Knowledge and preventive practices towards Covid-19 and associated factors among healthcare workers in selected health facilities of Illu Aba Bor and Buno Bedelle Zones, Southwest Ethiopia

The COVID-19 outbreak has been declared a public health emergency of international concern. As the virus is transmitted through close contact and droplets, frontline HCWs caring for COVID-19 patients are at risk of the infection. This study aimed at assessing knowledge and preventive practices towards Covid-19 among health care providers in selected health facilities of Illu Aba Bor and Buno Bedele zones, Southwest Ethiopia. An institution-based cross-sectional study was conducted from April to May 2020 among 330 health workers in selected health facilities of Illu Aba Bor and Buno-Bedelle Zones, Southwest Ethiopia. Data were collected using a self-administered structured questionnaire. The collected data were entered onto Epidata version 3.1 and exported to SPSS version 23 for analysis. Bivariate and multivariable logistic regression analysis was used to identify independent predictors of preventive practices towards Covid-19. Statistical signicance was declared at a p-value of < 0.05.

Province, when groups of pneumonia cases of unknown etiology were found to be associated with epidemiologically linked exposure to the seafood market and untraced exposures (2) According to the World Health Organization (WHO) daily situation report, after the coronavirus disease 2019 outbreak, 22,073 COVID-19 cases have been reported to the WHO as of April 2020 among healthcare workers (3). As of early March, this number increased to 3,300 and at least 22 died in China, over 2,600 infected with 13 deaths in Italy (4,5). Though the disease was initially slow to reach African countries, it is currently rising exponentially on the continent and is likely to cause severe illness and deaths (6). In Ethiopia, there have been 35 con rmed COVID-19 cases since the rst case on 13 March 2020 and the number increased to 117, as of April 24, 2020 (7,8).
According to the available evidence, the virus is transmitted from an infected person to another person through close contact and droplets, and therefore those most at risk of infection are frontline health care workers(HCWs) caring for COVID-19 patients (9,10).
Evidence shows that proper infection prevention and control (IPC) measures during outbreak management could change the course of the outbreak (11). However, the current IPC behaviors are far from optimal. A study on Lassa Fever outbreak among Health care workers (HCWs) showed that none of the study participants met the minimum standards of infection prevention practices during the rst contact with fever cases (12). Infection prevention and control behaviors are in uenced by factors such as the occurrence of an epidemic, contact with con rmed and suspected cases, key clinical departments (such as intensive care unit and emergency department) that are critical risk factors in the pandemic outbreak and always cited as important causes of high healthcare-associated prevalence worldwide (13)(14)(15). years of experience and preparedness are other factors associated with healthcare workers' infection prevention and control behaviors (14).
Owing to the current pandemic, an urgent interim guidance document was issued by the World Health Organization (WHO) which underscores the importance of proper sanitation and waste management practices for COVID-19 in health-care settings (16). The guideline builds on and further emphasizes the existing standard infection prevention and control guidelines for health facilities (17,18). Frontline Healthcare workers are at an increased risk of acquiring the virus owing to overcrowding and lack of sanitary facilities which may be compounded by inadequate awareness of some healthcare workers. To the best literature search, few studies were conducted on the level of awareness and infection prevention practice of healthcare workers. Thus, this study aimed at assessing health care workers' selfreported knowledge and infection prevention practices towards the VOVID-19.

Study setting and design
This institution based cross-sectional study was conducted in selected public health facilities and quarantine centers in Ilu Abba Bor and Buno Bedelle Zones, Oromia Regional State, southWest Ethiopia. Ilu Abba Bor zone and Buno Bedelle Zone are out of the 20 zones of Oromia regional state situated in the southwest of the region and located at a distance of about 600 km and 483 from the center of the region respectively. They cover the western part of the region and lies between 34 0 52'12'' E to 41 0 34' 55''E longitudes and 7 0 27' 40" N to 9 0 02' 10" N latitude. Illu Aba Bor Zone has one town administration and fourteen rural districts with a projected total population of 1,606,502. One referral and District hospital are found in the zone serving a population of the zone. Buno Bedelle Zone has one town administration and fourteen rural districts with a projected total population of 815,437. The zone has three functional hospitals and one under construction, 32 health centers, and 246 health posts. The study was conducted from April 27 -May 10, 2020.

