Perception of risk and compliance with COVID-19 safety guidelines among healthcare workers in Ghana: a cross-sectional study

Abstract

Background: Healthcare workers are the ‘frontline’ in the provision of effective and quality healthcare delivery, yet they are beset with several occupational hazards and risks when providing care especially during a global health crisis. With limited health resources availability during patient care delivery coupled with relatively little evidence on compliance to infection prevention practices, this study investigates healthcare workers’ compliance with COVID-19 safety protocols and identifies factors associated with their perceived risk of COVID-19.

Methods: This cross-sectional survey utilized non-probability sampling strategies to obtain primary data from both clinical and non-clinical health workers in various health facilities within four regions of Ghana. Structured questionnaires designed using Google forms and paper-based questionnaires were used. Binary logistic regression analysis was performed to identify the factors associated with the perceived risk of COVID-19.

Results: A total of 513 questionnaires were obtained at the end of the study. The results showed that healthcare workers are highly compliant with hand hygiene practices and wearing face masks. Results from the regression analysis showed that the number of working years a healthcare worker had spent, category of health professional, type of health facility, region of work, frequency of COVID-19 test, and compliance with hand hygiene practices were strongly associated with healthcare workers’ perception of risk of COVID-19.

Conclusion: Findings suggest that both individual and health system factors are significant in increasing the risk of COVID-19 among healthcare workers. Efforts at enforcing strict compliance with infection prevention should be implemented to protect the health workforce and mitigate against the transmission of the coronavirus. 

Background

Since the declaration of COVID-19 as a pandemic in March 2020 by the World Health Organization [1], strict compliance to infection prevention and control (IPC) practices have been accentuated in all countries. In response to combating the transmission of the coronavirus among health workers, several IPC measures targeted at eliminating or minimising the spread of the virus were recommended by the WHO. IPC is an essential component of the healthcare infrastructure that is concerned with preventing healthcare associated infection [2]. The guidelines associated with healthcare for suspected COVID-19 range from ensuring triage; early recognition and source control; application of standard precautions for all patients; contact and droplet precautions; airborne precautions for aerosol-generating procedures; implementing administrative controls and using environment and engineering controls [1]. These safety precautions are protective only if they are strictly complied with.

Healthcare workers (HCW) are at the front line of the COVID-19 pandemic [1] because of their direct contact with both infected and asymptomatic clients in the hospital environment. Compared to non-healthcare workers, health professionals have the highest occupational hazards, risks, and exposure to contracting the coronavirus [3, 4]. The incidence of HCWs contracting coronavirus has been reported in different settings [5, 6, 7, 8, 9]. Recent estimates provided by the Centers for Disease Control indicate that approximately 9,282 HCWs in the United States have been infected with COVID-19 [6]. Gomez-Ochoa and colleagues in their systematic review and meta-analysis of the prevalence of COVID-19 among HCWs found the estimated prevalence of SARS-COV-2 infection to be 11% from samples of HCWs with nurses being the most populous group of HCWs infected [5].

In Ghana, recent estimates by the Ghana Health Service (GHS) indicate a low infection rate of COVID-19 among HCWs than the population [10]. For instance, as of 15th April 2021, the incidence of COVID-19 cases in the population was 91,709 with 771 deaths. The Ghana Medical Association (GMA) and other health workers’ associations projected approximately 779 health workers to have contracted COVID-19 as of 30th June 2020 with 9 deaths [11]. Of this number, 190 were doctors, 410 were nurses and midwives, 156 comprised of different categories of health workers, and 23 pharmacists. As of 28th February 2021, this figure had increased to 900 infections with less than 50 mortalities.

