Healthcare workers’ compliance with COVID-19 preventive and control measures at De Martino Hospital, Mogadishu, Somalia: a cross-sectional study

doi:10.21203/rs.3.rs-4232936/v1

Background

Healthcare workers are a high-risk group for COVID-19 and protecting them is crucial for healthcare delivery. Limited studies have explored compliance with infection prevention and control (IPC) practices among Somali healthcare workers. This study aimed to determine compliance with IPC practices among healthcare workers in De Martino Public Hospital, Somalia.

Methods

A cross-sectional study was conducted at De Martino Public Hospital, Mogadishu, Somalia from August to October 2022, with the participation of 204 healthcare workers (response rate = 97%). Compliance was assessed using responses to 25 questions on a five-point Likert-type scale, and a median score of 20 was used to dichotomize compliance scores. A chi-square test and logistic regression analysis were performed to check the associations between healthcare workers’ sociodemographic information, related factors to IPC, work conditions and practices on COVID-19, and IPC compliance during healthcare interventions using SPSS 23 version.

Results

In total, 58.3% of the participants had good compliance with IPC. There were significant associations between IPC compliance and the type of healthcare worker (doctors and doctor assistants: 72.3%, nurses and paramedical staff: 67.3%, non-clinical staff: 5.7%, p < 0.01). After adjusting for potential confounding factors, compared to non-clinical staff, doctors and doctor assistants (OR: 12.11, 95% CI: 2.23–65.84) and nurses and paramedical staff (OR: 21.38, 95% CI: 4.23–108.01) had higher compliance with infection prevention and control measures. There were no significant associations between compliance and sex, marital status, vaccination status, or smoking (p > 0.05 for all).

Conclusions

Inadequate compliance with COVID-19 IPC measures was observed among hospital workers. Prioritizing awareness campaigns and behavior change interventions, especially among non-clinical staff, is crucial for effective COVID-19 infection prevention and control within hospitals.

Compliance

Healthcare workers

COVID-19 prevention and control

Hospital

The COVID-19 pandemic was the most recent and worst pandemic in the 21st century, and resulted in 765 million confirmed cases and 6.9 million deaths worldwide as of May 3, 2023 [1].

This highly infectious virus can be transmitted by asymptomatic carriers and those in the incubation period, making isolation until testing negative crucial [2]. Quarantine measures are essential for persons from endemic areas or with confirmed contact and for mild cases not requiring medical attention [3]. All age groups are susceptible to the virus, but elderly people with underlying health conditions are at greater risk of severe illness [4]. Healthcare workers (HCWs) are also vulnerable, emphasizing the importance of infection prevention and control (IPC) practices and personal protective equipment (PPE) use [5].

IPC strategies include non-pharmaceutical interventions such as school and workplace closures, event bans, stay-at-home orders, and movement restrictions, which have reduced transmission [6]. Personal protective measures are also an important component of COVID-19 infection prevention and control [7]. Vaccines have been developed, but their effectiveness varies by variant, with better protection against severe outcomes. Vaccine effectiveness against symptomatic disease was greater for the delta variant than for the omicron variant. With previous variants, vaccine effectiveness against severe disease, including hospitalization and death, has been higher and retained for longer than effectiveness against mild disease [8].

The World Health Organization (WHO) declared that COVID-19 is an emergency public health problem of international concern that posed a high risk to countries with vulnerable health systems on January 30, 2020 [9]. Although the Director General of the WHO declared the end of COVID-19 as a public health emergency and is no longer a global threat on May 5th 2023, he said that COVID-19 is still killing and warned of the risks from the new emerging variants [10]. In fragile settings like Somalia where the number of HCWs is significantly lower than that required for Sustainable Development Goals, the protection of health workers is vital [11]. To protect HCWs, Enough supplies of PPE should be ensured and HCWs should be trained in using it. The environmental hygiene of hospitals and the personal hygiene of HCWs should be maintained [2]. HCWs should maintain contact reduction to reduce the number of infections [7].

It was reported from China that the potential risk of COVID-19 has largely improved the IPC behaviors of HCWs working in hospitals [12]. Determination of the compliance of hospital workers with the COVID-19 IPC practices and the factors affecting this compliance is important for the protection of hospital workers during the pandemic. Studies assessing COVID-19 IPC practices in Somali hospitals and HCWs are limited. This cross-sectional study assessed COVID-19 IPC compliance among HCWs at De Martino Public Hospital during healthcare interventions and determined the factors affecting compliance to improve hospital workers’ compliance with COVID-19 IPC practices.

