Knowledge and Compliance with Covid-19 Infection Prevention and Control measures among Health Workers in Regional Referral Hospitals in Northern Uganda: A cross-sectional Online Survey

Infection prevention and control (IPC) has increasingly been underscored as a key tool for limiting the transmission of Covid-19 and safeguarding health workers from infections during their work. Knowledge and compliance with IPC measures is therefore essential in protecting health workers. However, this has not been established among Ugandan health workers in light of the Covid-19 pandemic. Objective: To determine the knowledge and compliance with Covid-19 infection prevention and control measures among health workers in regional referral hospitals in Northern Uganda. Methods: An online cross-sectional descriptive study was conducted among 75 health workers in regional referral hospitals within Northern Uganda. A structured questionnaire was distributed to health workers via WhatsApp messenger. Sucient knowledge was considered at a correct response score of ≥ 80%, while adequate compliance was rated ≥ 75 of the maximum score. Data were analyzed using SPSS v21. Results: The majority of the health workers had good knowledge (69%) and compliance (68%) with Covid-19 IPC. Good compliance was signicantly associated with training in Covid-19 IPC (p=0.039), access to Covid-19 IPC at work stations (p=0.036), and having sucient institutional support (p=0.031). However, there was no signicant relationship between knowledge and compliance with IPC (p=0.007). The sociodemographic characteristics of health workers, including age, sex, education level, occupation, working hours and work experience, had no statistically signicant relationship with Cvid-19 IPC knowledge or compliance. Discussion: Our ndings provide support for IPC training and guidelines as well as adequate PPEs to be available to health workers to improve compliance with Covid-19 IPC.

working hours and work experience, had no statistically signi cant relationship with Cvid-19 IPC knowledge or compliance.
Discussion: Our ndings provide support for IPC training and guidelines as well as adequate PPEs to be available to health workers to improve compliance with Covid-19 IPC.

Background
Coronavirus Disease of 2019  is arguably the greatest global health threat of our time. As of 9 th August, 19,462,112 people were infected globally, with more than 700,000 deaths (World Health Organization, 2020a). In Uganda, the cases are on the rise, with 18,379 cases as of 17 th August 2020 (Ministry of Health Uganda, 2020a). As the cases rise, health workers are increasingly becoming at risk of infection as they care for the ever-so-growing number of Covid-19 patients. Uganda has thus far reported 49 cases of Covid-19 infection among health workers (Ministry of Health Uganda, 2020a), raising a concern that many more will become infected as the Covid-19 cases rise. Because the safety of health workers is key to winning the ght against the virus, infection prevention and control (IPC) measures remain critical tools.
Recently, the World Health Organization (WHO) issued interim guidance on IPC that emphasized several measures, including applying standard precautions to all patients, ensuring early triage and case recognition, and applying additional precautions such as wearing masks (World Health Organization, 2020c). As the Covid-19 pandemic grows, countries have further stepped up IPC measures, including mandatory wearing of face masks and handwashing in all public places (Museveni, 2020, Ministry of Health Uganda, 2020b. Without compliance, however, these measures will not help in achieving the intended goal, and the health workers will increasingly be at risk of Covid-19 infection, a fact becoming evident in Uganda where health workers have been infected(WHO African Region, 2020).
Whereas Uganda has designated treatment sites for Covid-19 patients where rigorous IPC standards are implemented, some asymptomatic Covid-19 patients are likely to seek care from non-designated hospital departments where IPC measures might be inadequate. We believe that health workers in these departments are much more at risk of Covid-19 as they could be managing undiagnosed Covid-19 patents and therefore may not feel compelled to practice strict Covid-19 IPC measures. In this study, we evaluated the knowledge and compliance with Covid-19 IPC measures among health workers in regional referral hospitals in Northern Uganda.

Study setting and design
A descriptive cross-sectional online study was conducted among health workers at regional referral hospitals (RRHs) in Northern Uganda. The RRHs include Lira RRH, Arua RRH, and Gulu RRH, which serve as referral centers for the 30 districts in northern Uganda.

Study population
The study targeted health workers whose work involves primary contact with patients, including doctors, nurses, midwives, clinical o cers, and laboratory o cers.

Study procedure and tool
Purposive sampling was used to identify and select WhatsApp groups with the health workers of interest from the respective RRHs. The researchers obtained verbal consent from the group administrator and requested mobilizing members on the WhatsApp platforms. A link to the questionnaire on Google forms (Alphabet Inc., California, USA) was shared to the potential respondents via WhatsApp messenger (Facebook, Inc., California, USA). Participants randomly participated in the study by following the link shared.
Data were collected from 75 health workers using an anonymous, self-administered, online, structured questionnaire adapted from the literature. Knowledge and institutional support were assessed using an 8item questionnaire adapted from Haridi et al (Haridi et al., 2016) and modi ed to assess Covid-19 IPC knowledge among HCWs. Compliance was assessed using an 8-item questionnaire from the WHO protocol for the assessment of potential risk factors for Covid-19 infection among health care workers (World Health Organization, 2020d). The data collection tool consisted of 4 sections. The rst section captured the demographic characteristics of the participants. The second section comprised eight questions ascertaining the level of knowledge and understanding of the concept of IPC and was scored as follows: One (1) point was awarded for each correct response and zero (0) for an incorrect response, and a correct response score of ≥80% was considered su cient knowledge. The third section comprised eight questions to ascertain the level of compliance with IPC measures and scored as follows: 1, for 'never'; 2, for 'rarely'; 3, for 'sometimes'; and 4 for 'always', giving a total score of 32 points. Adequate compliance was set at ≥75% of the maximum score. The fourth section comprised three questions concerned with the perception of institutional commitment to IPC and was rated on a Likert scale (never, rarely, sometimes, and always). A scoring system was assigned as follows: 1, for 'never'; 2, for 'rarely'; 3, for 'sometimes'; and 4 for 'always', giving a total score of 12. Strong institutional support was considered with a score of ≥75%.

