Abstract
Background: The increasing number of coronavirus disease 2019 (COVID-19)-related deaths among healthcare workers in Eswatini suggests that there may be suboptimal compliance with standard precautions among healthcare workers in the country.
Aim: The study aimed to assess healthcare worker knowledge of and compliance with COVID-19 standard precautions.
Setting: A quantitative descriptive cross-sectional study using stratified sampling was conducted among healthcare workers in two major regional referral hospitals of Eswatini.
Methods: Data were collected using a structured self-administered questionnaire, and analysed using Statistical Package for Social Sciences version 29. Statistical measures for analysis included descriptive statistics, cross-tabulations, Pearson correlation, 95% confidence interval and a significance level set at p < 0.05.
Results: A total of 146 study participants were recruited, and a response rate of 68.9% (146/212), of which the majority (61%) were nurses was received. Overall knowledge of and compliance with COVID-19 standard precautions were 81.27% and 72%, respectively. Nurses were more knowledgeable of the standard precautions (82.9%), while cleaners and/or orderlies were more compliant with the standard precautions (83.88%). There was no significant correlation between knowledge of and compliance with standard precautions.
Conclusion: Healthcare workers are knowledgeable and compliant with COVID-19 standard precautions. Receiving training on standard precautions does not improve knowledge of or compliance with standard precautions. Furthermore, knowledge of the standard precautions does not improve compliance with the standard precautions.
Contribution: The study findings benefits the National IPC programme in its revision of IPC policies, guidelines and standard precautions training curricula and also inform improvements to interventions aimed at maximising compliance with COVID-19 standard precautions.
Keywords: compliance; knowledge; standard precautions; COVID-19; healthcare workers; occupational exposure; infection control; Eswatini; cross-sectional study.
Introduction
Healthcare workers are exposed to pathogens such as the flu and associated viruses including coronavirus disease 2019 (COVID-19) daily; therefore, standard precautions exist to protect them from occupational exposure. Training healthcare workers has always been an important part of sustaining and increasing the quality of healthcare. The COVID-19 pandemic underlined the significance of continual training, and it continues to influence healthcare environments in numerous ways. The World Health Organization (WHO) has repeatedly emphasised the significance of training healthcare workers in response to the COVID-19 pandemic. Furthermore, the WHO’s ‘Health Worker Safety Charter’ emphasises the crucial significance of providing safe working conditions for healthcare workers to sustain effective patient care during the pandemic.1
In Eswatini, at least 291 healthcare workers were infected with COVID-19 despite the numerous trainings conducted on COVID-19 standard precautions.2 This aspect of training healthcare workers was advocated during the pandemic and is a continued phenomenon in healthcare settings.1 One of the hospitals reported 86 COVID-19-related deaths among healthcare workers.3 Although factors associated with compliance with standard precautions have been studied in various settings, little is known on this matter in Eswatini. The increased number of healthcare workers who contracted COVID-19 in Eswatini suggested that there could be suboptimal implementation and compliance with the standard precautions in the country. Therefore, the aim of this study was to assess healthcare worker knowledge of and compliance with COVID-19 standard precautions.
Research methods and design
Study setting and population
A quantitative descriptive cross-sectional study was conducted in two major regional hospitals in Eswatini in September 2022. The two regions where these facilities are situated continuously recorded the highest cumulative numbers of COVID-19 cases in the country.4 The two hospitals serve populations of 350 000 and 250 000, respectively.5,6 Given the high numbers of healthcare workers at these two sites, it was envisaged that these sites would provide enough study participants for enrolment in the study. In addition, being referral hospitals, these hospitals had a well-represented mix of all the healthcare categories of interest for this study, which may not have been the case in smaller health facilities. The target population included healthcare workers who were employed at the two hospitals during the study period and who were assigned to clinical services in any department in the two hospitals, who had direct interaction or contact with patients and/or hospital treatment equipment, irrespective of age, sex, educational background and duration. A stratified random sampling method was adopted for the study. The six strata considered for the study were doctors, nurses, nurse assistants, healthcare lay category (human immunodeficiency virus [HIV] testing counsellors, phlebotomists and expert clients), laboratory personnel, and cleaners. A list of all the healthcare workers in each stratum was obtained from each of the two study sites. The percentage proportion of each stratum to the overall study population was then calculated. Study participants included healthcare workers assigned clinical services during the study period, healthcare workers who were present on duty during data collection and healthcare workers who consented to participate in this study. This study excluded healthcare workers who were assigned administrative duties during the study period and those who never consented to participate in this study.