This hospital-based cross-sectional study aimed to assess COVID-19 IPC compliance among HCWs at De Martino Public Hospital during healthcare interventions and to determine the factors affecting their compliance. De Martino Public Hospital is located in Mogadishu, Somalia’s capital. It was built during Italy’s colonial era and is currently under the control of the Ministry of Health and Human Services of the Federal Government of Somalia. It provides free medical care, especially for inpatients. During the COVID-19 pandemic, the hospital exclusively served COVID-19 patients. The hospital has 115 beds and offers a range of services, including polyclinics, inpatient care, emergency services, and intensive care.

In 2019, there were a total of 61 health facilities run by the government in the Benadir region, which encompasses the capital city [13]. De Martino Hospital in this region serves as a secondary referral hospital (RH) indicating its role in providing specialized care. It’s important to note that while RHs like De Martino Hospital offer valuable specialist services, they may face challenges in meeting the extensive demand due to limited capacity and resources [14]. During the COVID-19 pandemic, De Martino Hospital emerged as a key center for managing COVID-19 cases, playing a vital role in the national response. This underscores its importance in addressing public health challenges, even during unprecedented events like a global pandemic.

Study population and sample size

The study population is 210 HCWs working at De Martino Hospital between August and November 2022. HCWs include all hospital staff who provide health services directly or indirectly, such as managers, secretaries, doctors, nurses, laboratory technicians, radiologists, pharmacists, cleaners, security personel, or other personnel. All HCWs working in the hospital were included in the study. In total, 204 HCWs were reached during data collection in the study and their informed consent was obtained using a written form.

The study variables

To assess HCWs’ compliance with COVID-19 prevention and control practices (IPC), the use of personal practices during their healthcare interactions in the hospital was measured using a self-report questionnaire. Accordingly, the questionnaire was created under three main headings; personal protective equipment (PPE), hand washing and hygiene (HH) and other COVID-19 IPC practices. The data on personal characteristics, related factors to IPC, work conditions and practices on COVID-19 were also included in the questionnaire. The questionnaire was adapted from the WHO’s risk assessment tool for healthcare workers in the context of COVID-19 [15], with some modifications according to the suitability of the hospital facility and using literature guidelines. The questionnaire is attached as "Supplementary file 1".

The anonymity and confidentiality of the participants were ensured; a specific number was given to every questionnaire, and there was no information that could identify individual participants during or after data collection. A pilot study was conducted initially; then, the questionnaire was distributed to the hospital staff and the data were collected between August and November 2022. There were 25 questions measuring the compliance of HCWs with COVID-19; 12 questions for PPE, 7 questions for HH and 6 questions for other COVID-19 IPC IPC on the questionnaire. Responses to each question were measured using a 5-point Likert scale: "always (5 points), often (4 points), sometimes (3 points), rarely (2 points), or never (1 point)". The scores of each person’s responses were categorized into two categories and the answers "always" and "most of the time" were taken as compliance. Then, the compliance responses of each participant were summed and the median was taken into account as the cut-off point; scores above the median were considered “high compliance”.

Data analysis

For descriptive analyses, the variables measured by scale values were converted into categorical ones, and all independent variables are presented as percentages. To determine the association between independent variables and high compliance with the COVID-19 IPC measures, the chi-square test was used by converting the scores of compliance with the COVID-19 IPC measures into two categories, and the answers "always" and "most of the time" were taken as “compliance”. Then, the compliance responses of each participant were collected and the median was considered the cut-off point. Scores above the median were considered “high compliance” and presented by percentage for descriptive analysis.

To identify the key independent factors associated with a high level of compliance with COVID-19 IPC measures, variables that showed significant associations with high compliance in univariate analyses were included in logistic regression models. The backward LR method was used to identify predictive variables associated with compliance with IPC measures and the association was presented with odds ratio and 95% confidence interval.

The Statistical Package for Social Sciences (SPSS 23) was used for the data analysis. P values lower than 0.05 were considered significant.

In total, data from 204 HCWs were analyzed, achieving a response rate of 97%. Among the participants, 51% were male (Table 1, column 4). The majority of HCWs (46.1%) fell in the 20 to 29 age group, while only 15.7% were aged 40 and above (Table 1, column 5). Approximately, 77.8% held bachelor’s degrees or higher (Table 1, column 6). Nurses and paramedical staff constituted the largest group (51%), followed by (31.9%) doctors and doctor assistants (Table 2, column 4). Outpatient workers accounted for 20.1% of the participants, while inpatient workers made up 26.5%. HCWs in other clinical departments comprised 29.9% of the total (Table 2, column 5).