Several factors account for HCWs inability to fully comply with the COVID-19 safety protocols instituted in health facilities. For instance, a Cochrane review conducted by Houghton and colleagues [12] to explore barriers and facilitators to HCWs adherence with IPC guidelines showed that, minimal support from management, insufficient isolation spaces, lack of quality and adequate personal protective equipment (PPE) and fear of patients being stigmatized when PPE were used accounted for difficulties in compliance to IPC guidelines. In Ghana, the GMA reports that inadequate and erratic supply of PPEs to HCWs both in quantity and quality, laxity in adherence to IPC guidelines, delay in COVID-19 tests and results and inadequate contact tracing within facilities accounts for the high infection rate among health workers [11]. Evidently, these conditions increase HCWs exposure and risk of COVID-19.

Recent empirical evidence on compliance with COVID-19 IPC among HCWs have been investigated [12, 13, 14, 15]. Other studies have also identified factors associated with preventive and adherence to IPC measures among HCWs [6, 16]. For example, Agarwal and colleagues [13] evaluated HCWs preventive practices during the coronavirus pandemic in India and found that age, gender, and occupational roles of HCWs were associated with the extent of adherence to IPC practices. Female HCWs above 31 years, nurses and senior doctors were more compliant to COVID-19 preventive behaviours compared to other categories of health workers. Lai and others [117] and Olum et al [18] reported similar findings from Agarwal’s study in their work. Ashinyo and colleagues [19] reported high compliance with hand hygiene, PPE use, and performance of aerosol generating procedures among health personnel at COVID-19 treatment centres in Ghana. However, lower compliance was found among non-clinical workers, HCWs who had inadequate PPEs, staff who had ever married, and pharmacists. Additionally, Ranjan and colleagues [15] found that resident doctors were at a lower risk of COVID-19 compared to the other HCWs.

The study builds on recently published studies of compliance to COVID-19 IPC practices among HCWs and fills the gap and dearth of empirical research by investigating healthcare workers’ perceptions of their risk of COVID-19. The study further investigates the association between adherence to COVID-19 safety guidelines and perceived risk of COVID-19. Our study is timely and relevant particularly in highlighting the plausible factors that significantly expose Ghanaian HCWs to occupational risks and infections during the provision of healthcare delivery in light of mitigation strategies to reduce the spread of transmission. We hypothesize that HCWs who are always compliant with hand hygiene practices at the workplace are less likely to perceive themselves at risk of COVID-19 compared to those HCWs who are not compliant with hand hygiene practices.

Methods

Setting

Four regions (Greater Accra, Ashanti, Central and Western) were purposively selected because they were the epicenters with the highest incidence of the coronavirus infections. For instance, as of 8th April 2021, Greater Accra Region (GAR) had recorded 50,241 cases; Ashanti 15,379; Western 5,717 and Central 3,294 [20].

Characteristics Of Participants And Sample Size

Eligible respondents included both clinical and non-clinical HCWs recruited from different health facilities. Clinical staff should be providing direct patient care in any department/unit of the hospital such as physicians, general registered nurses, midwives, pharmacists, laboratory technologists, and nurse aides or health assistants. On the other hand, non-clinical staff were personnel who did not directly provide patient care, example, administrative support staff. At the time of the study, they should not have been infected with COVID-19. The sample size was calculated using Cochran’s formula N = z² * p(1-p)/d² assuming a response rate of 50%, 95% confidence interval (CI), z of 1.96, and 5% margin of error. A further 10% was added to counteract any errors in completing the questionnaires, resulting in a final estimated sample size of 414.

Sampling

Non-probability sampling techniques were used to recruit potential participants - purposive, convenience and ‘chain referral’ techniques. The aim was to complement and facilitate ease of access to data collection. For instance, the ‘chain referral’ sampling strategy was purposed at reaching several other HCWs indirectly in the specified regions through peer and social networks, and groups. We anticipated that given the double burden of work (including shift system schedules) at this time, they may not be easily accessible to participate in the study, hence, these multiple sampling procedures.

