key: cord-1012836-7hqoc1sv
authors: Brooks, S. K.; Greenberg, N.; Wessely, S.; Rubin, G. J.
title: Factors affecting healthcare workers' compliance with social and behavioural infection control measures during emerging infectious disease outbreaks: Rapid evidence review.
date: 2020-05-29
journal: nan
DOI: 10.1101/2020.05.27.20114744
sha: 054adfba3c685991b8c9aac09d13e1330fcad6c8
doc_id: 1012836
cord_uid: 7hqoc1sv

The 2019-2020 outbreak of novel coronavirus has raised concerns about nosocomial transmission; that is, transmission within healthcare settings. Research from previous outbreaks of emerging infectious diseases suggests a major cause of nosocomial transmission is healthcare professionals' poor compliance with recommended personal protective behaviours. This rapid evidence review explored existing literature on emerging infectious disease outbreaks to identify factors associated with compliance with social and behavioural infection control measures among healthcare staff. 56 papers were reviewed and several positive associations were found: Staff working in emergency or intensive care settings appeared more likely to comply with recommendations than those in other settings, and there was some evidence that contact with confirmed cases could improve compliance. There was some evidence that staff with higher levels of anxiety and higher concern about the risk of infection were more likely to comply with recommended behaviour, and that monitoring from superiors could improve compliance. Several negative associations were also found. Observed non-compliance of colleagues could hinder compliance. Staff identified many barriers to compliance related to personal protective equipment, including availability; perceived difficulty and effectiveness; inconvenience; discomfort; and a negative impact on patient care. There appeared to be many issues regarding the communication and ease of understanding of infection control guidance. Based on the results of this review we recommend provision of training and education tailored for different occupational roles within the healthcare setting; managerial staff 'leading by example'; ensuring adequate resources for infection control; and timely provision of practical evidence-based infection control guidelines.

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Recent years have seen frequent outbreaks of emerging infectious diseases [1] . Examples include severe acute respiratory syndrome (SARS) [2] .

A major cause of nosocomial transmission is poor compliance with personal protective behaviours among healthcare staff [3, 4] . Early reports from the COVID-19 frontline have noted poor compliance of healthcare workers with recommended behaviours: in one hospital in China, many had their masks hung from one ear or pulled downwards, while more than half had inadequate hand hygiene [5] .

Compliance with infection control behaviours can be difficult. Previous literature has reported on difficulties in the general population with adhering to protective behaviours such as facemask-wearing [6] , using hand sanitising gel [7] and quarantine [8] during infectious disease outbreaks. The main facilitators of compliance in the general population appear to be perceived susceptibility, perceived severity of being afflicted and perceived benefits of compliance as well as accurate knowledge about the disease and the recommended behaviours, while major barriers include discomfort, embarrassment and practical issues [6, 8] .

A review [9] of healthcare workers' perceptions of barriers and facilitators to compliance with guidelines during respiratory outbreaks suggested that protective practices are influenced by understanding of guidelines, support received from managers, communication about guidelines, sufficient resources, perceived value of following guidance, comfort of personal protective equipment (PPE), perceived impact of PPE on patients, and workplace culture. However, this review focused only on qualitative literature, the majority of which related to tuberculosis.

We systematically reviewed existing literature on compliance with social and behavioural protective behaviours among staff involved in healthcare, specifically during outbreaks of emerging infectious diseases and encompassing quantitative and qualitative research.

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This rapid evidence review was carried out according to World Health Organization guidelines [10] : the basic principles of a systematic literature review were followed, with certain aspects simplified in order to produce evidence rapidly at a time when urgent evidence synthesis is required. Searching of grey literature and quality appraisal of included studies were not carried out.

The search strategy consisted of four search strings (adherence terms; protective behaviour terms; emerging infectious disease terms; and healthcare worker terms). The full search strategy can be seen in Appendix I. Five databases were searched from date of inception to May 4 th , 2020: MEDLINE®, PsycINFO®, Embase, Global Health, and Web of Science.

To be included, studies had to: i) contain primary data; ii) be published in peer-reviewed journals in English; iii) include participants who worked in healthcare; iv) include data on factors predicting adherence to social or behavioural infection control practices during emerging infectious disease pandemics. For the latter criterion, quantitative data needed to report statistics on factors associated with compliance, while the qualitative component of the review considered studies reporting on participants' beliefs about facilitators and barriers to compliance as well as any reported difficulties in complying with protective behaviours.