Table 1

COVID-19 IPC compliance in HCWs during healthcare provision by sociodemographic characteristics and related factors to IPC
Independent variables	n	%	COVID-19 IPC compliance
			Total IPC%		PPE use%		HH%		Other IPC%
			High	p*	High	p*	High	p*	High	p*
Sex Male Female	105 98	51.7 48.3	60 56.1	0.58	61 51	0.15	55.2 55.1	0.98	52.4 51.0	0.85
Age group 20–29 30–39 40 and above	94 78 32	46.1 38.2 15.7	62.6 61.5 37.5	0.03	59.6 59 37.5	0.07	62.8 55.1 34.4	0.02	57.4 44.9 53.1	0.26
Education level -Secondary degree and below -Associate degree -Undergraduate and graduate degrees	23 22 158	11.3 10.8 77.8	8.7 54.5 66.5	< 0.01	13 50 63.3	< 0.01	8.7 45.5 63.9	< 0.01	26.1 54.5 55.7	0.03
Experience years 1–5 6–10 11 and above	118 59 20	59.9 29.9 10.2	58.5 64.4 50	0.50	57.6 59.3 45	0.52	58.5 57.6 45	0.53	55.9 45.8 50	0.43
Marital status Married Unmarried Divorced/Widow	102 16 84	50.5 7.9 41.6	57.8 56.3 59.5	0.96	55.1 50 59.5	0.66	53.9 64.3 57.1	0.91	50 31.3 58.3	0.12
Having a child Yes No	107 94	53.2 46.8	57.9 58.5	0.94	55.1 57.4	0.74	54.2 57.4	0.64	47.7 57.4	0.17
Training on COVID-19 Yes No	171 33	83.8 16.2	61.4 42.4	0.04	59.1 39.5	0.04	56.9 51.5	0.63	53.2 45.5	0.41
COVID-19 information From official sources From social media	85 113	42.9 57.1	48.2 67.3	0.01	41.2 69	< 0.01	40 69	< 0.01	43.5 60.2	0.02
COVID-19 infection Yes No Unknown	95 46 63	46.6 22.5 30.9	66.3 41.3 58.7	0.02	62.1 26.2 60.3	0.01	58.9 39.1 61.9	0.04	50.5 47.8 57.1	0.59
COVID-19 Vaccination Yes No	180 24	88.2 11.8	59.4 50	0.38	57.2 45.8	0.29	56.7 45.8	0.32	50.6 62.5	0.27
Vaccination doses 0 1 2 and above	24 56 124	11.8 27.5 60.8	50 48.2 64.5	0.08	45.8 55.3 58.1	0.54	45.8 55.4 57.3	0.59	62.5 42.9 54	0.21
Smoking cigarette Yes No	33 168	16.4 83.6	48.5 60.1	0.22	48.5 57.1	0.36	39.4 58.3	0.05	36.4 54.8	0.05
An old /chronic patient in the family Yes No	103 96	50.8 48.2	52.5 63.5	0.11	52.4 58.3	0.40	50.5 59.4	0.21	50.5 54.2	0.60
*Chi square test

Note: N: Number of participants, IPC: Infection Prevention and Control, PPE: Personal Protective Equipment, HH: Hand Hygiene.

Table 2

COVID-19 IPC compliance in HCWs during healthcare provision by working conditions and practices on COVID-19
Independent variables	n	%	COVID-19 IPC compliance
			Total IPC%		PPE use%		HH%		Other IPC%
			High	p*	High	p*	High	p*	High	p*
Profession Doctors and doctor assistants Nurses and Paramedical staff Non-clinical staff	65 104 35	31.9 51 17.2	72.3 67.3 5.7	< 0.01	66.2 66.3 5.7	< 0.01	70.8 60.2 11.4	< 0.01	46.2 61.5 34.3	0.01
Department Outpatient Inpatient Other clinical departments Non-clinical departments	41 54 61 48	20.1 26.5 29.9 23.5	68.3 70.4 70.5 20.8	< 0.01	65.9 64.8 70.5 18.8	< 0.01	65.9 62.9 70.5 18.8	< 0.01	46.9 53.7 59 45.8	0.47
Direct COVID-19 care Yes No Unknown	109 56 39	53.4 27.5 19.1	67.9 37.5 61.5	< 0.01	66.1 30.4 64.1	< 0.01	62.4 35.7 64.1	< 0.01	49.5 51.8 59	0.60
Face-to-face contact with COVID-19 patient Yes No Unknown	109 63 30	53.9 31.2 14.9	75.2 31.7 53.3	< 0.01	72.5 28.6 53.3	< 0.01	68.8 33.3 53.3	< 0.01	54.1 50.8 50	0.88
Direct contact with COVİD-19 environment Yes No Unknown	95 66 41	47 32.7 25.3	69.5 41 58.5	< 0.01	70.5 33.3 56.1	< 0.01	57.9 45.5 63.4	< 0.14	52.6 47 58.5	0.50
Presence at AGP performance Yes No Unknown	112 76 13	55.7 37.8 6.5	82.1 27.6 30.8	< 0.01	77.7 26.3 38.5	< 0.01	78.6 31.6 7.7	< 0.01	56.3 44.7 53.8	0.30
Type of AGP procedure -Not applicable -Open airway aspiration +Sputum collection +Tracheotomy -Tracheal intubation +Cardiopulmonary resuscitation -Nebulizer treatment -More than one	89 12 25 42 32	44.5 6 12.5 21 16	28.1 83.3 84 73.8 93.8	< 0.01	28.1 83.3 80 69 84.4	< 0.01	28.1 83.3 80 69 90.6	< 0.01	46.1 50 60 50 65.6	0.36
*Chi square test

