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

BMC Infectious Diseases volume 24, Article number: 1046 (2024) Cite this article

Abstract

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 the 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’ socio-demographic information, IPC-related factors, 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 IPC measures. There were no significant associations between compliance and sex, marital status, vaccination status, or smoking (p > 0.05 for all).

Conclusions

Low levels of compliance with COVID-19 IPC measures were 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.

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Background

The COVID-19 pandemic is considered the most severe global health crisis of the 21st century resulting in 775,615,736 confirmed cases and 7,051,323 deaths worldwide as of June 9, 2024 [1].

Asymptomatic carriers and those in the incubation period can transmit COVID-19 virus, highlighting the critical need for isolation until a negative test result is confirmed [2]. Quarantine measures are essential for persons from endemic areas, those with confirmed contact, and mild cases not requiring medical attention [3]. While all age groups are susceptible, elderly people with underlying health conditions are at greater risk of severe illness [4]. Healthcare workers (HCWs) are also vulnerable due to the nature of their work, highlighting the importance of infection prevention and control (IPC) practices and the use of personal protective equipment (PPE) [5]. Factors increasing HCWs’ risk of COVID-19 infection compared to the general population include prolonged patient contact, insufficient access to PPE, inadequate time for training, and physical and psychological issues such as fatigue, stress, and anxiety [6].

IPC strategies include non-pharmaceutical interventions such as school and workplace closures, event bans, stay-at-home orders, and movement restrictions, which have helped reduce transmission [7]. Personal protective measures are also crucial for COVID-19 IPC [8]. Although vaccines have been developed to mitigate the impact of COVID-19, their effectiveness varies by variant. For instance, vaccine efficacy against symptomatic disease was higher for the delta variant compared to the omicron variant. With previous variants, vaccine efficacy against severe disease, including hospitalization and death, has been higher and retained for longer periods than efficacy against mild disease [9].

A combination of PPE and other non-pharmaceutical interventions is considered effective in protecting HCWs. However, vaccination is regarded as the most effective measure. Vaccines have been proven effective in protecting HCWs from infection, even against variants of concern (VoC) [10].

The World Health Organization (WHO) declared that COVID-19 is an emergency public health problem of international concern that poses a high risk to countries with vulnerable health systems on January 30, 2020 [11]. 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 cautioned that COVID-19 is still causing deaths and warned of the risks from new emerging variants [12]. In fragile settings like Somalia where the number of HCWs falls significantly short of the Sustainable Development Goals, ensuring the protection of these workers is vital [13]. To protect HCWs, it is essential to ensure adequate supplies of PPE and provide comprehensive training in its proper use. Additionally, maintaining environmental hygiene in hospitals and personal hygiene among HCWs is crucial [2]. HCWs should also minimize contact to reduce the risk of infections [8].

It was reported from China that the potential risk of COVID-19 significantly improved the IPC behaviors of HCWs working in hospitals [14]. Determination of the compliance of HCWs with the COVID-19 IPC practices and the factors affecting this compliance is crucial for their protection during the pandemic. However, studies on COVID-19 IPC practices in Somali hospitals and among HCWs are limited. This cross-sectional study aimed to assess the compliance of HCWs with COVID-19 IPC practices at De Martino Public Hospital and to identify the factors influencing this compliance in order to improve HCWs’ compliance with COVID-19 IPC practices.

Methods

This hospital-based cross-sectional study was conducted at the De Martino Public Hospital, located in Mogadishu, Somalia, which is among 61 health facilities run by the government in the Benadir region and provides specialized care despite capacity challenges [15, 16]. De Martino Public Hospital provides free medical care and it exclusively served COVID-19 patients during the COVID-19 pandemic.

Study population and sample size

The study included all 210 HCWs at De Martino Hospital between August and November 2022, achieving a response rate of 97.1% with 204 participants providing written informed consent. HCWs included staff providing health services directly or indirectly, such as managers, secretaries, doctors, nurses, laboratory technicians, radiologists, pharmacists, cleaners, security personnel, or other personnel.

The study variables

HCWs’ compliance with COVID-19 IPC practices was assessed using a self-report questionnaire adapted from the WHO’s risk assessment tool [17]. The questionnaire was modified to suit the hospital’s specific context guided by relevant literature. It was structured into three main sections: PPE (12 items), hand washing and hygiene (HH) (7 items), and other COVID-19 IPC practices (6 items). The questionnaire also included data on personal characteristics, IPC-related factors, work conditions, and COVID-19 practices. The questionnaire is attached as “Supplementary file 1”.