Population
All health care providers working in service delivery units in selected health facilities in both Illu Aba Bor and Buno Bedelle Zones were the study population.

Sample size determination and sampling techniques
The sample size was determined by using single population proportion formula: n = (Zα/2)² p (1-p)/ (d)², where n denotes the sample size, Zα/2 is the reliability coe cient of standard error at 5% level of signi cance = 1.96, (5%) margin of error tolerated, p = proportion of good preventive practice of COVID-19 (50%, since there was no previous study available). Hence, the nal sample size calculated was 345 after adjusting for the total health worker population in the two Zones. Finally, all health care workers in the selected health facilities were included.

Data collection tools and procedures
A self-administered structured questionnaire adapted from WHO resources and a review of relevant literature was used to collect the data (10,19,20). The questionnaire was rst prepared in English, then translated to the local language (Afan Oromo) and translated back to English by another person who was blinded to the English version to ensure its consistency. The tool was pretested on 5% of the sample selected from health facilities in Illu aba Bor Zone that were not included in the main study and modi ed based on the pretest observations. The facilitators were given intensive training for two days before the actual data collection.
The knowledge questions had 12 items covering issues such as COVID-19 symptoms, risk conditions, prognosis, modes of transmission and safety, and precautions. The knowledge score was converted into tertile and the highest tertile was used to de ne "good knowledge", while the two lower tertiles combined were labeled as "poor knowledge".
The infection prevention practice was assessed using 16 items. The practice was computed by adding the responses, scoring one for each correct answer, and zero otherwise. The practice score was converted into tertile and the highest tertile was used to de ne "good practice", while the two lower tertiles combined were labeled as "poor practice".

Data processes and Analysis
Data were entered onto EpiData version 3.1.0 to control skip patterns and allow double entry and exported to SPSS version 23 for analysis. Recoding, transforming, and re-categorization of some variables were performed to compute some of the analyses. In all analyses of the data a two-sided p-was used. Independent sample t-test and one-way analysis of variance (ANOVA) were performed in assessing any difference in mean knowledge score by demographic characteristics. Binary and multivariable logistic regression analyses were computed to examine the association between dependent and independent variables. Odds ratio with 95% con dence interval was used to identify the factors associated with good infection prevention and control practices. Multicollinearity between different predictor variables was assessed. Adequacy of the model was checked using the Hosmer and Lemeshow test for goodness of t.

Results
Socio-Demographic Characteristics of the respondents A total of 330 HCWs were included in the study making the response rate 95.7%. More than half (56.1%) were between 25-34 years of age. Two hundred and three (61.5%) were male participants. More than two-thirds (69.4%) of the respondents were married. Nearly half (47.6%) were protestant by religion and Oromo is the dominant ethnic group (87.9%). More than half (53.7%) of the respondents were degree holders. One hundred eighty-four (55.8%) of the HCW were nurses and 108(40.3%) had less than ve years of experience (Table.1).