Note: N: Number of participants, IPC: COVID-19 Infection Prevention and Control, PPE: Personal Protective Equipment, HH: Hand Hygiene, HCW: Healthcare Worker, AGP: Aerosol Generating Procedure.

Compliance with COVID-19 IPC practices among healthcare workers

The total IPC compliance rate was 58.3% among the participants. HCWs demonstrated 55.9% compliance with PPE during healthcare interactions, 55.4% compliance with HH, and 52% compliance other COVID-19 IPC measures during healthcare interactions (Fig. 1).

Figure 1. COVID-19 IPC compliance in the HCWs (total IPC, PPE use, HH, other IPC), %

Note

IPC: infection prevention and control, PPE: personal protective equipment, HH: hand hygiene.

Age and educational status were significantly associated with overall COVID-19 IPC and HH compliance (P < 0.05 for all). Educational status was associated with compliance with PPE (p < 0.01) and other COVID-19 IPC measures (p = 0.03). Younger age groups and higher education level groups expressed better compliance (Table 1). There was no association between any of the IPC, PPE, HH compliance and marital status, having a child at home, having an old/chronic disease patient at home, or having COVID-19 vaccination. There was no significant association between the IPC dimensions and work experience years (Table 1). Participants who received training on COVID-19 reported higher compliance with total IPC and PPE than those who did not receive training (p < 0.05).

There was a significant association between the type of HCW and overall compliance with COVID-19 IPC, PPE and HH; non-clinical staff members showed significantly lower levels of compliance for all three dimensions (p < 0.01 for all). The same pattern was observed in the departments where HCWs worked; non-clinical departments showed lower compliance (p < 0.01 for all). HCWs not providing direct care to COVID-19 patients, not having face-to-face contact, and not being present during the AGP performance reported lower compliance (p < 0.01 for all). HCWs not having direct contact with the COVID-19 environment reported lower compliance in total IPC and PPE use (p < 0.01 for all). There was no significant association with any of the working conditions or practices on COVID-19 and compliance with other IPC measures except the type of HCW (p = 0.01) (Table 2).

In the logistic regression model, profession, having training on COVID-19, providing direct care to COVID-19 patients and presence when performing AGP were independent factors associated with total IPC compliance among HCWs. Doctors and doctor assistants and nurses and paramedical staff expressed a higher level of compliance with overall IPC compared to non-clinical staff (Doctors OR: 12.11, 95% CI: 2.23–65.84, nurses and paramedical staff OR: 21.38, 95% CI: 4.23–108.01). HCWs who received training on COVID-19 exhibited higher COVID-19 compliance than those who did not (OR: 3.48, 95% CI: 1.06–11.35). HCWs who were present when AGPs were performed exhibited higher compliance compared to those uncertain about that (OR: 12.45, 95% CI: 12.16–71.76) (Table 3).