Instrumentation

We designed and pre-validated a questionnaire based on HCWs background characteristics, and compliance with IPC practices which included: hand hygiene, PPE use (face masks), social distancing, and disinfection practices at the workplace. These four main IPC practices are the most basic yet importantly observed IPC measures observed by all categories of health workers in health facilities globally. The questionnaire comprised of 19 items with two sections: section A focused on participants background details such as age, sex, marital status, number of living children, highest educational level (completed), religious affiliation, category/type of HCW, number of years since being employed, type of health facility, and region of workplace. Section B consisted of eight items on compliance with hand hygiene practices, wearing of PPE (face masks), social distancing, and disinfection practices at the workplace (Table 2). The internal consistency with Cronbach’s alpha coefficient on the eight-item compliance measures was 0.80.

Measures

The outcome variable was perceived risk of COVID-19. It was measured as a dichotomous variable: 1 = Yes, and 0 = No. The explanatory or predictor variables were the level of compliance constructs assessed by eight items. These items focused on hand hygiene, wearing of face masks, social distancing, and disinfection practices. These items were assessed on a three-point scale from Not compliant at all = 0, Sometimes compliant = 1 and Always compliant = 2. The control variables were age, sex, marital status, highest educational level, religious affiliation, category/type of HCW, number of years since being employed, type of health facility, and region of workplace. Questions on the frequency of COVID-19 tests, and ever tested for COVID-19 were included.

Ethical Consideration

This study is part of a larger study on HCWs knowledge, attitude and perceived vulnerability to COVID-19 and the likelihood of contracting COVID-19. It was approved by the University of Ghana Ethics Committee for the Humanities (ECH016/20–21) and the Ghana Health Service Ethics Review Committee (GHS-ERC 012/08/20). All ethical principles and considerations in the study were in accordance with the Declaration of Helsinki. Informed consent (mostly written) was obtained from all the study participants for the paper-based questionnaires while a statement of informed consent was included in the Google form prior to starting the questionnaire.

Results

<<<<<<<<<<<< Insert Table  1 >>>>>>>>>

Results Of Bivariate Analysis

We performed bivariate analysis with chi-square tests to identify the factors associated with HCWs perceived risk of COVID-19. Two variables were excluded during the analysis- marital status and religious variables because of missing values. The results in Table 3 showed that health workers’ age, years in service, category/type of HCW (clinical/non-clinical), region of workplace, ever tested for COVID-19, and frequency of COVID-19 test were significantly associated with HCWs perceived risk of COVID-19 at p < 0.05.

<<<<<<<<<<<<< Insert Table  3 >>>>>>>>>>>>>>>>>>>>>

The results showed that, years in service, category/type of HCW, region of HCWs workplace, type of health facility, and frequency of COVID-19 test were significantly associated with HCWs perceived risk of COVID-19 at p < 0.05. Our results showed that health workers who had spent seven and more (7+) years since being employed were as four times more likely as those who had spent less than a year in service to perceive the risk of COVID-19 (OR = 4.62 95%CI = 1.549–13.802). Compared to clinical workers, non-clinical HCWs perceived a lower risk of COVID-19 (OR = 0.46 95%CI = 0.286–0.734). HCWs working in government hospitals were as likely as HCWs in CHAG health facilities to perceive the risk of infection (OR = 1.97 95%CI = 1.059–3.659). We found that, compared to health workers in the Ashanti region, HCW in the Greater Accra region were two times more likely to perceive that they could become infected with COVID-19 (OR = 2.05 95%CI = 1.102–3.839). There was a strong association between the frequency of COVID-19 test and HCWs perceived risk of COVID-19 at p < 0.05. HCWs who had tested once for COVID-19 perceived themselves as having a lower risk of becoming infected compared to HCWs who had tested twice and more (OR = 0.49 95%CI = 0.262–0.942).