Sampling and sample size
The sample size was determined using a statistical software tool, CDC (Centers for Disease Control) Epi Info version 7.2. The sample comprised a population of 305 healthcare workers, with 163 healthcare workers and 142 healthcare workers, respectively. With an acceptable error margin of 5% and two clusters, the estimated sample size at 95% confidence level was 170. Adding a 25% contingency of 42, the sample size was calculated to be 212.
Data collection
A standard questionnaire was developed to gather information from respondents which used both closed-ended and open-ended questions. The content of the questionnaire was adapted from the literature on Standard Precautions Guidelines. Administration and completion of the questionnaire took approximately 20 minutes. The respondents were provided with a questionnaire to self-administer at their duty stations during their work shift. Responses to the closed-ended questions were pre-coded. Using the self-administered questionnaire approach for the study was deemed less expensive in terms of funding. The questionnaire was distributed by hand directly to the consenting respondents. The respondents answered the questions by ticking the appropriate option or writing down their responses. To ensure validity and reliability of the study, the questionnaires were piloted, and double entry of data took place to prevent any misinterpretation and mistakes. The questionnaire was piloted on a small group of participants to evaluate its consistency and to determine if participants could comprehend fully. This pre-tested data did not form part of the main study. The questionnaire was filled out anonymously after consent was obtained. The researcher collected the completed questionnaires from duty stations.
Data analysis
The data that were collected were captured and cleaned on Microsoft Excel and thereafter exported to Statistical Package for Social Sciences (SPSS) version 29, a software tool that is used for data management and statistical analysis. Study variables for the study consisted of independent, dependent and confounding variables. The independent variables were derived from institutional factors (training about infection prevention and availability of infection prevention supplies). The dependent variables were derived from the knowledge and compliance characteristics of the research participants. The confounding variables were derived from socio-demographic characteristics (age, gender, nature of work and work experience). Frequencies were run on all categorical variables and summary statistics on continuous variables. Stratification by healthcare category, age, gender and length of employment was pursued to test interactions with the level of compliance, determining the significance of interactions. Chi-square tests, p-values and 95% confidence intervals were used to test if there was a significant association. Frequency distributions and cross-tabulations were used to examine the relationship between socio-demographic characteristics and healthcare workers’ knowledge of and compliance with COVID-19 standard precautions.
Ethical considerations
Approval to conduct the study was obtained from the University of Johannesburg, Health Science Faculty Higher Degrees Committee (FHDC) referenced MPH HDC-01-05-2022 and ethical clearance was granted by the Research Ethics Committee (REC) referenced REC-1387-2022 as well as the Eswatini Health and Human Research Review Board (EHHRRB020-2022). Before carrying out the study, permission was obtained from the two study sites. Written informed consent was requested and obtained from all participants, before administering the questionnaire. Participants were not exposed to any form of harm in this research study. The names and addresses of participants were not requested, required, or recorded for the study, allowing them to remain anonymous and their identities confidential. The informed consent letter was used to inform all participants of their right to withdraw at any time during the study and that they would have access to the data collected during the research study through the researcher or the study’s supervisor. This study fully adhered to the stipulations outlined in the Protection of Personal Information Act (POPIA).
Results
Study participants’ demographics
A total of 146 study participants were recruited with a response rate of 68.9% (n = 146/212). Frequency distributions were used to analyse the demographic profiles of the participants. The distribution by age showed that majority of the participants were females (76%). A greater proportion (24%) of participants were aged 30–35 years while participants in the age group of 41–45 years made up the least proportion of the study population at 13 (8.9%). More than half (61%) of the participants were nurses (Figure 1). A greater proportion of the participants (50.7%) had worked in healthcare for less than 10 years; 23.3% worked for less than 5 years and 27.4% worked between 5 years and 10 years. The least proportions were found to be those who had worked for a longer duration, for example above 30 years (2.7%).