Table 3

Independent determinants of COVID-19 IPC compliance in HCWs during healthcare provision: Results of multivariate logistic regression analysis* (Backward elimination method)
	COVID-19 IPC compliance
Variables in the model	Total IPC OR (95% CI)	PPE use OR (95% CI)	HH OR (95% CI)	Other IPC OR (95% CI)
Profession
Doctors & doctor assistants	12.11 (2.23–65.84)	11.59 (1.94–69.01)	-	1.35 (0.56–3.24)
Nurses & paramedical staff	21.38 (4.23–108.01)	17.91 (3.22–99.64)	-	2.59 (1.13–5.93)
Non-clinical staff	Ref.	Ref.	-	Ref.
Department
Inpatient	-	-	4.97 (1.62–15.21)	-
Other clinical departments	-	-	6.2 (2.1–18.35)	-
Outpatient	-	-	4.21 (1.34–13.23)	-
Non-clinical departments	-	-	Ref.	-
COVID-19 material
From official sources	-	0.38 (0.17–0.83)	0.45 (0.22–0.92)	-
From social media	-	Ref.	Ref.	-
Direct COVID-19 care
Provide	0.26 (0.07–0.98)	1.02 (0.38–2.76)	-	-
Unknown	0.9 (0.2–3.99)	4.10 (1.12–15.03)	-	-
Does not provide	Ref.	Ref.	-	-
Face-to-face contact with COVID-19 patient
Have	1.5 (0.27–8.07)	-	1.06 (0.32–3.51)	-
Does not have	0.37 (0.07–1.98)	-	0.4 (0.12–1.33)	-
Unknown	Ref.	-	Ref.	-
Direct contact with COVID-19 environment
Have	-	2.59 (0.88–7.6)	-	-
Does not have	-	1.08 (0.36–3.23)	-	-
Unknown	-	Ref.	-	-
Presence at AGP performance
Present	12.45 (2.16–71.76)	4.36 (0.8–23.79)	-	-
Not present	1.59 (0.3–8.21)	0.7 (0.13–3.52)	-	-
Unknown	Ref.	Ref.	-	-
Training on COVID-19
Received	3.48 (1.06–11.35)	2.66 (0.93–7.66)	-	-
Did not receive	Ref.	Ref.	-	-
Education level
Undergraduate and graduate degrees	-	-	8.48 (1.64–43.94)	-
Associate degree	-	-	3.67 (0.56–24.04)	-
Secondary degree and below	-	-	Ref.	-
*Variables included in the logistic regression model
For the total COVID-19 IPC: age group, education, receiving training, source of COVID-19 information, covid infection, type of HCW, type of department, providing direct COVID-19 care, Having face-to-face contact with COVID-19 patients, having direct contact with the COVID-19 environment, presence at AGP performance and type of AGP.
For PPE: education, training, source of COVID-19 information, covid infection, Type of HCW, Type of department, providing direct COVID-19 care, having face-to-face contact with COVID-19 patients, having direct contact with the COVID-19 environment, presence at AGP performance and type of AGP.
For HH: age group, education, source of COVID-19 information, COVID-19 infection, type of HCW, type of department, providing direct COVID-19 care, having face-to-face contact with COVID-19 patients.
For Other COVID-19 IPC: education, source of COVID-19 information, Type of HCW.

Note: IPC: Infection Prevention and Control, OR: Odds Ratio, CI: Confidence Interval, PPE: Personal Protective Equipment, HH: Hand Hygiene, AGP: Aerosol Generating Procedure.

For PPE; profession, the source of COVID-19 material and providing direct care to COVID-19 patient were independent factors. Compliance with PPE showed significant differences among HCWs in various roles. Doctors and doctor assistants (OR: 11.59, 95% CI: 1.94–69.01) and nurses and paramedical staff (OR: 17.91, 95% CI: 3.22–99.64) exhibited higher compliance compared to non-clinical staff. HCWs who accessed COVID-19 information from official sources expressed lower compliance compared to those who accessed information from social media (OR: 0.38, 95% CI: 0.17–0.83) (Table 3).

For HH, departments where HCWs worked, source of COVID-19 material and education level were independent factors. Clinical departments showed higher compliance compared to non-clinical departments (inpatient OR: 4.97, %95 CI: 1.62–15.21, outpatient OR: 4.21, %95 GA: 1.34–13.23, other clinical departments OR: 6.2, %95 GA: 2.1–18.35). HCW participants who read COVID-19 related material from Official sources reported lower compliance than those who read from social media (OR: 0.45, 95% CI: 0.22–0.92) (Table 3).

For Other IPC compliance, profession was the only predictor. Nurses and paramedical staff expressed higher compliance compared to non-clinical staff (OR: 2.59, 95% CI: 1.13–5.93) (Table 3).

This study was designed to assess COVID-19 IPC compliance among HCWs during healthcare interventions and to determine the factors affecting compliance. The study showed that 58.3% of HCWs had high compliance with COVID-19 IPC measures during healthcare interventions. The compliance was over 50% in all domains (PPE use, HH, and other IPC). Non-clinical staff had lower compliance compared with clinical staff.

There are several studies that reported high compliance with COVID-19 IPC among HCWs. In Ghana, a study with 424 HCWs in COVID-19 treatment centers reported high compliance with hand hygiene (88.4%) and PPE usage (90.6%) [16]. Two Ethiopian studies, involving 403 and 422 participants, reported good COVID-19 infection prevention practices in 64.3% and 63.5% of healthcare workers, respectively. The first study revealed 96.1% compliance with hand hygiene but only 45.2% compliance with PPE usage, possibly due to PPE availability, comfort, negligence, or education [17, 18].

Compared to previous studies, our findings indicated lower IPC compliance rates. This variance may be attributed to differences in study methods and the timing of data collection. While our study used compliance scores above the median for each domain, the referenced studies used either above-average scores or cutoff points of 60% or 75% of total compliance scores. It is also possible that healthcare workers’ adherence to IPC measures decreased over time since the pandemic’s onset. A study on healthcare worker HH practices revealed a 13.7% increase upon room exit during the initial COVID-19 wave. Compliance decreased by 9.9% post-lockdown but rebounded by 2.8% in the second wave [19].