One author (SKB) ran the searches on all databases on May 4 th , 2020. Resulting citations were downloaded to EndNote© version X9 (Thomson Reuters, New York, USA). The same author evaluated titles for relevance, then used the inclusion criteria to screen abstracts and then full texts of remaining citations and exclude any which were irrelevant. Reference lists of all remaining papers were hand-searched for additional relevant studies.

SKB extracted the following data from papers: authors, publication year, country of study, design, participants (including n, demographic information and profession), disease outbreak, protective behaviours measured, measures used, and key results. We used thematic analysis [11] to synthesise the data and group results into themes.

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The initial search strategy yielded 1900 papers, of which 744 duplicates were removed and 1090 were excluded based on title or abstract. An additional twelve papers were found via hand-searching the reference lists of included papers. After full-text screening, 56 papers remained for inclusion. A PRISMA flow diagram of the process can be seen in Appendix II.

Countries represented in the literature included Canada (n=13), Saudi Arabia (n=7), Singapore (n=7), China (n=5), South Korea (n=5), USA (n=5), Netherlands (n=2), Australia (n=1), Greece (n=1), India (n=1), Iran (n=1), Taiwan (n=1), Turkey (n=1), UK (n=1) and

Vietnam (n=1). A further five papers included participants from multiple countries. Papers discussed H1N1 (n=22), SARS (n=20), MERS (n=11), avian influenza (n=2) and COVID-19 (n=2). The participants represented in the literature were from a wide range of roles and departments in the healthcare profession, and a wide range of protective behaviours were considered. A full overview of study characteristics is presented in Supplementary Table I. Eight main themes were identified. These were socio-demographics and personal characteristics; occupational role; training and knowledge; work-related factors; personal protective behaviour-related factors; guidance; distress and risk perception; and attitudes and behaviours of others. A number of other potential predictors of compliance were considered but only appeared in one paper each; these are presented in Supplementary Tables I and III but not covered in the text. Supplementary Table II provides a summary of themes and subthemes and identifies for each theme which papers showed a significant association with protective behaviours, which papers found no significant association, and which papers supplemented these findings by reporting on the theme but without statistical analysis (e.g. qualitative papers and papers with descriptive statistics only). Supplementary Table III summarises the evidence extracted from the literature for each theme.

Overall, there appeared to be no significant association between age [12, 13, 14, 15, 16, 17, 18] or gender [12, 13, 14, 17, 19, 20, 21] and protective behaviour. Only one study [20] found that older age was significantly associated with protective behaviours, while two found that female staff were significantly more likely to comply with protective behaviours [16, 22] .

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The copyright holder for this preprint this version posted May 29, 2020. . https://doi.org/10.1101/2020.05.27.20114744 doi: medRxiv preprint 8 One study examined nationality as a predictor [12] and found that Saudi staff were significantly more likely to comply with protective behaviours than non-Saudi staff working in the same city. Mixed findings were reported in the studies comparing behaviours across countries. Staff in Hong Kong and Singapore were more likely to comply than UK staff [23] , whereas staff in Singapore vs Indonesia [24] or Hong Kong vs Canada [25] were more likely to comply with some recommendations but not others (see Supplementary Table III for details). Particular attention should be given to a worldwide study [26] that found no significant differences between countries in terms of taking protective measures.

There was no evidence of association between compliance and religion [20] or marital status [18, 19] . One paper found that staff in 'high or middle' socioeconomic status were more likely to comply than those of lower socioeconomic status [22] , and one found a significant association between compliance and qualification [12] (see Table III for details); these were offset by four studies finding that level of education was not associated with compliance [13, 18, 20, 21] . One study found that H1N1 influenza vaccination was significantly associated with high compliance [27] . Having a chronic illness, being pregnant, or having a pregnant spouse, elderly person or school-aged child at home were not associated with compliance, but staff with babies at home were more likely to comply with protective behaviours [19] .

Many studies which examined role as a predictor of compliance found a significant relationship [12, 19, 23, 28, 29, 30, 31, 32, 33, 34, 35, 36] ; however, due to the variety of different roles compared across studies, it was not possible to identify a consistent pattern (see Supplementary Table III for details) . Five studies found no significant association between role and compliance [13, 16, 17, 37, 38] .

Length of time in role was not significantly associated with compliance in five studies [12, 16, 17, 18, 30] , while two studies suggested that longer experience of working in healthcare was associated with greater compliance [31,33] and one suggested that less than ten years' experience was associated with significantly higher compliance than more experience [36] .