 |
FIGURE 1: Distribution of participants by healthcare category. |
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Institutional factors
Majority (86%) indicated that they had received training on standard precautions, but of these only 22% received a refresher training on the standard precautions. A greater proportion (59.2%) of participants indicated that they received training on standard precautions during the last 2 years while only 2.4% indicated that they received the training more than 5 years ago. The results showed that the training on standard precaution targets mostly healthcare workers with few years in employment with 22% trained among those who have worked for less than 5 years and 28% among those who have worked for 5–10 years. Most participants were nurses (63%) indicating that the trainings on standard precautions target nurses.
Availability of infection prevention and control guidelines and availability of essential infection prevention and control equipment
To further assess institutional support for compliance with standard precautions, participants were asked about the availability of Standard Precautions Guidelines at their workstation and the frequency of working without essential infection prevention and control (IPC) equipment because of unavailability of the equipment. Most participants (66%) reported that they had Standard Precautions Guidelines at their workstations. A greater proportion (60%) indicated that they often worked without essential IPC equipment while only 10% indicated that they have uninterrupted supply of IPC essential equipment.
Knowledge of COVID-19 standard precautions
Frequency distributions and cross-tabulations were used to assess the knowledge of COVID-19 standard precautions. Overall, the participants were knowledgeable of the standard precautions with a mean score of 81.27% with a standard deviation of 10.822 (Table 1). The frequency distribution curve showed a slightly left-skewed distribution indicating that most participants scored above average, and a few scored far below average. There were variations in knowledge scores observed when comparing the scores between demographic groups. Nurses were found to be more knowledgeable with a mean score of 82.9% followed by lay category with a mean score of 80.89%. The least knowledgeable were laboratory personnel with a mean score of 75% (Table 1). The knowledge scores by age groups were comparable across all age groups. However, the age group of 46–50 years was more knowledgeable with a mean score of 84.68% and the least knowledgeable was the age group of 36–40 years with a mean score of 75.89%. Assessment of knowledge disaggregated by the number of years in healthcare employment showed that those who have worked for 21–25 years were more knowledgeable (mean score 88.21%) while those who have worked for less than 5 years as well as those who have worked for more than 30 years were least knowledgeable with mean scores of 79.74% and 79.75%, respectively. There was no significant difference noted when comparing knowledge scores between those who received training on standard precautions and those who did not receive the training. Participants who had received training had a mean knowledge score of 81.65% while those who had not received training had a mean score of 79%. Pearson correlation tests were performed to assess interactions between knowledge and demographic characteristics and institutional factors. A significant interaction was observed between knowledge and years of work and receiving training. A statistically significant weak negative relationship (r = –2.54 and p = < 0.05) was observed between knowledge of standards precautions and years of work indicating that with an increase in the number of years worked, the knowledge of standard precautions decreases.
| TABLE 1: Knowledge and compliance scores by participants (N = 146). |
Compliance with COVID-19 standard precautions
Frequency distributions and cross-tabulations were used to assess compliance with COVID-19 standard precautions. Overall, the compliance levels among the participants were high with a mean score of 72% with a standard deviation of 16.389. The frequency distribution curve showed a normal and symmetrical distribution with a mean of 72%, median of 71% and mode of 71%. This result means that most of the participants had an average compliance score with a few scorings far above and below the average score. There was variation in compliance scores observed when comparing the scores between demographic groups. Cleaners and/or oderlies were found to be more compliant with a median of 83.8%. The lowest compliance scores were observed among doctors with a mean score of 53.6% (Table 1). Participants in the age group of 41–45 years were found to be more compliant with a mean score of 82.69% and the least compliant age group was 36–40 years with a mean score of 63.44%. When comparing the compliance levels by the number of years worked in healthcare, the study found that those who had worked between 5 years and 10 years were more compliant (77.95%). The greatest variance within each group was observed in those who had worked for less than 5 years with a minimum compliance score of 19% and a maximum compliance score of 95%. There was slight difference in compliance scores between those who had received training on standard precautions (72.1%) and those who did not receive the training (71.38%). Analysis of compliance scores by each item assessed (Table 2) showed compliance to handwash with alcohol or soap was highest (72%) followed by compliance with wearing masks (66%), and the least compliance was observed with wearing aprons (27%). Cross-tabulations were used to explore the reasons that lead to non-compliance with the COVID-19 standard precautions. The majority (73%) of participants reported that the reason for non-compliance with IPC standards was non-availability of the essential IPC equipment including gloves, masks and aprons. The major reasons reported for non-compliance with handwashing after touching a patient’s surroundings were that it is not practical (34%) and non-availability of handwash equipment (32%). For non-compliance with surface cleaning standard, half (50%) reported that it was not practical as it interferes with their work processes. Pearson correlation tests were performed to assess interactions between compliance and demographic characteristics and institutional factors. There was no statistical significance observed between compliance and all other variables assessed. This means that compliance to COVID-19 standard precautions can be explained by other factors, which were not assessed in this study.