Some studies have reported low HCW compliance with COVID-19 IPC measures. For instance, in a study involving 422 HCWs at COVID-19 referral hospitals in Ethiopia, overall compliance with COVID-19 prevention practices was only 22% [20]. In this study, only 63.4% of the participating HCWs received training on COVID-19, 58.2% read COVID-19 materials and 83.2% of the HCWs felt a shortage of appropriate PPE in the hospital.

A review identified various barriers to HCWs’ compliance with IPC guidelines for respiratory infectious diseases, including the availability of training programs, PPE supply, and individual factors such as knowledge, attitudes, beliefs, and PPE discomfort [21]. Additionally, a study conducted in Uganda; involving 657 HCWs at community hospitals, revealed that only 37.0% of participants had good COVID-19 IPC practices, despite high rates of mask usage and hand washing [22].

In our study, doctors, doctor assistants, nurses, and paramedical staff demonstrated higher COVID-19 IPC compliance than non-clinical staff, except in HH practices. This aligns with prior research. For instance, a study performed in private-not-for-profit community hospitals in Uganda revealed a significant association between clinical HCWs and good COVID-19 IPC practices [22]. Similarly, a study in COVID-19 treatment centers in Ghana revealed that non-clinical staff exhibited significantly lower compliance with hand hygiene and PPE usage compared to clinical staff [16].

The difference in compliance may be due to the higher risk faced by clinical healthcare workers in close contact with COVID-19 patients. A study from Somalia, reported that ancillary staff, including security workers and cleaners, have a higher infection risk due to lower knowledge and adherence to infection control measures when handling suspected COVID-19 patients. Healthcare assistants are often informally employed and receive less attention than formal employees such as doctors, nurses, and technologists [11].

Our study showed that HCWs who were present during AGPs exhibited higher compliance with overall IPC measures compared to those who were uncertain about that. Our study aligns with Ashinyo ME et al.’s study that reported high compliance with COVID-19 IPC protocols during AGPs [16]. Healthcare workers performing AGPs face a higher risk of COVID-19 infection, possibly explaining their heightened compliance [23].

Our study also showed that HCWs who had received training on COVID-19 exhibited higher COVID-19 compliance with overall IPC than those who did not. This is in line with 2 studies on 422 HCWs in Ethiopia; Etafa W. et al [20] and Arsemahagn MA [24], and a review study by Cooper S. et al. [25].

Interestingly, our study revealed that HCWs who obtained COVID-19 information from official sources showed lower compliance with PPE and HH compared to those who accessed information from social media. In contrast, a study on the Somali population reported the opposite, where HCWs who relied on social media for COVID-19 information exhibited lower compliance, likely due to misinformation [26]. However, De Martino HCWs may follow specific social media pages they trust for COVID-19 information.

To improve compliance, HCWs must receive continuous awareness and training in COVID-19 IPC guidelines. Policymakers should develop comprehensive programs to increase awareness among HCWs at all levels and provide the necessary equipment and supplies for effective IPC practices in healthcare settings.

This study has limitations. Firstly, there could be recall bias; because participants were asked about their compliance with COVID-19 IPC measures during the late stages of the pandemic when no COVID-19 patients were likely admitted, and some PPE like respirators, gowns, and face shields might not have been used. To minimize this bias, we asked about daily IPC practices and included specific questions for suspected or confirmed COVID-19 patients. Since the study was a single-center study, De Martino Public Hospital may not fully represent other pandemic hospitals in Somalia, although it plays a significant role in treating COVID-19 patients. Nonetheless, the inclusion of all staff members and the high response rate enhances the generalizability of the results within the hospital. Furthermore, the limited number of participants resulted in a wide confidence interval for the odds ratio derived from the model.

A notable portion of hospital workers reported inadequate compliance with COVID-19 IPC measures, with particularly low adherence among non-clinical staff. This lower compliance might be linked to their perception of low risk and a lack of awareness regarding COVID-19. It is essential to recognize that all HCWs hospitals are susceptible to COVID-19 infection. Therefore, prioritizing awareness campaigns and behavior change interventions, especially among non-clinical staff, is crucial for effective COVID-19 prevention and control within hospitals.

IPC: infection prevention and control

HCWs: healthcare workers

PPE: personal protective equipment

WHO: World Health Organization

RH: referral hospital

HH: Hand washing and Hygiene

Supplementary information
Supplementary file 1: Questionnaire for compliance of healthcare workers with COVID-19 prevention and control measures.docx: is the questionnaire used for data collection in English.

Acknowledgments
First, we would like to express our sincere gratitude to the managers of De Martino Hospital for allowing us to conduct our study at the hospital.