Training and availability of hygiene facilities
The study revealed that more than half (59.1%) of the study participants did not receive training related to infection prevention. One hundred seventy-seven (53.6%) of the study participants reported that the institution does not have an infection prevention program and 201(60.9%) did not have an active infection prevention team. More than half (54.5%) reported that the institution does not have an emerging infectious disease taskforce (dealing with outbreaks). One hundred eighty (54.5%) of the health workers reported that they do not have infection prevention and control guidelines at their work unit. Nearly twothirds (65.8%) and 180(54.5%) of the health workers reported the availability of water and soap at their work unit respectively. Three-fourth (75.2%) of the respondents reported the availability of alcohol and hand sanitizer. Two-third of the respondents reported adequate availability of the necessary personal protective equipment (PPE) at their facility. One hundred ninety (42.4%) of the respondents reported the availability of colored dust bin to segregate medical wastes at their work unit. One hundred twenty-eight (38.8%) of the health workers reported that their place of assignment at the time of data collection was at the outpatient department (Table 2.   Greater part (93.3%) of the respondent demonstrated self-reported good knowledge towards COVID-19 and the mean (± SD) knowledge score was 9.0 4 ± 1.06. Three hundred twenty-two (97.6%) correctly answered the mode of transmission of the virus. Greater part (97%) of the respondents correctly answered that COVID-19 is a viral infection. Two hundred twenty-three (97.9%) of the respondents correctly answered that fever, cough, sore throats, and shortness of breath are common symptoms of COVID-19. More than 90% of HCPs were well aware of the route of transmission of the virus, frequent hands wash with soap and water or alcohol-based hand rub, and using face masks can help in the prevention of disease transmission, and healthcare workers are at a higher risk of infection. Two hundred ninety-one (88.2%) correctly identi ed that the isolation period is 2 weeks, 263(79.7%), 251(76.1%), and 232(70.3) correctly answered that COVID-19 vaccine is not available in markets, COVID-19 could be fatal and antibiotics are not a rst-line treatment, respectively (Table 3).  Fig. 1).

Perceived barriers to infection prevention and control practices
A mixed perception was reported by HCWs regarding barriers to infection prevention and control practice.
Of the total participants, 29.7% presumed that overcrowding in the emergency room is a barrier, and 26.7% strongly agreed that insu cient training on infection control is also a barrier towards infection prevention and control practice. A quarter (25.8%) of the participants strongly agreed that the limitation of infection material is a barrier to infection prevention practices ( Figure. 2).

Differences in knowledge among HCPs towards COVID-19
Independent sample t-test and one-way ANOVA analysis were done to assess the mean difference between groups regarding socio-demographic characteristics. In both tests, knowledge did not differ signi cantly (P > 0.05) with age, gender, education, experience, or profession (Table 4).   (21), and the nding from China (89%) (22). This high percentage of knowledge about COVID-19 among healthcare workers is due to prolonged exposure to information since its global topic of discussion on the media and public. Another reason could be the effort of government and media in providing information starting from the time of the outbreak.
The study revealed that 64.2% of the study participants had self-reported good infection prevention practices towards COVID-19. This nding is in agreement with the study in Northern Ethiopia among nurses in which 67% had good infection prevention practice towards the COVID-19(23) but lower than the nding of a study from Makerere University Teaching Hospitals, Uganda that showed 74% of the study participants demonstrated good practice towards COVID-19 prevention (20). The possible reason for the current low practice might be due to variation in the cut of point which is used to determine the outcome variable and variation in type and number of healthcare facilities included in these studies.
The study further revealed that HCWs perceived overcrowding in the emergency room and limited availability of infection prevention material as the major barriers to infection prevention practice. This nding is supported by the study in Pakistan where overcrowding in emergency rooms and limited infection control material were the major barriers in infection control practice (21). Knowledge, and availability of personal protective equipment were signi cantly associated with good infection prevention practices. Accordingly, male HCWs were more likely to have good infection prevention practices than female health care workers. This study is supported by a study among health care workers in selected hospitals that revealed male HCWs promoted IPC behavior compared to females (24).
Healthcare workers having bachelor's degrees were more likely to have good infection prevention practices compared to diploma holders. The nding from a study at Makerere University Teaching Hospital, Uganda in which holding a diploma is signi cantly associated with good practices contradicts this study nding (20). This difference could be attributed to the difference in workload of staff wherein our study the degree holders might be overburdened with different responsibilities.
The health workers' profession was another factor signi cantly associated with infection prevention practices. Physicians were more likely to practice infection prevention than nurses. This difference could be due to disparities of knowledge among HCWs. Doctors are actively involved in seeking information due to their active roles in improving treatment outcomes of patients with COVID-19. This nding is inconsistent with another study conducted in Pakistan in which Pharmacists were more likely to practice infection prevention practice (21).
The study revealed that service year was signi cantly associated with infection prevention practice.
Healthcare workers having longer years of service were more likely to have good infection prevention practices compared to those who have served for less than ve years. This nding is in line with the nding of the study conducted among health care workers in Pakistan that revealed experienced (> 5 years) HCWs were more likely to follow precautionary practices (21). The possible explanation is that experienced workers have skills and experience in dealing with public health emergencies.
Knowledge of the health care workers towards COVID-19 was signi cantly associated with infection prevention practice. Healthcare workers who had self-reported good knowledge were more likely to have self-reported good practice scores towards COVID-19 than those who had poor knowledge. This nding is supported by a study nding from Chitwan, Nepal that revealed higher knowledge scores were signi cantly associated with higher practice scores (25).
The study revealed that the availability of personal protective equipment at their work unit was signi cantly associated with good infection prevention practices towards COVID-19. In contrary to this study, nding from a study among Orthopedic Surgeons in Wuhan, People's Republic of China revealed that insu cient supply of PPE was not associated with Exposures and the COVID-19 Morbidity (26). This difference could be due to the difference in the supply of personal protective equipment and study settings.
The limitation of this study is that the knowledge level and preventive practice of HCWs may be overestimated, as the HCWs might have answered the questions in a way that they believed was socially acceptable rather than being completely accurate. To make the self-reported compliance closer to the actual, the authors devoted all the staff in the research group and trained carefully, to orient the HCWs to complete the questionnaires based on the actual situation.