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The copyright holder for this preprint this version posted May 29, 2020. . https://doi.org/10.1101/2020.05.27.20114744 doi: medRxiv preprint 9 There was mixed evidence on the effectiveness of outbreak-specific training and education:

one study [21] found no significant association between protective behaviours and having received education; another [17] found a non-significant increase in protective practices posttraining; and a third [30] found that recent infection control training was a significant predictor of compliance with recommended behaviours. Jeong et al. [22] found that staff who sought information about the outbreak and infection control were more likely to comply with recommended behaviours. Qualitative evidence suggested that staff felt their prior training and education were not useful in dealing with the rapidly-changing nature of emerging infectious disease outbreaks [39, 40] . Participants believed that inadequate training was a barrier to compliance [28] and that infection control training with annual refresher courses would benefit them [41] .

Sources of knowledge about the outbreak and protective behaviours were not associated with protective behaviours in two studies [20, 21] while knowledge from textbooks and attending Continuing Medical Education activities were significantly associated with higher levels of protective practice in one study [12] . Kim and Choi [20] found that receiving outbreakspecific training was not significantly associated with compliance, but higher outbreakrelated knowledge did result in significantly higher compliance. Another study examining knowledge of the outbreak itself [28] found the majority of participants believed lack of knowledge about mode of transmission contributed to poor compliance. Knowledge of current recommendations was associated with compliance in three studies [4, 16, 27] , associated with compliance in one hospital but not three other hospitals in another study [14] and was not associated with compliance in one further study [12] . Hsu et al. [42] found that a minority of participants believed that lack of education explained lack of compliance.

Unsurprisingly, compliance was better in higher acuity settings such as emergency, intensive care or inpatient departments [14, 35, 38, 43, 44] . Wong et al. [45] found that staff in highinfection districts were more likely to wear gowns, wash hands and use disinfectants but less likely to comply with quarantine measures. But even then, two studies found no significant association between setting and compliance [19, 21] .

Having contact with confirmed cases was associated with higher compliance in four studies [14, 18, 35, 43] whereas one study found no association [19] . Wong et al. [45] found that . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.

The copyright holder for this preprint this version posted May 29, 2020. . https://doi.org/10.1101/2020.05.27.20114744 doi: medRxiv preprint 1 0 SARS-exposed staff were more likely than non-SARS-exposed staff to comply with mask guidance, but less likely to quarantine themselves.

There was reasonably consistent evidence that high workload may be a barrier to compliance with recommended personal protective behaviours [23, 30, 35, 39, 41, 46] , with only one study reporting the opposite -namely higher workload (in terms of working overtime) was associated with increased compliance in terms of giving patients appropriate infection control advice [36] . [35] participants were less likely to comply with recommended behaviours when providing care for patients with more severe illness (which the authors suggest may be due to the time required to don barrier equipment leading staff to put patient safety above self-protection) and if they were only observing procedures, rather than performing or assisting with them.

Many studies, although mostly without statistical analysis, reported issues in performing personal protective behaviours, most notably due to lack of availability of appropriate PPE, perceived difficulty of protective behaviours, logistic issues, perceived effectiveness, perceived importance, convenience, comfort, and the impact on patient care.

Concerns about lack of PPE, largely due to insufficient resources, were very common [14, 39, 40, 41, 42, 48, 49, 50, 51, 52, 53] . Shortage of PPE created difficulties such as having to wear the wrong size PPE [40, 41, 51] . One study showed that availability of PPE was . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.

The copyright holder for this preprint this version posted May 29, 2020. Many qualitative studies found that discomfort of PPE was a barrier to compliance [39, 40, 41, 46, 52, 56, 57, 58] . In several studies, participants reported discomfort and/or symptom due to PPE, including dehydration and skin peeling [41] , difficulty breathing [40, 52, 58, 59] , sweating and dizziness [58] , headaches [40, 52, 60] and skin rashes [40, 52] .

Comfort of PPE was a predictor of compliance in one quantitative study [33] , with staff who reported always or often feeling comfortable wearing protective eyewear and N95 respirators . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.

The copyright holder for this preprint this version posted May 29, 2020. . https://doi.org/10.1101/2020.05.27.20114744 doi: medRxiv preprint 1 2 significantly more likely to wear them; however, no significant association was found in compliance between staff who reported always or often feeling short of breath, claustrophobic or dizzy when wearing protective eyewear or N95 respirators and those who rarely experienced these symptoms.

Qualitative data confirmed that many healthcare professionals believe that PPE use has an impact on patient care, making it difficult to communicate with patients due to muffled speech [40, 41, 52, 56, 57, 59] , being unable to establish non-verbal cues with patients [60] and making them less 'visible' to their patients [61] . Masks were reported as being frightening to psychiatric patients [52] , whilst PPE created anxiety in some patients who assumed the staff were wearing it because they had been exposed to the virus already [40] . what should be prioritised [50] and external guidance with little relevance to specific locations [39] . The manner of communication of guidance also created problems. New guidelines were sent to them by email, which they did not check before work [39] ;

information was filtered down from other sources rather than given to them first-hand was frustrating [64] ; and finally communication about changes to protocols was too slow [63] .