| TABLE 2: Compliance level with each item assessed (N = 146). |
Association between level of knowledge of and compliance with COVID-19 standard precautions
Pearsons correlation test was performed to assess the association between the level of knowledge of and compliance with COVID-19 standard precautions which showed weak to no correlation between knowledge of COVID-19 standard precautions (r = 0.003). This correlation was not statistically significant with a p-value of more than 0.05 (0.973).
Discussion
Knowledge on COVID-19 standard precautions
The study findings show that healthcare workers are knowledgeable of COVID-19 standard precautions, with an overall mean score of 81.27% across all the knowledge items assessed. This finding was similar to a previous study that found good knowledge of standard precautions.7 Similarly, the finding is comparable to that of a similar study in Northern Uganda that showed a knowledge score of 69%.8 Previous studies found that healthcare workers performing clinical roles were 2.5 times more likely to have good knowledge compared to healthcare workers performing non-clinical roles.7 In this study, nurses were found to be more knowledgeable of the standard precautions when compared with the other health categories. The study results showed that efforts are made by healthcare institutions to ensure that healthcare workers are provided with the knowledge required, as shown by most participants (86%) having received training on the COVID-19 standard precautions. The study also found that the trainings are mostly targeting nurses; within the nurse category group (89%), they received training on standard precautions. The study also found that receiving training on COVID-19 standards does not improve knowledge of the standard precautions. There was no significant difference in knowledge levels between those who received training on COVID-19 standard precautions and those who had not received the training.
Compliance with COVID-19 standard precautions
The study aimed to prove that healthcare workers are compliant with COVID-19 standard precautions and found that to be true, as depicted by a high compliance level of 72%. Aung et al. also found a prominent level of compliance with standard precautions among healthcare workers.9 This study also found that the non-clinical category (cleaners and orderlies) had higher levels of compliance with the standards. In this study, more participants reported the unavailability of essential equipment and supplies as a major barrier to compliance. Other reasons provided were that wearing personal protective equipment (PPE) was time-consuming and that cleaning frequently touched surfaces at the stipulated time intervals was not practical as it interfered with patient care (e.g. during counselling sessions). Similar results were reported which included the fact that because of the demands of patient care, healthcare workers did not have time to comply with the demands of standard precautions.10 The major barriers to compliance with standard precautions in a similar study were a lack of adequate facilities, the absence of regular training on infection control and the uncomfortable nature of PPE.7
Association between the level of knowledge and compliance with COVID-19 standard precautions
The study also aimed to prove that there is an association between the level of knowledge of and compliance with standard precaution practices. The study did not find a significant interaction between knowledge of and compliance with the standards. This finding found no significant relationship between knowledge of and compliance with standard precautions.8 Together these findings suggest that other factors beyond the knowledge of standard precautions influence healthcare workers’ compliance with the standards. This is contrary to findings, which indicates that the respondent’s knowledge and compliance with standard precaution had a statistically significant association.7
Conclusion
The study findings suggest that healthcare workers are knowledgeable of the COVID-19 standard precautions and comply with the standards. The findings also suggest that beyond the knowledge of standard precautions there are other factors that are barriers to compliance. The unavailability of essential IPC supplies and equipment, the time-consuming rigours of wearing PPE and the impracticality of adhering to the stipulated frequencies of some IPC-related activities are some of the barriers to compliance. Although training on standard precautions was conducted, it did not improve knowledge of or compliance with standard precautions. Furthermore, knowledge of the standard precautions did not improve compliance with the standard precautions.
