COVID-19 Pandemic and its Implication on Hand Hygiene Status by Alcohol-based Hand Sanitizers Among Healthcare Workers in Jimma University Medical Center, Ethiopia

Background: Pandemic corona virus disease (COVID-19) is a global health crisis of our time. The consistent practice of hand hygiene, especially by proper use of alcohol-based hand sanitizers in health facilities and community is a cardinal step in combating it. This study was designed to assess self-reported level of knowledge, attitude and compliance to WHO recommended hand hygiene status by alcohol-based hand sanitizers among healthcare workers during a COVID-19 pandemic in Jimma University Medical Center, Ethiopia. Methods: Questionnaire-based descriptive cross-sectional study was conducted between April and June 2020. Data were analyzed using SPSS version 21 with signicance level at p<0.05. Results: From a total of 96 volunteer study participants (27nurses; 21pharmacists, 15academicians, 13medical laboratory technicians, 7physician, 7dental doctors, 6midwives) 61 were males. Their mean age was 28.69+4.048years. Alcohol-based hand sanitizers were used by 95.8% respondents to prevent spreading of COVID-19. The majority (93.8%) of the respondents had good knowledge; 74% had a good attitude and 76% had good hand hygiene practices by alcohol-based hand sanitizers. They got information about this technique mainly from mass media 71(74%) and training (40.6%). 84.5% respondents were facing challenges during alcohol-based hand sanitizer use due to it is unavailable 66(68.8%), expensive 50(52.1%), forgetting 11(11.5%), experiencing and/or fearing health-associated risks (skin irritation(28.1%), skin dryness(62.5%), ocular irritation(11.5%), etc).

Current evidence indicates that human-to-human transmission of SARS-CoV-2 is through respiratory droplets or contact. Contact transmission occurs when contaminated hands touch the mucosa of the mouth, nose, or eyes. The virus can also be transferred from one surface to another by contaminated hands, which facilitates indirect contact transmission. The infected persons can transmit the virus even when they have no, or only mild, symptoms 3,7,8 . Consequently, preventing the spread is extremely important to reduce the general burden of the disease. Currently the WHO is recommending social distancing, appropriate use of all personal protective equipment (masks, goggles and others) and hand hygiene (HH) practices to prevent COVID-19 virus transmission 7 .
Practicing HH which includes the use of alcohol-based hand sanitizer (ABHS) or hand washing with soap and water is a simple and yet effective way to prevent the spread of COVID-19 in healthcare settings 9,10 . Unless hands are visibly soiled, ABHS is recommended by WHO over hand washing with soap and water in most clinical situations. This may be due to ABHS related wide microbiological spectrum, time and cost effectiveness, availability at the point of care, improved skin tolerance and better compliance. The ABHS should contain at least 60% ethanol or 70% isopropanol to kill COVID-19 virus 11,12,13,14 .
Following the outbreak of COVID-19, the popularity of ABHSs in healthcare and community settings is increased. But, different studies done before COVID-19 outbreak showed that overall compliance is poor in developing countries, and it is hard to promote HH by using WHO multi-strategy 15,16 . And also improper use of ABHS can results in development of antimicrobial resistance. So, situational analysis of HH structures, resources, promotion and practices within healthcare facility is needed to facilitate the development of an action plan for strengthening the facility's HH program. So, this study focused on assessing the self-reported level of knowledge, attitude and compliance with WHO recommended HH status by ABHS among healthcare workers (HCWs) during COVID-19 pandemic in Jimma University Medical Center (JUMC), Ethiopia

Study setting and design:
A descriptive cross-sectional study was conducted between April and June 2020 in JUMC. JUMC is one of the oldest hospitals in Ethiopia and the only teaching and referral hospital in southwest Ethiopia. It has 800 bed capacity and a catchment population of over 15 million people. More than 400,000 patients can be served at emergency, outpatient departments and various inpatient units per budget year. Study population, sample size and sampling method: The study populations were HCWs (clinical nurses, pharmacists, academicians, medical laboratory technicians, physicians, dental doctors and midwives) working in JUMC. They were all HCWs who were on duty in the months of data collection. All volunteers that agreed to participate in the study and had served health institute for a minimum of one year were included in the study. The study participants were >18 years of age. Due to data collection was paper based and it can be the means of COVID-19 virus transmission, the respondents were only 96 HCWs.

Data collection:
It was done with pretested, structured and self-administered questionnaires. The questionnaires were delivered to the respondents when they were at work area and collected soon after lled.
Data quality assurance: The necessary correction was made on the questionnaires that need correction accordingly and invalid questions were removed before the actual data collection. All lled questionnaires were checked regularly for clarity, completeness and validity individually.

Statistical analysis:
The collected data were entered, tabulated and the results described using appropriate descriptive statistical tests with IBM SPSS version 21. The level of signi cance was set at 5% (p< 0.05).
Knowledge, attitude and HH practice of the respondents were assessed and described using qualitative terms of self-evaluation. Awareness of the respondents was assessed and categorized as knowledgeable and not knowledgeable. Those who agreed to the fact on the WHO guidelines on HH in health care and responded > 50% correctly were considered as knowledgeable 15 . For attitude description, terms like strongly agree, agree, neutral, disagree and strongly disagree were used and those who agreed and strongly agreed to the facts and responded >50% correctly were considered as good attitude 17 . For evaluation of compliance to ve moments on WHO guidelines (before patient contact, before clean/aseptic procedures, after risk of body uids, after patient contact and after contact with patient surroundings) always, often, sometimes, seldom and never were used. Practicing always and responding >50% correctly were considered as compliant/ good practice 18 .

