PoorCOVID-19 PreventivePracticeamongHealthcareWorkers in Northwest Ethiopia , 2020

Department of Women’s and Family Health, School of Midwifery, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia Department of Internal Medicine, School of Medicine, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia Department of Midwifery, College of Health Sciences, Woldia University, Woldia, Ethiopia Department of Midwifery, College of Medicine and Health Sciences, Debre Tabor University, Debre Tabor, Ethiopia Department of Human Nutrition, Institute of Public Health, University of Gondar, Gondar, Ethiopia


Introduction
e novel coronavirus disease , defined as an illness caused by severe acute respiratory syndrome coronavirus 2 (SARS-Cov-2), was first identified as an outbreak of respiratory illness cases and first confirmed in December 2019 in Wuhan, Hubei Province, China [1,2]. Astonishingly, in the first three months after COVID-19 emerged, a devastating number of new cases were reported across China and several countries around the world [3], and it was finally declared as a global pandemic by the World Health Organization (WHO) on March 2020 [4]. Evidence indicates that COVID-19 transmitted through respiratory droplets via contact routes such as the mouth, nose, and conjunctiva or eyes [5,6].
According to the Worldometer report, the outbreak has been confirmed in over 21,628,638 individuals worldwide and resulted in more than 769,128 deaths as of August 16, 2020, of which 99% cases were found in mild condition. More than 213 countries reported laboratory-confirmed coronavirus cases. In Africa, 1,113,246 confirmed cases and 25,385 deaths were reported. Moreover, in Ethiopia, 28,894 confirmed cases and 509 deaths were reported [7].
Even though the outbreak is a global pandemic, it is important to note that the problem needs more attention in Africa because the African countries have limited healthcare system capacity to control the pandemic [8]. Measures to prevent transmission in healthcare settings are an immediate priority to slowdown the demand for specialized healthcare such as intensive care unit beds, safe guarding risk groups, protecting healthcare workers, and minimizing the export of the cases to other healthcare facilities and the wider community [9].
Healthcare workers (HCWs) are at a high risk of exposure to COVID-19 due to their direct contact with patients, so the triage of the patient with acute respiratory symptoms should be determined, the contact distance should be arranged to be at least 2 meters, and patients should wear face masks. During the care of these patients, the HCW should wear necessary personal protective equipment (PPE) and keep hand hygiene [10]. us, poor WASH (Water, Sanitation, and Hygiene) and infection prevention and control (IPC) lead to hospital-acquired infections and transmission of disease from health facilities to the community that will exacerbate the outbreak and spread of infections [6].
A Cochrane trusted evidence showed that long and constantly changing local guidelines, low level of support by the management, lack of enough space for isolation, lack of quality and adequate PPE, and fear of the patients being stigmatized if mask is worn are important impeding factors to follow the IPC guidelines by the healthcare workers [11].
Ultimately, HCWs play a pivotal role in averting acquired infections from hospitals via practicing effective and evidence-based infection prevention and control strategies [12]. However, despite limited data available on practice compliance of HCWs for other infectious diseases [13], no data are available on practice compliance of HCWs against the predefined COVID-19 preventive measures in the study area and the country at large. erefore, the study will be the first of its kind in informing the healthcare taskforce about the status of HCWs in preventing COVID-19 and an immediate action will be taken. HCWs will take an alarming precaution to protect themselves, as well as the community as a whole.

Study Design and Setting.
is institution-based crosssectional study was conducted from March to April 2020 in Northwest Ethiopia, Central and South Gondar zones of the Amhara regional state, to explore the preventive practice of healthcare providers towards COVID-19. e administrative zones have an estimated population of 5, 137, 443, and there are 18 public hospitals and 181 public health centers (North Gondar: 10 hospitals and 85 health centers; South Gondar: 8 hospital and 96 health centers).

Sampling Strategy.
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 nonresponse rate, the final sample was 634 HCWs. A multistage sampling technique was used to select participants. From the total 18 hospitals and 181 health centers, 5 hospitals and 20 health centers were selected using simple random sampling. en, based on the number of HCWs in each facility, the total sample was proportionally allocated to each facility, and then, each study participant was selected from the list of HCWs in each respective facility using simple random sampling.