Regarding compliance with COVID-19 safety guidelines, only hand hygiene practices significantly predicted HCWs perceived risk of COVID-19 at p < 0.05. The results showed that, health workers who sometimes complied with hand hygiene practices as well as those who were not compliant at all had a lower likelihood to perceive getting infected compared to those health workers who always adhered to hand hygiene practices (OR = 0.39 95%CI = 0.184–0.830; OR = 0.47 95%CI = 0.245–0.892). This result suggests that our hypothesis that HCWs who always adhere to hand hygiene practices are less likely to perceive themselves at risk of COVID-19 compared to HCWs who are non-compliant with hand hygiene practices is not supported.

Discussion

This cross-sectional study was conducted among HCWs to examine their compliance with COVID-19 protocols at the workplace as well as the association between compliance to COVID-19 protocols and perceived risk of COVID-19. The study also investigated the factors associated with health workers perceived risk of COVID-19. The results showed that HCWs were highly compliant with hand hygiene practices and wearing face masks when providing patient care at the workplace (or health facility). We find that these findings echo similar results in recent studies conducted by Ashinyo et al [19] and Agarwal [13] while Kassie and colleagues [14] found contrary results. This result suggests that health workers probably prioritize these infection preventive measures as more effective in minimizing the transmission of the coronavirus; hence, the high adherence practices. Further, it is likely that health workers find it relatively less difficult to observe hand hygiene practices and wearing face masks than disinfecting frequently shared items and maintaining social distance. Adherence to infection prevention is critical since suboptimal IPC measures have been found to be risk factors of COVID-19 [6, 16] and which could lead to hospital acquired infections. On the other hand, health system factors, behavioural characteristics, and availability of PPE could account for health workers’ moderate adherence with social distancing and disinfection practices at the hospital such as difficulty in providing care while socially distanced, limited, or insufficient space within the ward.

Our results also showed that HCWs working in the Greater Accra Region (GAR) perceived a greater risk of becoming infected compared with other healthcare workers in the Ashanti and Central regions (OR = 2.05, 95%CI = 1.102–3.839, p < 0.023). Several factors and explanations can be adduced for this finding. First, GAR is the epicentre of COVID-19 with the highest prevalence of COVID-19 infections in the country as of 19th April 2021 [10]; second, the health worker population distribution in the country is skewed to the GAR with a high proportion of health professionals (both clinical and non-clinical) working in the GAR [22]; third, the majority of public health facilities are concentrated in the GAR and Ashanti regions than the other regions in the country as well as other private, and faith-based hospitals. Thus, government hospitals record a high attendance of the insured and non-insured population for a wide range of health care services. Essentially, for HCWs working in the GAR of Ghana, all these myriad factors underscore their constant exposure to the risks of contracting COVID-19 since they more often provide health care for many possibly infected clients daily.

The study found that health workers working in government health facilities were as likely to perceive the risk of becoming infected compared to those working in CHAG and quasi-government hospitals (OR = 1.97 95%CI = 1.059–3.659 p < 0.032). The choice of receiving health care from government health facilities is based on many factors: availability of specialized services, geographical access and proximity, cost issues specifically related to insurance package for selected medical services, and referral services. Since the pandemic, selected government-owned health facilities were designated for COVID-19 testing, treatment, isolation, and management of cases. In addition, inadequate supply and unavailability of PPE were reported in such facilities and therefore increased HCW susceptibility to the risk and exposure to HCWs contracting the virus from possibly infected and asymptomatic individuals visiting such hospitals.

We also found a statistically strong association between the type of HCW and perceived risk of COVID-19. Compared to non-clinical staff, clinical HCWs (such as physicians, nurses, midwives, allied health staff and laboratory technologists) were as likely to perceive the risk of becoming infected (OR = 0.46 95%CI = 0.286–0.734 p < 0.001). During patient care delivery, exposure to infected patients are unavoidable; except when strict observance to infection prevention is adhered with to minimize the exposure and transmission of the virus. Clinical health professionals are directly involved in providing care to clients/patients daily and this places them at the ‘front line’ of contracting any type of infection when appropriate patient care procedures are not adhered to. As reported in other contexts, physicians, and nurses are characterized as having critical and essential roles in healthcare delivery, thus making them frontline staff [1]. Since the first cases of COVID-19 was recorded in Ghana, there has been no clear consensus on who a frontline HCW is despite the pre-existing roles and contributions played by all health workers in the country’s health sector in mitigating the effects of the pandemic.