The anonymity and confidentiality of the participants were ensured by assigning a specific number to each questionnaire, with no identifying information collected. The questionnaire was piloted on a separate HCW group in Somalia to ensure validity. The questionnaire included 25 items measured on a 5-point Likert scale “always (5 points), often (4 points), sometimes (3 points), rarely (2 points), or never (1 point)” with ‘always’ and ‘often’ responses indicating compliance. Compliance scores were summed, and a median cut-off point determined “high compliance”.

Data analysis

Descriptives of the categorical variables and dichotomized compliance scores were presented as percentages. Associations between independent variables and high compliance with COVID-19 IPC measures were analyzed using the chi-square test.

Key factors associated with high compliance were identified through logistic regression models. Variables showing significant associations in univariate analyses were included in the logistic regression model and backward LR method was used to identify predictive variables. Associations were presented with odds ratios and 95% confidence intervals.

Data analysis was performed using SPSS program, version 23, with p-values < 0.05 considered statistically significant.

Results

Data from 204 HCWs were analyzed, with a 97% response rate. 51% of the participants were males, 46.1% were aged 20–29, and 15.7% were age 40 and above. About 77.8% held bachelor’s degrees or higher. The largest professional group was nurses and paramedical staff (51%), followed by doctors and doctor assistants (31.9%). 20.1% of the participants worked in outpatient departments, 26.5% in inpatient departments, and 29.9% in other clinical departments.

Compliance with COVID-19 IPC practices among healthcare workers

The overall IPC compliance rate was 58.3%. HCWs showed 55.9% compliance with personal protective equipment (PPE), 55.4% with hand hygiene (HH), and 52% with other COVID-19 IPC measures (Fig. 1).

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

Full size image

Age and educational status were significantly associated with overall IPC and HH compliance (p < 0.05). Educational status was also significantly associated with compliance with PPE (p < 0.01) and other IPC measures (p = 0.03). Younger age groups and higher education levels were linked to better compliance (Table 1). No significant associations were found between compliance (IPC, PPE, HH) and marital status, having children or elderly/chronic disease patients at home, or COVID-19 vaccination. Work experience years also showed no significant association with compliance (Table 1). HCWs who received COVID-19 training reported higher compliance with overall IPC and PPE (p < 0.05).

Table 1 COVID-19 IPC compliance in HCWs during healthcare provision by sociodemographic characteristics and IPC-related factors
Full size table

The type of HCW was significantly associated with overall compliance with IPC, PPE, and HH, with non-clinical staff showing lower compliance across all dimensions (p < 0.01 for all). Similarly, this pattern was observed in different departments, where HCWs in non-clinical departments reported lower compliance (p < 0.01 for all). HCWs not directly caring for COVID-19 patients, lacking face-to-face contact, and not present during aerosol-generating procedures (AGP) reported lower compliance (p < 0.01 for all). HCWs without direct contact with the COVID-19 environment also showed lower compliance with overall IPC and PPE (p < 0.01 for all). No significant association was found between working conditions/practices and compliance with other IPC measures, except for the type of HCW (p = 0.01) (Table 2).

Table 2 COVID-19 IPC compliance in HCWs during healthcare provision by working conditions and practices on COVID-19
Full size table

Logistic regression identified profession, COVID-19 training, direct care of COVID-19 patients, and presence during AGPs as independent factors for overall IPC compliance. Doctors (p < 0.01, OR: 12.11, 95%CI: 2.23–65.84) and nurses/paramedical staff (p < 0.01, OR: 21.38, 95% CI: 4.23–108.01) showed higher compliance than non-clinical staff. HCWs who received COVID-19 training exhibited higher compliance (p = 0.04, OR: 3.48, 95% CI: 1.06–11.35). Those present during AGP performance had also higher compliance compared to those who were uncertain (p = 0.01, 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)
Full size table

For PPE; the profession, the source of COVID-19 material, and providing direct care to COVID-19 patients 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, %95CI: 1.62–15.21, outpatient OR: 4.21, %95 CI: 1.34–13.23, other clinical departments OR: 6.2, %95 CI: 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).

Discussion

This study aimed to evaluate the compliance of HCWs with IPC measures at De Martino Public Hospital and identify factors influencing this compliance. Overall, 58.3% of HCWs demonstrated high compliance, with compliance rates over 50% across PPE use, HH, and other IPC measures. Notably, non-clinical staff exhibited lower compliance compared to their clinical counterparts.