Conclusions
The study revealed that 93.3% of the HCWs had su cient knowledge towards COVID-19 symptoms, risk conditions, prognosis, modes of transmission and safety, and precautions. There was no statistically signi cant difference in the level of knowledge about COVID-19 among health care workers for their age, gender, education level professions, or quali cations. Despite the high knowledge level, the preventive practice towards the COVID-19 was relatively low. Overcrowding in the emergency room, insu cient training on infection prevention, and limited availability of infection prevention equipment was the perceived barrier to infection prevention practices. Gender, educational status, profession, year of service, knowledge towards COVID-19, and availability of personal protective equipment were signi cantly associated with the good infection prevention practices. Hence, education intervention and campaigns are required for HCWs to improve their preventive practices, and optimizing the infection prevention and control loop of the health facilities is recommended. The study was conducted following the Declaration of Helsinki. Ethical clearance was obtained from the Ethical review committee of Mettu University. The purpose and signi cance of the study were explained to each participant. Written informed consent was obtained from each study participant before they lled in the questionnaire, and participants' involvement was only voluntary. Participants who were not willing to participate and want to resign at any step of lling the questionnaire were informed to do so without any restriction. Names of participants were not included in the questionnaire, and the con dentiality of the data was kept at all levels of the study. The supervisors and facilitators wore a face mask and maintained a minimum distance of two meters. They also used alcohol-based hand sanitizers before handing and receiving the questionnaire to/from the study participants.

Consent to publish
Not applicable Availability of data and materials Data will be available upon the request of the corresponding author.

Competing interests
The authors assert that they have no opposing interests.

Role of funding sources
The views presented in this article are of the authors and not necessarily express the views of the sponsoring organization. Mettu University did not involve in the data collection, analysis, and interpretation of the results.

Funding
Limited funding was received from Mettu University to support the travel and data collection expenses.
Authors' Contributions MS, DO, SD, GB, KB, and DT conceived the idea for the study, designed the study, developed the analysis parameters, and collected the data. MS, DO, SD, GB, KB, and DT involved in the analysis and interpretation of the ndings. DT produced the initial draft of the paper and MS, DO, SD, GB, and KB provided contributions to various sections. All authors read and approved the nal manuscript.