The results of the study further showed a significant relationship between compliance with hand hygiene practices and perceived risk of COVID-19 at p < 0.05. HCWs who were sometimes compliant and not compliant at all with hand hygiene practices were less likely to perceive a risk of becoming infected compared to those HCWs who were always compliant with hand hygiene practices (OR = 0.39 95%CI = 0.184–0.830; OR = 0.47 95%CI = 0.245–0.892). While this finding was not expected, it is supported by other studies which found HCWs practicing suboptimal handwashing practices, improper use, and reuse of PPE, and working in high-risk department as critical risk factors for infection [6, 19]. Generally, with regards to the four aspects of infection prevention practices examined in our study, the results suggests that adherence to hand hygiene practices alone is not a sufficiently protective measure against transmission of the coronavirus. It is possible that health workers who always adhered to hand hygiene practices did so because of the nature of their work (for instance, being in a high-risk department, continuous exposure to direct patient care) and which they felt increased their susceptibility to getting infected. Also, multiple factors could have mitigated against adherence to hand hygiene preventive practices such as fatigue, forgetfulness, apathy, negligence, and inadequate PPE as has been reported in studies elsewhere [12, 13].

Our study has a few limitations. First, like other studies which employed online-based data collection procedures, and given the non-probability sampling techniques, generalizations of the findings are limited. Second, some potentially mediating variables were excluded during the statistical modelling such as HCWs knowledge and awareness of the transmission of COVID-19, symptoms of COVID-19, average number of patients attended to daily, access to and availability of PPE.

Conclusions

Poor preventive behaviours and suboptimal compliance to COVID-19 guidelines at the health facility during patient care increases HCWs risk of the coronavirus. The results of our study imply that health system factors mostly contribute to influence HCWs risk of COVID-19 compared to individual factors. While these risk factors increase health professionals’ vulnerability to the coronavirus, effective communicative strategies, management support, training and behavioural change mechanisms are necessary to enforce health workers’ compliance with COVID-19 protocols. Future research could qualitatively explore HCWs barriers to non-compliance to COVID-19 safety guidelines. In addition, other researchers could design an experimental study on HCWs who have contracted and recovered from COVID-19 with HCWs who are not infected but perceive the risk of infection and the associated risk factors.

Abbreviations

CHAG Christian Health Association of Ghana

GAR    Greater Accra Region 

GHS    Ghana Health Service

GMA   Ghana Medical Association

HCW   Healthcare worker

PPE     Personal Protective Equipment 

Declarations

Ethics approval and consent to participate

The study was approved by the University of Ghana Ethics Committee for the Humanities (ECH016/20-21) and the Ghana Health Service Ethics Review Committee (GHS-ERC 012/08/20). Written consent was obtained from all study participants for the paper-based questionnaires while a statement of consent was included in the Google form prior to starting the questionnaire.

Consent for publication

Not applicable

Availability of data and materials

The datasets used and/analysed during the current study are available from the corresponding author on reasonable request. 

Competing interests

“The authors declare that they have no competing interests”.

Funding 

The authors did not receive any funding for this study.

Author’s contributions

 EAK conceptualised the study and DOB, GAA and NNAA designed the methodology and collected data for the study. EAK and DOB executed the statistical analysis. EAK drafted the manuscript. DOB, GAA and NNAA reviewed and revised the manuscript. All authors read and approved the final manuscript.   

Acknowledgements 

The authors are grateful to the management of the various health facilities and all health workers who participated in the study. 

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