Several studies have reported high compliance with COVID-19 IPC measures among HCWs. In Ghana, a study involving 424 HCWs in COVID-19 treatment centers found high compliance with HH (88.4%) and PPE usage (90.6%) [18]. Similarly, two studies in Ethiopia, with 403 and 422 participants respectively, reported good IPC practices in 64.3% and 63.5% of HCWs, though compliance with PPE usage was lower (45.2%) in the first study due to factors like availability, comfort and education [19, 20].

Our study’s lower IPC compliance rates compared to previous studies might be due to methodological differences and the timing of data collection. While our study used median compliance scores for each domain, other studies employed different thresholds. Additionally, HCWs’ adherence to IPC measures may have declined over time, as suggested by a study showing fluctuating hand hygiene compliance during different pandemic phases [21].

Conversely, some studies have reported low IPC compliance among HCWs. For instance, in Ethiopian COVID-19 referral hospitals, overall compliance was just 22%, with only 63.4% of HCWs having received training, 58.2% reading COVID-19 materials, and 83.2% experiencing PPE shortages [22].

Barriers to HCWs’ compliance with IPC guidelines include insufficient training programs, inadequate PPE supply, and individual factors such as knowledge, attitudes, beliefs, and PPE discomfort [23]. Furthermore, a study in Uganda found that only 37.0% of 657 HCWs had good COVID-19 IPC practices despite high mask usage and hand washing rates [24].

Our finding that clinical staff exhibited higher IPC compliance than non-clinical staff is consistent with previous research. Studies in Ghana and Uganda also reported lower compliance among non-clinical staff compared to clinical staff [18, 24].

Differences in compliance might stem from the higher risk faced by clinical HCWs who have close contact with COVID-19 patients. In Somalia, ancillary staff such as security workers and cleaners have lower adherence to infection control measures than clinical staff due to lower knowledge. Informal employment and less attention to these roles also contribute to this discrepancy [13].

HCWs present during aerosol-generating procedures (AGPs) showed higher overall IPC compliance compared to those who were uncertain about their presence, consistent with findings by Ashinyo ME et al. likely due to the increased risk of infection during these procedures, [18, 25]

HCWs who received COVID-19 training exhibited higher overall IPC compliance, consistent with studies on HCWs in Ethiopia by Etafa W. et al. and Arsemahagn MA, as well as a review study by Cooper S. et al. [22, 26, 27]

Interestingly, our study found that HCWs who relied on official sources for COVID-19 information had lower compliance with PPE and HH than those who used social media, contrasting with findings from the general population that social media led to lower compliance due to misinformation [28]. This discrepancy might be due to De Martino HCWs following trusted social media pages.

To enhance compliance, continuous training and awareness programs on COVID-19 IPC guidelines for HCWs are essential. Policymakers should implement comprehensive programs to educate HCWs and ensure the provision of adequate PPE and other necessary equipment and supplies.

This study has several limitations. Recall bias might have affected responses, as participants were surveyed during the late stages of the pandemic when some PPE was likely underutilized. To mitigate this, we focused on daily IPC practices and specific scenarios involving suspected or confirmed COVID-19 cases. Being a single-center study, may hinder generalization of findings to other hospitals in Somalia, though the high response rate and comprehensive staff inclusion support internal validity. Additionally, the small sample size led to wide confidence intervals for the odds ratios.

Conclusions

This study highlights significant gaps in COVID-19 IPC compliance among hospital workers, particularly non-clinical staff, likely due to perceived low risk and lack of awareness. Based on susceptibility to the infection, ensuring all HCWs are informed and equipped to follow IPC guidelines is critical. Targeted awareness campaigns and behavior change interventions are essential to improve compliance and enhance COVID-19 prevention and control in hospital settings.

Data availability

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

Abbreviations

IPC:

Infection prevention and control

HCWs:

Healthcare workers

PPE:

Personal protective equipment

WHO:

World Health Organization

RH:

Referral hospital

HH:

Hand washing and Hygiene

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Acknowledgements

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.

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Author notes

  1. Abdullahi Ibrahim Janay, Bulent Kilic and Belgin Unal contributed equally to this work.

Authors and Affiliations

  1. Department of Public Health, Institute of Health Sciences, Dokuz Eylul University, Izmir, Turkey

    Abdullahi Ibrahim Janay, Bulent Kilic & Belgin Unal

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Contributions

All authors (A.I.J, B.K, B.U) 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.

Corresponding author

Correspondence to Abdullahi Ibrahim Janay.

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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.

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Janay, A.I., Kilic, B. & Unal, B. Healthcare workers’ compliance with COVID-19 prevention and control measures at De Martino Hospital, Mogadishu, Somalia: a cross-sectional study. BMC Infect Dis 24, 1046 (2024). https://doi.org/10.1186/s12879-024-09819-7

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