Data Collection.
e self-reported questionnaire was developed through reviewing different literatures that included sociodemographic characteristics such as age, sex, ethnicity, religion, marital status, types of working facility and level of education, knowledge questions on the clinical presentations and transmission routes, attitude of HCWs, and preventive practice towards COVID-19 outbreak. A pretest was conducted among providers out of the study area. Training was provided on data collection, and necessary COVID-19 precautions were provided during data collection. Six BSc public health officers and two master of public health holders collected data and supervised data collection, respectively.

Measurements.
e dependent variable is preventive practice towards COVID-19. Preventive practices of HCWs were measured by 5 practice-related questions (Table 1). A correct answer was assigned 1 point, and an incorrect/unknown answer was assigned 0 points. e total score ranged from 0 to 5, with a higher score based on the mean value (≥3.13) denoting a "good preventive practice" of COVID-19.
Attitudes towards COVID-19 were measured by six questions (Table 2) about the agreement on the final control and confidence in winning the battle against COVID-19. A correct answer was assigned 1 point, and an incorrect/unknown answer was assigned 0 points. e total attitude score ranged from 0 to 6, with a score above the mean value (≥4.02) denoting a "good attitude" towards COVID-19.
e COVID-19 knowledge of HCWs was assessed by using 15 questions (Table 2). A correct answer was assigned 1 point, and an incorrect/unknown answer was assigned 0 points. e total knowledge score ranged from 6 to 15, with a higher mean score (≥13.56) denoting a "good knowledge" of COVID-19.

Statistical
Analysis. Data were entered into Epi Info 7 and analyzed using STATA 16. Descriptive statistics were used to describe participants' sociodemographics and response of knowledge, attitude, and preventive practice questions. Cronbach's alpha coefficient of the knowledge questionnaire was checked. Age of the respondents, knowledge, attitude, and preventive practice data were reported as mean ± SD. A binary logistic regression model was fitted to identify the associated factors. en, variables with a P value less than 0.2 were fitted to multivariable analysis. e goodness of fit was checked by using the Hosmer-Lemeshow goodness of fit. Multivariate logistic regression analysis with the enter method was used to identify predictors of preventive practice of COVID-19. A P value less than 0.05 was considered as statistically significant.

Sociodemographic Characteristics of Study Participants.
A total of 630 HCWs participated in the study, with the response rate of 99.2%. Of these, 395 (62.7%) were male providers. e mean age of participants was 31.2 ± 7 years. More than one-third of the participants were working in the health center. A highest proportion of respondents were found to be 20-30 years old (62.22%), have a bachelor's degree (BSc) in their current level of education (56.35), were Orthodox Christian followers (92.38%), and have one to five years of work experience (51.11%) ( Table 3).
e most common source of information was news from television and radio. About two-thirds (67.3%) of the respondents reported that they use social media (Facebook, Twitter, WhatsApp, YouTube, and Instagram) to obtain information about COVID-19 ( Figure 1). Table 2 presents the response of the respondent's knowledge and attitude. HCWs were generally knowledgeable, and almost 64.1% of the participants had good knowledge on the cause, clinical symptoms, and prevention mechanisms. Moreover, 445 (70.63%) respondents had positive attitude towards COVID-19 (Table 2).

Preventive Practice towards COVID-19.
e overall COVID-19 preventive practice among HCWs found was to be 244 (38.7%) (95% CI; 34.8, 42.5%). In the previous 4 weeks, about 84% of the participants washed their hands frequently with soap/hand sanitizers before and after contacting patients and entering their home and 36.3% of healthcare providers were not using face mask in the working place (Table 1).