High levels of distress were associated with higher compliance in two studies: Chia et al. [43] found that higher distress was associated with higher use of respiratory protection while Wong et al. [45] found that staff who were highly anxious were more likely to comply with recommended protective behaviours. However, when the protective measure involved . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.

The copyright holder for this preprint this version posted May 29, 2020. . https://doi.org/10.1101/2020.05.27.20114744 doi: medRxiv preprint 1 3 quarantine, some staff felt such high stress that it tempted them to break guidelines, although it is unclear if any actually did [47] .

Risk perception was consistently associated with compliance. Four studies found that compliance was significantly more likely in staff who perceived the disease to be a serious risk [20, 22, 34, 66] and another found that perceived seriousness of the outbreak was significantly associated with compliance in Hong Kong but not in Singapore or the UK [23] .

Three qualitative papers also suggested that participants themselves believed staff complied with recommended behaviours when they perceived the risk to be severe [39, 47, 51] .

However, one study [21] showed a significant negative correlation between protective behaviours and fear of infection. Attitudes of family members were also deemed important in two qualitative studies [39, 46] with healthcare staff reporting they were encouraged to comply by anxious family members who were afraid of getting infected.

Overall the studies reviewed provided mixed and sometimes contradictory results.

Nonetheless, some risk factors stood out as being promising either for identifying specific groups at-risk for poor compliance or for targeting in interventions. These included: working outside of emergency or intensive care settings; not working with confirmed infection cases;

lack of concern about risk of infection; lack of monitoring by superiors; observed non-. CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.

The copyright holder for this preprint this version posted May 29, 2020. . https://doi.org/10.1101/2020.05.27.20114744 doi: medRxiv preprint 1 4 compliance of colleagues; lack of PPE; perceived difficulty using PPE; perceived lack of effectiveness or lack of importance of PPE; perceived inconvenience and discomfort of PPE;

perceived negative impact of PPE on patient care; lack of infection control guidance; and inconsistent or unclear guidance. Organisations faced with nosocomial transmission would be wise, as part of their mitigation efforts, to look to these areas in an effort to help staff adhere to protective behaviours.

There was little evidence for an association between compliance with protective behaviours and socio-demographic or personal characteristics. There was inconsistent evidence that compliance levels differ across countries: it is not clear whether this is due to betweencountry differences in the communication of guidance, different risk perceptions due to different countries' media coverage of the outbreak, different levels of training received, or possible cultural differences in the participants themselves.

This review suggests that compliance may differ between different roles and different settings. Targeted interventions for specific occupational groups with different levels of patient contact, hierarchies and cultures, may be helpful. Whilst it was unclear which occupational groups might need more attention, it seems that those not in emergency departments or intensive care units and not working directly with infected patients could benefit from additional focus.

We found little evidence that training and education significantly improved compliance. This with what is actually covered in training, or even that wanting more knowledge/training was the driver behind better compliance, and not simply the knowledge itself. In addition, because the perceived importance of PPE was also related to compliance, it may be that training that covers the 'why' rather than the 'how' of PPE is particularly useful. Overall, though, training itself is no panacea. Many of the factors identified by our review, and discussed below, are not amenable to better training.

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The copyright holder for this preprint this version posted May 29, 2020. . https://doi.org/10.1101/2020.05.27.20114744 doi: medRxiv preprint 1 5 A small amount of evidence suggested that observed non-compliance by others -including colleagues -could affect healthcare workers' own levels of compliance. This is likely to be particularly problematic where managers and supervisors fail to 'lead by example' and ensure that they comply with the recommended policies and procedures. 'Role modelling' by superiors could be useful, with supervisors setting the standards for infection control practices and reinforcing them. or is perceived to change, over the course of an outbreak.

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The copyright holder for this preprint this version posted May 29, 2020. . https://doi.org/10.1101/2020.05.27.20114744 doi: medRxiv preprint 1 6 We are aware that many papers (particularly on SARS and MERS) have been published in other (predominantly Asian) languages, but due to the rapid nature of this review we limited inclusion to English-language papers only. Future reviews should consider translating and analysing the many relevant foreign-language papers. Also due to the rapid nature of the review, quality appraisal of individual papers was not carried out as this is not always deemed necessary when urgent evidence synthesis is required [71] .

Overall this review identified many potential facilitators and barriers to adhering with recommended personal protective behaviours. . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.

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