Second, we thank Dr. Lul Ahmed Abdi, Maternity Department, De Martino hospital who was the link person between us and the hospital administration. She also supported us in delivering the questionnaire papers to the hospital workers and collecting it after filling during the data collection process, since she works at the hospital and knows the hospital well.

Third, we extend our gratitude to the different groups of healthcare workers at De Martino hospital for participating in the study.

Funding

There is no funding support for this research.

Competing interests

The authors declare that they have no competing interests.

Ethics approval and consent to participate

The study received ethical approval from Dokuz Eylul University’s Non-Interventional Research Ethics Committee (approval date: 17.08.2022, decision number: 2022/26-08) and adhered to the principles of the Declaration of Helsinki and local institutional guidelines. Official permission was granted by De Martino Public Hospital in Mogadishu, Somalia. Research participants were informed about the study’s purpose and methodology, and their consent was obtained during the data collection process.

Consent for publication

Not applicable

Data availability

All data generated or analyzed during this study are included in this published article and its supplementary information files.

Author contributions

All authors (AIJ, BK, BU) contributed equally to the conception and design of the research, data collection, data analysis, data interpretation and creating the manuscript. All authors revised the manuscript and approved the final version of the article.

World Health Organization. WHO Coronavirus (COVID-19) Dashboard. Updated May 3, 2023 [Cited 2023, May 5]. Available from: https://covid19.who.int/
Yang Y, Peng F, Wang R, Guan K, Jiang T, Xu G, et al. The deadly coronaviruses: The 2003 SARS pandemic and the 2020 novel coronavirus epidemic in China. Journal of Autoimmunity, 2020;111:2-3. https://doi.org/10.1016/j.jaut.2020.102434
Lombardi A, Bozzi G, Mangioni D, Muscatello A, Peri AM, Taramasso L, et al. Duration of quarantine in hospitalized patients with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection: a question needing an answer. Journal of Hospital Infection, 2020; 105: 404. https://doi.org/10.1016/j.jhin.2020.03.003
Han Q, Lin Q, Jin S, You, L. Coronavirus 2019-nCoV: A brief perspective from the front line. journal of infection, 2020; 80 (4): 374. https://doi.org/10.1016/j.jinf.2020.02.010
Wang J, Zhou M, Liu F. Exploring the reasons for healthcare workers infected with novel coronavirus disease 2019 (COVID-19) in China. Journal of Hospital Infection, 2020; 105(1):100-101. https://doi.org/10.1016/j.jhin.2020.03.002
Li Y, Campbell H, Kulkarni D, Harpur A, Nundy M, Wang X, Nair H. The temporal association of introducing and lifting non-pharmaceutical interventions with the time-varying reproduction number (R) of SARS-CoV-2: a modeling study across 131 countries. The Lancet Infectious Diseases, 2021;21(2):193–200. https://doi.org/10.1016/S1473-3099(20)30785-4
Goyal R, Gautam RK, Chopra H, Dubey AK, Singla RK, Rayan RA, Kamal M.. Comparative highlights on MERS-COV, SARS-COV-1, SARS-COV-2 and NEO-COV. EXCLI Journal 2022;21:1260. https://dx.doi.org/10.17179/excli2022-5355
Andrews N, Stowe J, Kirsebom F, Toffa S, Rickeard T, Gallagher E, et al. Covid-19 Vaccine Effectiveness against the Omicron (B.1.1.529) Variant. The New England Journal of Medicine, 2022;386(16):1532-1541. DOI: 10.1056/NEJMoa2119451
Sohrabi C, Alsafi Z, O’neill N, Khan M, Kerwan A, Al-jabir A, et al. Review World Health Organization declares global emergency: A review of the 2019 novel coronavirus (COVID-19). International Journal of Surgery, 2020;76:71. https://doi.org/10.1016/j.ijsu.2020.02.034
United Nations. WHO chief declares end to COVID-19 as a global health emergency. Published May 5, 2023 [Cited 2023, May 7]. Available from: https://news.un.org/en/story/2023/05/1136367#:~:text=%E2%80%9CLast%20week%2C%20COVID%2D
19,the%20agency’s%20headquarters%20in%20Geneva.
Abdi A, Ahmed AY, Abdulmunima M, Karanjaa MJ, Solomona A, Muhammad F, et al. Preliminary findings of COVID-19 infection in health workers in Somalia: A reason for concern. International Journal of Infectious Diseases, 2021;104:735–736. https://doi.org/10.1016/j.ijid.2021.01.066