Factors Associated with HCWs' COVID-19 Preventive
Practice. Both bivariate and multivariable logistic regression analyses were used to see the effect of those variables on preventive practice towards COVID-19. In bivariate logistic regression analysis, variables such as sex, age, level of education, years of working experience, and attitudes of HCWs were associated with COVID-19 preventive practice. After controlling for the effects of potentially confounding variables using multivariate logistic regression sex, years of working experience and attitude were found to be significantly associated with poor COVID-19 preventive practice.

Discussion
HCWs are at significant risk of COVID-19 infection during patient care delivery [14]. As consistent application of prevention mechanisms, use of PPE can diminish the risk of infection for healthcare workers [11].
is study assessed HCWs' compliance with the recommendations of COVID-19 preventive practice in Northwest Ethiopia. e finding of this study showed that the overall good COVID-19 preventive practice among HCPs was found to be 38.7% (95% CI: 34.8, 42.7). is finding was lower than that of a study conducted among HCWs in China (87%) [15], and Uganda (74%) [16]. e possible explanation for the disparity might be due to the difference in the economic status of the country, which increases the capacity and distribution of protective equipment of the healthcare system. Moreover, the compliance towards COVID-19 prevention recommendations among those HCWs could be due to differences in measurement, country context, and disease burden. In the Uganda study, all samples were taken from a single facility.
In this study, only 36.1% reported consistent use of face masks in the workplace which significantly facilitate the chance to acquire and transmit the disease. is could be because some HCPs may find it difficult to use masks and other equipment when it made patients feel isolated, frightened, or stigmatized and some HCWs even found masks uncomfortable to use [11]. Even though the WHO and other partners announced there will be a global shortage of PPE due to increased demand [17], there are suggestions that facemasks may be used intermittently or continuously for around eight hours [18]. Adverse effects of facemasks increase with more than eight hours of use [19]; however, in this study, the median duration of using a single face mask was found to be 6 days, which contradicts with evidence that pathogens may be present on the outer surface of around 10% masks and risks increase with prolonged mask use [20].
Moreover, 84% of HCPs had practiced frequent hand washing with soap and water or using sanitizer before and after contacting patients and entering their home. is could be a good practice in the context of a country with limited resources. However, in the recent 4 weeks prior to data collection, 43.3% providers reported that they had been in a crowded place as in churches, markets, and funeral ceremonies and 64.1% had shaken hands with staff, friends, or other people. is could be due to the influences from cultural and social intimacy in the community and being absent from such social and cultural events might cause misunderstanding and get stigma from the community. In this study, compliance towards COVID-19 prevention was significantly affected by sex. Female HCWs were found to better comply with prevention recommendations.
is finding is consistent with that of a community-based study conducted among Chinese residents [21] that female participants implemented preventive practice than males. Moreover, in another study in Malaysia, females were found to better practice hand washing than males [22]. is could be due to the women's responsibility in taking care of children and family in the Ethiopian culture, which may influence them to fear and comply with prevention recommendations.
HCPs having 6-10 years of experience had reported better compliance with COVID-19 prevention recommendations than providers with 11 or more years of experience.
is finding is also supported by a study conducted among the Malaysian community [22] that those older people with the age of greater than 50 years were found to be less likely to wear facemasks. is could be because as the HCPs age and experience increases, the exposure and fear for such outbreaks will reduce and may tend to normalize things as normal.
Attitude towards COVID-19 transmission, prevention, and control was among the factors that showed a significant association with compliance, and those providers who had poor attitude towards the disease, its transmission, and controlling movements were less likely to comply with the COVID-19 prevention recommendations. is finding was in line with studies conducted among communities in China [21] that those who were hopeful and confident that the disease will finally be controlled successfully were more likely to implement preventive practices.

Conclusions
Multiple education and training platforms with a focus on COVID-19 preventive measures need to be provided for HCPs. As a risk group for acquiring and transmitting the  Advances in Public Health diseases and the absence of any vaccine or treatment as of today, HCPs should comply with COVID-19 preventive measures and should rely on infection prevention and patient safety measures. A lack of or poor quality PPE is a serious concern for healthcare providers [11]. is would contribute to the reduced utilization of facemasks in the work place, which requires the need to avail the required protective supplies.