Infection control Knowledge, Practices, and Perceived barriers towards COVID-19 among physicians in university hospitals, Cairo, Egypt.


 Background: WHO declared COVID-19 a global pandemic on 11th March 2020. Due to the lack of adequate treatment and approved vaccines, proper infection control practices are the only effective tools for prevention and control of COVID-19 infection among the health care facilities. Objectives: This study aimed to assess the infection control knowledge, practices, and perceived barriers towards COVID-19 among physicians working at Ain Shams University hospitals. Methods: Cross-sectional was carried out among a sample of physicians working at Ain Shams university hospitals, Cairo, Egypt, by using an online questionnaire. The design of the questionnaire was based mainly on the WHO guidance for infection prevention and control during health care when novel coronavirus infection is suspected and CDC guidance for COVID-19. Results: A total of 318 physicians with different job titles and specialties participated in this study, results showed average infection control knowledge (the mean correct answer rate was 57.1%+ 15.9%) and practices (infection control practices score was 78.76% + 12.17%) among our studied group. Patients overload and improper design of the working places were perceived as barriers to infection control practices by the majority (90%) of our participants. Conclusion: Our study results showed average infection control knowledge and practices towards COVID-19. There are defects in certain aspects related to infection control knowledge and practices that needed more practical training and properly designed working places to improve it.


Background
On 31st December 2019, it was announced the presence of viral pneumonia of unknown cause in Wuhan city, China. The pathogen causing this pneumonia has been de ned as severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) [1].
SARS-COV-2 is a highly transmissible viral infection. It got discovered more than twenty million people were infected worldwide. It is transmitted from person-to-person by close contact via the respiratory droplets during coughing and sneezing or through touching contaminated surfaces by the virus [5][6].
Due to the lack of adequate treatment and approved vaccines. The WHO recommends for the prevention of COVID-19 spread to apply primary preventive measures that include Proper hand washing, physical distancing, respiratory hygiene, cough etiquette, and wearing face masks in crowded areas that will serve as the rst line of defense in public and also applying effective infection control measures within the different health care settings [7][8].
Physicians are at the front-line of COVID-19 ghting during this pandemic. They are exposed to infection due to frequent contact with and exposure to con rmed and suspected cases. They are also exposed to psychological stress, fatigue due to long working hours, and physical violence [9][10].
The transmission of COVID 19 among physicians is enhanced by multiple factors as patients overcrowding, lack of isolation rooms within the health care facilities, soiled environment by patient secretions, and absence of knowledge or insu cient awareness of infection control practices among them [11]. A prospective cohort study has been conducted in the UK and the USA to compare the risk of COVID-19 infection among front-line Health care workers (HCWs) with the general community. The result revealed that front-line HCW had a twelvefold increase in the risk of COVID-19 infection [12] Understanding physicians' knowledge, attitudes, and possible perception of risk of infection directly in uence practices and lead to proper diagnosis and decrease the spread of disease. So, this study has been conducted to assess the infection control knowledge, practice, and perceived barriers toward COVID-19 among physicians at Ain Shams University, Egypt.

Methods
Study design, setting, and population: This Cross-sectional survey has been carried out among physicians working at Ain Shams university hospitals, Cairo, Egypt, using an online questionnaire in English language form from 1 June to 30 July 2020. During this period, most of the Physicians worked at either the emergency units or at the COVID-19 isolation hospital, so it was not feasible to contact them, we have been designing an online questionnaire to allow proper reaching to our target population.
Ain Shams university hospital is one of the largest university hospitals in Egypt, it includes 7 hospitals (surgery hospital, internal medicine hospital, pediatrics hospital, obstetrics, and gynecology hospital, emergency hospital , and geriatrics hospital), and multiple speci c units and centers as clinical toxicology center, psychiatric center, bone marrow transplant unit, digestive endoscopy unit and clinical research unit. It involves more than 3000 inpatient beds, in addition to ICUs at the different hospitals.
Our study population represents physicians with different specialties and positions, who working at Ain Shams university hospitals. The sample size has been calculated using the PASS11 program based on reviewing results of previous relevant studies which have shown that the mean correct answer rate of knowledge related to COVID-19 was (80.4%) [13], and good infection control practices were (94.3%) [7], with a margin of error = 0.05 and at 95% con dence level. The required sample size was 250 physicians, but at the end of the speci ed time period, the collected sample was 318 physicians.
Data collection tool: Data has been collected using an anonymous online questionnaire. The design of the questionnaire mainly was based on the WHO guidance for infection prevention and control during health care when novel coronavirus infection is suspected [8], and CDC guidance for COVID-19 [14]. The validity of the items has been veri ed by three experts, including microbiologists, infection control specialties and epidemiologists. A pilot study has been conducted on 10 physicians before the gathering of data. The data of this study has been excluded from the nal analysis. The questionnaire has been created on Google Forms. The URL link has been shared with all physicians on the WhatsApp group so that they can participate in the questionnaire.
The questionnaire was composed of four sections: 1. Demographic data (e.g. age, gender, specialty).

Level of COVID-19 Related infection control Knowledge: Knowledge has been assessed using 12
questions covering mode of transmission and general infection control practices. Each question has been answered as follows: yes, no, or I don't know. The correct answer was assigned 1 point and an incorrect answer or 'I don't know' were assigned 0 points. The total score ranged from 0-12 and has been converted into a percentile.
3. Infection control practices: This section consisted of nine items covering the infection control practices related to applying the standard precautions and other WHO recommended empirical precautions during contact suspicious or con rmed COVID-19 cases. The choices were provided as 'Rare, sometimes' or Always, and answers have been coded as rare=1, sometimes=2, and always=3. The total score ranged from 0 to 27 and has been converted to a percentile. 4. Infection control perceived barriers: Based on reviewing results from a previous study [7], six items have been selected to assess the perception of physicians regarding infection control barriers. Responses have been coded as yes, or no for each barrier.
Data management and analysis: Data have been revised, coded and analyzed using SPSS package version number 25. Quantitative data has been described as mean, standard deviation (SD), and range values. Qualitative data has been described as numbers and percentages.
To study the association between the physicians' socio-demographic characteristic and their infection control knowledge and practice scores, independent t-test, and ANOVA test have been used. P-value ≤ 0.05 has been considered signi cant.

