, pharmacists were found less likely to be fully compliant with proper use of PPE than physicians which is consistent with results of Ghana study (Ashinyo et al., 2021) . One explanation might be that pharmacists are less likely to have direct contact with patients in general and with suspected or confirmed COVID-19 cases. In addition, the duration of their contact is usually short, and in most cases like in hospitals patient's family or friends are the ones who attend the pharmacy for medication pick up upon discharge not the patient him/herself. Also, at almost all pharmacies in Qatar, most of the contacts happen through glass shields which might be perceived as protective by many pharmacists against countering infection. On the other hand, dentists were found more likely to be compliant with PPE and with overall infection prevention and control measures than physicians. This might be explained by the closer contact dentists have with their patients while managing them, as their job involves more contact with aerosols and droplets produced during many dental procedures that have the potential to spread the infection to dental personnel. This will push dentists to be more fully compliant with infection prevention and control measures in a step to protect themselves from getting infected. Health care workers in the governmental sector showed higher compliance rates with overall infection prevention and control measures and with PPE than those in the private sector. This can be explained by the fact that health care workers in governmental sector deal more frequently with suspected or confirmed COVID-19 cases than other sectors as shown in Table 1 . In Qatar, COVID-19 positive cases are managed in the governmental sector. Private health care facilities deal with suspected cases, but they are transferred to the governmental sector once confirmed. This finding is also supported by another finding in our study that showed that those who deal more frequently with suspected or confirmed cases were more likely to be compliant which is also consistent with established findings in the literature (Brooks et al., 2020) . We found that lack of time, discomfort caused by certain types of PPE, shortage of PPE, and skin irritation caused by handwashing agents as barriers for 

This study has several strengths. First, it is the first national study in Qatar, and one of the few studies worldwide to address this important issue during the current COVID-19 pandemic. Second, we were able to recruit an acceptable number of health care workers from all health care sectors strengthening our confidence in generalizing our results to the health care workers population in Qatar. Although this study provides new insights on the use of infection prevention and control measures by health care workers during this emerging challenging pandemic of COVID-19, we do acknowledge some limitations. First, the data was collected by self-reporting by health care workers not by direct observation of their practices, which might lead to recall, and social-desirability bias. So, the detected compliance rates should be viewed cautiously. However, online surveys were the only and safest means to collect data for research purposes in light of national recommendations of keeping physical distancing as a way to contain the spread of the infection. Second, with the cross-sectional design of this study we could not establish how compliance with infection prevention and control measures translates into lower incidence of COVID-19 infection. Lastly, individual institutional infection prevention and control recommendations and instructions might influence health care workers compliance and affect our results.

Despite the significant improvement in the perceived self-rated compliance of health care workers with different infection prevention and control measures (PPE, and hand hygiene), their compliance with overall infection prevention and control measures was found to be moderate (44.1%). The highest compliance rate was found with hand hygiene at the five moments (83.1%), and the lowest with PPE during patient interactions (52.6%). This study shows gaps in infection prevention and control compliance across different health professional groups with higher compliance rates among dentists, and lower compliance with pharmacists compared to physicians. Health care sector, nationality, and frequency of dealing with suspected or confirmed COVID-19 cases were found to be predictors of compliance with PPE and with overall infection prevention and control measures. On the other hand, gender, nationality, profession, and previous training on hand hygiene were found to be associated with hand hygiene compliance. Several barriers were reported to the proper use of infection prevention and control measures including work overload, and shortages of PPE and handwashing agents. Compliance of health care workers with infection prevention and control measures need to be further improved.

Frequent quality checks, continuous monitoring, provision of adequate supplies (PPE, and handwashing agents), and behavior change interventions are top strategies that can be enforced by policymakers, safety managers of health care institutions, hospital, and nursing administrators to improve compliance. Conducting further research that involves direct observation of infection prevention and control related practices is needed.

 Low compliance with infection prevention and control measures may have negative consequences for workers, patients, and institutions such as the occurrence of occupational accidents, health care associated infections and institutional damage.

 Health care workers' compliance with infection prevention and control measures changes after epidemics as evident from previous infectious outbreaks. This article is protected by copyright. All rights reserved.  This study showed gaps in infection prevention and control compliance across different health professional groups with higher compliance rates among dentists, and lower compliance rates with pharmacists compared to physicians.

 Compliance with overall infection prevention and control measures was found to be moderate (44.1%), highest with hand hygiene (83.1%), and lowest with personal protective equipment during patient interactions (52.6%). 

A familial cluster of pneumonia associated with the 2019 novel coronavirus indicating person-toperson transmission: a study of a family cluster

Appropriate use of personal protective equipment among healthcare workers in public sector hospitals and primary healthcare polyclinics during the SARS outbreak in Singapore

Adherence to Personal Protective Equipment Guidelines during the COVID-19 Pandemic among Healthcare Personnel in the United States

Barriers to using personal protective equipment by healthcare staff during the COVID-19 outbreak in China

COVID-19 and healthcare workers: A systematic review and metaanalysis

Barriers and facilitators to healthcare workers' adherence with infection prevention and control (infection prevention and control) guidelines for respiratory infectious diseases: A rapid qualitative evidence synthesis

Clinical features of patients infected with 2019 novel coronavirus in Wuhan, China. The Lancet

Emergency Department Workers' Perceptions of Effectiveness and Reported Compliance of Infection Control Measures after Middle East Respiratory Syndrome Outbreaks

Compliance with standard precautions among operating room nurses in South Korea

Will healthcare workers improve infection prevention and control behaviors as COVID-19 risk emerges and increases

Early Transmission Dynamics in Wuhan, China, of Novel Coronavirus-Infected Pneumonia

Community Transmission of Severe Acute Respiratory Syndrome Coronavirus 2

Hand Hygiene Practices Among Health Care Workers in Rizgary Teaching Hospital

Occupational COVID-19 Prevention among Congolese Healthcare Workers: Knowledge, Practices, PPE Compliance, and Safety Imperatives

Adherence to personal protective equipment use among healthcare workers caring for confirmed COVID-19 and alleged non-COVID-19 patients

Knowledge and attitude regarding standard precautions in a Brazilian public emergency service: a cross-sectional study

Rational, scientific and standardized protection is the core of infection prevention and control in medical institutions

Health care workers' knowledge and confidence in personal protective equipment during the H1N1 pandemic in Israel

Factors associated with personal protection equipment use and hand hygiene among hemodialysis staff

World Health Organization (WHO). (n.d.). WHO | The burden of health care-associated infection worldwide

WHO Guidelines on Hand Hygiene in Health Care: First Global Patient Safety Challenge Clean Care Is Safer Care. Hand hygiene practices among health-care workers and adherence to recommendations

Infection prevention and control during health care when novel coronavirus (nCoV) infection is suspected

Rational use of personal protective equipment for coronavirus disease 2019 ( COVID-19 )

Risk assessment and management of exposure of health care workers in the context of COVID-19