Deressa W, Worku A, Abebe W, Gizaw M, Amogne W. Risk perceptions and preventive practices of COVID-19 among healthcare professionals in public hospitals in Addis Ababa, Ethiopia. PLOS ONE, 2021;16(6):11-12. https://doi.org/10.1371/journal.pone.0242471
Warsame A. Somalia’s Healthcare System: A Baseline Study & Human Capital Development Strategy Heritage Institute for Policy Studies and City University of Mogadishu. Mogadishu; 2020. Pp. 39-41.
WHO Regional Office for the Eastern Mediterranean. Somalia health profile 2015, Egypt; 2017. Pp.23. Available from: https://iris.who.int/handle/10665/254906
World Health Organization. Risk assessment and management of exposure of health care workers in the context of COVID-19: Interim Guidance March 19, 2020. Pp.1-6. Available from: https://www.who.int/publications/i/item/WHO-2019-nCov-HCW_risk_assessment-2020.2
Ashinyo ME, Dubik SD, Duti V, Amegah KE, Ashinyo A, Asare BA, et al. Infection prevention and control compliance among exposed healthcare workers in COVID-19 treatment centres in Ghana: A descriptive cross-sectional study. PLOS ONE, 2021;16(3):16. https://doi.org/10.1371/journal.pone.0248282
Gebremeskel TG, Kiros K, Gesesew HA, Ward PR. Assessment of Knowledge and Practices Toward COVID-19 Prevention Among Healthcare Workers in Tigray, North Ethiopia. Frontiers of Public Health, 2021;9:1-8. doi: 10.3389/fpubh.2021.614321
Jemal B, Aweke Z, Mola S, Hailu S, Abiy S, Dendir G. Knowledge, attitude, and practice of healthcare workers toward COVID-19 and its prevention in Ethiopia: A multicenter study. SAGE Open Medicine, 2021;9:4. https://doi.org/10.1177/20503121211034389
Huang F, Armando M, Dufau S, Florea O, Brouqui P, Boudjema S. COVID-19 outbreak and healthcare worker behavioural change toward hand hygiene practices. Journal of Hospital Infection, 2021;111:27-31. https://doi.org/10.1016/j.jhin.2021.03.004
Etafa W, Gadisal G, Jabessa S, Takele T. Healthcare workers’ compliance and its potential determinants to prevent COVID-19 in public hospitals in Western Ethiopia. BMC Infectious Diseases, 2021;21(1):1-7. https://doi.org/10.1186/s12879-021-06149-w
Houghton C, Meskell P, Delaney H, Smalle M, Glenton C, Booth A, et al. Barriers and facilitators to healthcare workers’ adherence with infection prevention and control (IPC) guidelines for respiratory infectious diseases: a rapid qualitative evidence synthesis. Cochrane Database of Systematic Reviews, 2020;4(4):8-15. DOI: 10.1002/14651858.CD013582.
Kamacooko O, Kitonsa J, Bahemuka UM, Kibengo FM, Wajja A, Basajja V, et al. Knowledge, Attitudes, and Practices Regarding COVID-19 among Healthcare Workers in Uganda: A Cross-Sectional Survey. International Journal of Environtal Research and Public Health, 2021;18(13):1-10. https://doi.org/10.3390/ijerph18137004.
Harrison D, Muradalia K, El Sahlyb H, Bozkurtc B, Jneid H. Impact of the SARS-CoV-2 pandemic on health-care workers. Hospital Practice, 2020;48(4):162. DOI: 10.1080/21548331.2020.1771010
Asemahagn MA. Factors determining the knowledge and prevention practice of healthcare workers towards COVID-19 in Amhara region, Ethiopia: a cross-sectional survey. Tropical Medicine and Health, 2020;48:1-9. https://doi.org/10.1186/s41182-020-00254-3
Cooper S, Wiyeh A, Schmidt B, Wiysonge CS. Cochrane corner: factors that influence compliance by healthcare workers with infection prevention and control guidelines for COVID-19 and other respiratory infections. Pan African Medical Journal,2020;35(2):2. DOI: 10.11604/pamj.supp.2020.35.2.23012
Ahmed M, Fodjo J, Gele A, Farah A, Osman S, Guled I, et al. COVID-19 in Somalia: Adherence to Preventive Measures and Evolution of the Disease Burden. Pathogens, 2020;9(9):10. doi:10.3390/pathogens9090735

No competing interests reported.

BMCPublicHealthSupplementaryfile1Questionnaire.docx.docx

Healthcare workers’ compliance with COVID-19 preventive and control measures at De Martino Hospital, Mogadishu, Somalia: a cross-sectional study

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Abstract

Background

Methods

Results

Conclusions

Figures

Introduction

Methods

Study population and sample size

The study variables

Data analysis

Results

Compliance with COVID-19 IPC practices among healthcare workers

Discussion

Conclusions

Abbreviations

Declarations

References

Additional Declarations

Supplementary Files

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