Results
A total of 318 physicians with different job titles and specialties have participated in our study ( 15.9), the highest correct answer was related to the item" Washing hands with soap or use of an alcoholbased antiseptic decrease the risk of the infection" as 99.7% of the participants answered it correctly.
While the least correct answer was related to the item "All types of face masks have the same protection level against the infection" as only 3.6% of the participants answered it correctly. Table2 Regarding the self-reported infection control practices assessment, the mean practice score was 78.76 + 12.17, most of our participants reported that they have been safely disposing of the used PPE. While only (20.8%) of them reported that they were always making seal test for N95 mask before use. Table 3 Table 4, Shows the association between socio-demographic characteristics and the level of COVID-19 related knowledge, the mean knowledge score was signi cantly higher in the old age group(>30 years), males, consultants, pediatric specialty , and among physicians who attended infection control courses.
Regarding the safe infection control practices, participants who attended infection control courses have a signi cantly higher safe practice than others.

Discussion
Our study results have revealed that physicians have an average level of COVID-19 related knowledge, the mean correct answer rate was 57.1%+ 15.9%. This is consistent with the results of a study conducted in the United Arab Emirates And another study conducted in Iran as the level of knowledge was 61% and 56.5% [15,16] But, lower than that reported in other studies conducted in Egypt, China, Vietnam and Uganda as the knowledge correct answer rate were 80.4%, 90%, 88.4%, and 82.4% respectively [17,18,19,20]. These dissimilarities could be due to differences in the characteristics of the surveyed populations and the scienti c level of the items used in evaluating the degree of the infection control knowledge among different studies.
In the current study, the most prevalent correct answers were related to the importance of hand washing with soap or the use of an alcohol-based antiseptic in decreasing the risk of the infection (99.7%), and the importance of maintenance of social distance (97.5%). These results are similar to that have been mentioned in two studies conducted among Saudi HCWs, and Indian undergraduate students were participants reported the importance of hand hygiene before touching the patients in a percentage of 94.1% and 85.4% respectively [21,22] .while the importance of social distancing was in line with a study conducted in El Fayoum governorate, Egypt and another study conducted in Iran as 97% of the participants reported that coronavirus spread via close contact [13,23] Knowledge level about COVID-19 has been signi cantly associated with younger age groups (less than 30 years old). Several studies results have found that the younger age group has a higher level of knowledge [17,18,24], contrary to other studies that have shown that a higher level of knowledge has associated with the older age group >30 years old [25,26]. While other studies have reported that there has no association between knowledge and age [27,28].
In the present study, a statistically signi cant relationship between physicians' knowledge and their years of experience was detected. This result is dissimilar to that have been mentioned in a study conducted in Pakistan as there was no association between years of experience and the knowledge level [29], on the other hand, other studies have shown that the mean knowledge score was signi cantly higher among those who had more than ten years of experience [25,30].
Regarding infection control practices we found that the mean infection control practices score was (78.76 + 12.17), this is in accordance with a study done in Saudi Arabia as 87.9% of health care workers reported good infection control practice [25].
In our study, the most prevalent correct practice was related to hand washing as only 5% of our participants rarely apply proper hand washing, while 58.5% of them always apply it properly. This is higher than that has been found in a study conducted in Brazil as the hand washing adherence rate was 46.25% in critical care unit [31] About 58.5.5% of the studied group always wears PPE, while only 8.2% rarely wears it properly and 23% always Uses N95 mask during all patient management procedures, this is in line with a study conducted in Saudi Arabia which has reported that 71% of health workers wear the mask during work [32]. Another study that has been carried out in Pakistan has shown that the correct usage of masks was good in 35.2%, moderate in 45.4%, and poor in 19.3% of the studied group [33].In contrast, a study has been carried out in Vietnam has reported that there is a limited number of correct responses regarding items related to the use of personal protective equipment [34].
Our results have revealed that the previous attendance of infection control training courses was the only signi cant factor affecting physicians' infection control practices. This result re ects the importance of practical training and learning by doing as essential and mandatory requirements for applying proper infection control practices.
Patients' overcrowding and limited infection control material have been reported as perceived barriers by the majority of our study participants, this is consistent with the results of other relevant studies that mentioned these factors as barriers to infection control practices [17, 29, and 35].

Limitations
Our study has been conducted among a sample of physicians who have accepted to ful ll the online questionnaire. Lack of presentation of all physicians has interfered with the generalization of our results. Medicine, Ain Shams University approved this study (Approval number: FMASU R 50/2020). Filling the questionnaire by physicians is considered an approval to participate in the study. Con dentiality of data has been maintained through the anonymity of the questionnaire.

Consent for publication: Not applicable
Availability of data and material: The datasets generated and analyzed during the current study are available from the corresponding author on request.
Competing interests: The authors state that they have no competing interests.
Funding There has been no signi cant nancial support for this work that could have in uenced its outcome.
Author Contributions: RS conceptualized the study idea, designed the online form, analyzed the data, and was a major contributor in writing the manuscript. SA conceptualized the study idea and participated in writing the manuscript. AF participated in writing and editing the draft of the manuscript. All authors participated in data collection. All authors have read and approved the manuscript