Acknowledgement
This article is partially based on the author, N.N.’s, minor dissertation entitled ‘Assessing the knowledge and compliance with COVID-19 precautions among healthcare workers in Eswatini’ in partial fulfilment of the Master of Public Health in the Faculty of Health Sciences, University of Johannesburg, South Africa, in 2023, with supervisor Ms R.H. Van Wyk. (see: https://hdl.handle.net/10210/505157).
Competing interest
The authors declare that they have no financial or personal relationships that may have inappropriately influenced them in writing this article.
Authors’ contributions
N.S.N. and R.H.V.W. contributed to the conceptualisation, methodology, formal analysis, investigation, writing of original draft, visualisation, project administration, validation, data curation and writing (review and editing). R.H.V.W. also acted as a supervisor. N.S.N. also contributed to funding acquisition. S.B.M. and C.M. contributed to the writing (review and editing).
Funding information
This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.
Data availability
The data supporting the findings of this study are available from the corresponding author, R.H.V.W., on reasonable request.
Disclaimer
The views and opinions expressed in this article are those of the authors and are the product of professional research. It does not necessarily reflect the official policy or position of any affiliated institution, funder, agency or that of the publisher. The authors are responsible for this article’s results, findings and content.
References
- World Health Organisation. Health worker safety charter [homepage on the Internet]. Geneva: World Health organisation; 2020 [cited 2024 Aug 01]. Available from: https://www.who.int/docs/default-source/world-patient-safety-day/health-worker-safety-charter-wpsd-17-september-2020-3-1.pdf
- International SOS. COVID-19 in Eswatini [homepage on the Internet]. International SOS; 2020 [cited 2020 Mar 24]. Available from: https://pandemic.internationalsos.com/reports/covid-19-cases-in-eswatini-mar-24-2020
- Rooney R. A total of 86 health workers die from coronavirus at a single Swaziland hospital [homepage on the Internet]. Swazi Media Commentary; 2021 [cited 2021 May 10]. Available from: https://swazimedia.blogspot.com/2021/05/total-86-health-workers-die-from.html
- Eswatini Ministry of Health. Coronavirus – Eswatini: COVID-19 update [Press Release]. Africa News [serial online]. [cited 2021 Mar 19]. Available from: https://www.africanews.com/2021/03/19/coronavirus-eswatini-covid-19-update-18-march-2021/
- Eswatini Nazarene Health Institutions. Clinics. 2019. [Internet]. [cited 2020 Mar 24]. Available from: https://www.enhicare.com
- Chowa P, Joiner A, Luong J, et al. Evaluating capacity at three government referral hospital emergency units in the kingdom of Eswatini using the WHO Hospital Emergency Unit Assessment Tool. BMC Emerg Med. 2020;20(1):33. https://doi.org/10.1186/s12873-020-00327-w
- Ogboghodo E, Osaigbovo I, Adio F, et al. Healthcare workers’ preparedness to tackle COVID-19: A study on knowledge and compliance with standard precautions in a Tertiary Hospital in Southern Nigeria. J Community Med Prim Health Care. 2021;33(1):50–63. https://doi.org/10.4314/jcmphc.v33i1.5
- Amanya S, Nyeko R, Obura B. Knowledge and compliance with COVID-19 infection prevention and control measures among health workers in regional referral hospitals in northern Uganda: A cross-sectional online survey. F1000Research. 2021;10:136. https://doi.org/10.12688/f1000research.51333.2
- Aung S, Nursalam N, Dewi Y. Improving compliance with standard precautions among Myanmar nurses using health belief model. Malaysian J Nurs [serial online]. 2016 [cited 2020 Oct 30];8(2):21–28. Available from: https://ejournal.lucp.net/index.php/mjn/article/view/518/488
- Ackumey M, Akagbo S, Nortey P. Knowledge of standard precautions and barriers to compliance among healthcare workers in the Lower Manya Krobo District, Ghana. BMC Res Notes. 2017;10(1):432. https://doi.org/10.1186/s13104-017-2748-9
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