Ethics approval:
It was obtained from the Ethics and Research Committee of the hospital. Verbal consent was obtained from the respondents prior to administration of questionnaire.

Operational De nition
Academician: Health professionals giving health services in JUMC and academic activity in Jimma University Knowledge is de ned as having adequate understanding about hand washing.
Knowledgeable: earning score of 50% and above on the knowledge questions Not knowledgeable: earning score less than 50% on the knowledge questions Practice is de ned as an act of performing given procedure(s) according to a set standard 18 .
Good practice: study participants who responded to the practice questions ≥50% in line with the recommended hand washing practice Poor practice: study participants who responded to the practice questions < 50% in line with the recommended hand washing practice Attitude is de ned as belief of the respondents towards the facts on the WHO guidelines on HH in health care.
Good attitude: who agree and strongly agree to the facts and responded >50% correctly the attitude questions Poor attitude: who responded <50% correctly the attitude questions

Results And Discussion
General characteristics of enrolled healthcare workers Taking into account a non-response rate, due to COVID-19 pandemic period and transmission ways, 96 questionnaires were adequately lled and returned by 96 volunteer HCWs. Among the participants, the majority of respondents were clinical nurses 27(28.1%); followed by pharmacists 21(21.9%), academicians 15(15.6%), medical laboratory technicians 13(13.5%), physicians 7(7.3%), dental doctors 7(7.3%) and midwives 6 (6.3%). Their mean age was 28.69+4.048 years (table 1).   Compliance of respondents to WHO recommended alcoholbased hand sanitizer practices: Following the WHO current recommendation, HH is the most effective and simple technique to prevent the spread of COVID-19 in healthcare settings 15 . This study showed that most of the HCWs were using both hand washing using water and soap and ABHS 62(64.6%); followed by hand washing using water and soap 23(24%) to keep their HH. Relatively ABHS is preferred than hand washing using soap and water because they believe that ABHS is most effective 45(46.9%), easily available 26(27.1%) (i.e. supply from health facility) 5(5.2%)), low cost 4(4.2%) and the others don't know the reason 16 (16.7%). This nding is in line with different study 14,15 .
Compliance for ABHS use of the WHO identi ed ve essential moments in a single care sequence by HCWs who work with patients in any health care setting anywhere in the world generally needs a great concern 21, 22 . According to this study, majority 73(76%) of the study participants were compliant to the ve moments of HH recommended by the WHO. This should be due to improved HCWs awareness of COVID-19 infection control techniques. This study nding shows more compliance to ABHS use than with other study conducted in University of Gondar teaching hospitals 23 and in a tertiary university hospital in Istanbul 24 . This variation might be due to sample size, study time and outbreak of COVID-19.  25 . This might be due to not adequate number of samples is used.
In multivariate analysis, there is a statistical association between compliance to the ve moments of HH recommended by WHO and attitude towards HH by ABHS (AOR 2.974; 95% CI 1.093 -8.093; P= 0.033). As a result, those who had a positive attitude on HH had more than 2 times more compliance than a negative attitude. But there is no difference in compliance due to knowledge of ABHS use and compliance to practicing it accordingly (COR 0.286; 95% CI 0.053-1.526; P= 0.143). This result does not agree to study conducted in Central Gondar zone public primary hospitals in which knowledgeable study participants are 6.74 times more compliant than those who have poor knowledge 23 . The difference might be due to sample size issue and study time (COVID-19 pandemic).
The present study demonstrated that lack of ABHS and increasing in cost were identi ed as the most common reasons for not using ABHS as their preferred technique to prevent spreading of COVID-19. This nding is in line with study conducted in Ruth K.M. Pfau Civil Hospital, Karachi (2019) 26 ; but higher than in study conducted in a tertiary university hospital in Istanbul (2014) 24 . The difference might be due to high consumption of ABHS in the healthcare setting and community during the study period to due to the outbreak and rapid prevalence of COVID-19 pandemic.

Recommendation
This study recommends that to prevent the spreading of COVID-19 virus, efforts to improve HCWs knowledge, attitude and adherence to the WHO guidelines for hand hygiene is needed. So hospital should catalyze behavioral change, provide educational information by mass media, posters and organizing training and developing guidelines with a worldwide perspective to achieve and sustain improvements.
Additionally, as most of the respondents were experiencing skin damage, the hospitals should prepare and supply ABHS containing appropriate emollients locally according to the WHO guideline or the respondents should use emollient containing ABHS to reduce these risks and increase compliance. This very important COVID-19 control approach should be monitored regularly to keep healthcare quality and patient safety.

Con ict of interest and consent for publication:
There is no potential con icts of interest exist with respect to the research, authorship, and publication of this article.
Availability of data and materials: The data used to support the ndings of this study are available from the corresponding author upon request. Funding: All authors have declared that no nancial support was received from any organization for the submitted work.

Figure 1
Knowledge of respondents about alcohol-based hand sanitizer storage condition Generally, this study demonstrated that most of the study participants got information about the use of ABHS to prevent COVID-19 and its storage condition from the mass media 71(74%); followed by books and published journals 33(34.4%), discussion with co-workers 26(27.1%), presence of posters for HH in work area 14(14.6%) and seminars conducted occasionally at hospital level 11(11.5%).