Data management and analysis
The responses from Google Forms were downloaded in an Excel sheet (Microsoft Inc. Albuquerque, New Mexico, United States) and then exported to Statistical Package for the Social Sciences (SPSS) software, version 21.0 (SPSS, Chicago, IL, USA) for analysis. Frequencies and percentages were used to summarize knowledge and compliance with IPC among HCWs, while means and standard deviations were used to summarize data on age, work experience and other numerical variables. The chi-square test was performed to determine the relationship between categorical variables, while the Pearson correlation test was used to determine the association between continuous variables. A variable was considered signi cant in this analysis if it had a p-value <0.05.

Results
Demographic characteristics of respondents A total of 75 health care workers responded, and the majority were females (52%). More than half of the respondents (60%) belonged to the age group of 18-39 years with a mean age of 36.92 (SD ±9.39). The majority of the health workers interviewed had a bachelor's degree as their highest level of education and had a mean work experience of 10.4 years (SD ± 8.79

Compliance with Covid-19 Infection Prevention and Control
Compliance with Covid-19 IPC was high, with the majority of the participants (68%) scoring more than 80% of the compliance score (Table 4) and varied by item assessed (Table 5). The mean compliance was 85.5 (SD ±10.3) and was associated with having received training in Covid-19 IPC (p=0.039), having Covid-19 IPC guidelines at work stations (p=0.036), and su cient institutional support (p=0.031). There was no statistically signi cant relationship seen between compliance and sociodemographic characteristics of participants such as age, level of education, working hours, work experience and health cadre. Additionally, compliance varied by parameter assessed (Table 5). Institutional support for Covid-19 infection prevention and control Generally, there was strong perceived institutional support, with the majority of participants (70.7%) feeling adequately supported by their respective institutions (Table 6). Moreover, adequate institutional support was associated with Covid-19 IPC compliance (p=0.031). Just as knowledge and compliance, institutional support score varied by item assessed. For example, only 18.7% of the participants reported being availed adequate personal protective equipment (PPEs) by their hospitals, while 50.5% reported always having access to handwashing facilities and products, and 49.3% reported always being availed su cient supplies for the collection of medical waste (Table 7).  (Yang et al., 2020). However, pre-Covid-19 pandemic studies have shown lower knowledge scores (Geberemariyam et al., 2018, Sahiledengle et al., 2018. Taken together, these ndings imply that training in IPC during the Covid-19 pandemic has enhanced health workers' IPC knowledge and therefore needs to be sustained.
Moreover, similar to previous studies (Russell et al., 2018, Haridi et al., 2016, Ibrahim and Elsha e, 2016, we demonstrate that knowledge on various parameters of IPC varies, with most health workers less knowledgeable about parameters related to airborne precautions and hand hygiene. This de ciency in knowledge suggests a need to focus on training, audit and feedback methods to improve knowledge in these areas, as they are central Covid-19 IPC. Furthermore, we did not nd a statistically signi cant relationship between knowledge and participants' sociodemographic characteristics, IPC training or presence of guidelines. However, previous studies have reported a positive association between knowledge of IPC and age, years of experience, training in IPC, and availability of guidelines (Russell et al., 2018, Desta et al., 2018. One possible reason for this discrepancy is the context in which the studies were conducted. Unlike these previous studies, our study was conducted during the Covid-19 pandemic, where health workers have been exposed to various training and information sources regarding IPC in the setting of Covid-19.
We also found that the majority of the health workers had good compliance (68%) with Covid-19 IPC measures. The high score of self-reported compliance is comparable to a previous self-report study (Russell et al., 2018). However, previous studies that used observation methods for data collection reported compliance rates with hand hygiene (53-57%) (Geberemariyam et al., 2018, Desta et al., 2018, Yang et al., 2020. This discrepancy could be due to the difference in methods, as self-reported studies are likely to nd more compliance with IPC. Moreover, compliance scores also varied by item assessed, as reported in previous studies (Powell-Jackson et al., 2020, Bedoya et al., 2017. In addition, compliance was found to be associated with having had training in Covid-19 IPC, having IPC guidelines, and perceived strong institutional support. Previous studies have shown that training in IPC and access to guidelines improves compliance with IPC (Sahiledengle et al., 2018, Desta et al., 2018, Geberemariyam et al., 2018. Accordingly, the WHO and the Uganda Ministry of Health (Ministry of Health Uganda, 2020b, World Health Organization, 2020b have emphasized training of all health care staff and developed and supplied guidelines for IPC. These efforts are likely to have contributed to the high knowledge and compliance scores noted in our study. Therefore, our ndings provide support for the notion that support to health care workers in terms of training, provision of guidelines and appropriate facilities and supplies for IPC increases compliance. In the present study, we also report adequate institutional support (70%) reported by health workers. Despite the high scores, fewer health workers reported adequate provision of PPEs. Indeed, inadequate supply of PPEs has been a key challenge in health care systems worldwide during this pandemic, with policy makers advocating for the provision of more PPEs to protect health care workers (Cooper et al., 2020). In this regard, Uganda is not spared as the Covid-19 cases and hospital admissions continue to grow. Currently, there are 18,379 reported cases, 49 of which are among health workers (Ministry of Health Uganda, 2020a). Our ndings point to the need for an adequate and consistent supply of PPEs to RRHs in Northern Uganda. Nonetheless, the small sample size coupled with the self-report method of measuring compliance are key limitations of this study, and we therefore suggest that further studies consider observation methods to improve the objectivity of the data. Declarations