SARS-CoV-2 infection prevention and control at healthcare facilities in South Africa: A knowledge, attitudes, and practices survey of health workers in four provinces

Background: Health workers are crucial to the successful implementation of infection prevention and control strategies to limit the transmission of SARS-CoV-2 at healthcare facilities. The aim of our study was to determine SARS-CoV-2 infection prevention and control knowledge and attitudes of frontline health workers in four provinces of South Africa as well as explore some elements of health worker and health facility infection prevention and control practices. Methods: A cross-sectional study design was utilised. The study population comprised both clinical and non-clinical staff working in the casualty and outpatient departments. A structured questionnaire was developed using the World Health Organization guidance as the basis for the knowledge questions. The questionnaire was self-administered, and COVID-19 protocols were observed during data collection. Results: A total of 286 health workers from 47 health facilities at different levels of care participated in the survey. The mean score on the 10 knowledge items was 6.3 (SD=1.6). Approximately two-thirds of participants (67.4%) answered six or more questions correctly while less than a quarter of all participants (24.1%) managed to score eight or more. A knowledge score of 8 or more was signi�cantly associated with occupational category (being either a medical doctor or nurse), age (<40 years) and level of hospital (tertiary level). Only half of participants (50.7%) felt adequately prepared to deal with patients with COVD-19 at the time of the survey. The health workers displaying attitudes that would put themselves or others at risk were in the minority. Only 55.6% of participants had received infection prevention and control training. Some participants indicated they did not have access to medical masks (11.8%) and gloves (9.9%) in their departments. Conclusions: The attitudes of participants re�ected a willingness to engage in appropriate SARS-CoV-2 infection prevention and control practices as well as a commitment to be involved in COVID-19 patient care. Ensuring adequate infection prevention and control training for all staff and universal access to appropriate PPE were identi�ed as key areas that needed

Version of Record: A version of this preprint was published at BMC Infectious Diseases on November 11th, 2020.See the published version at https://doi.org/10.1186/s12879-021-05812-6.

Background
Coronavirus disease 19 (COVID-19) is a communicable disease caused by a novel coronavirus designated SARS-CoV-2 (severe acute respiratory syndrome coronavirus 2) [1].Evidence indicates that SARS-CoV-2 has a zoonotic source with a wholesale food market in Wuhan City, China either being the source of the outbreak or contributing to amplifying the outbreak [2].This animal coronavirus spill over to humans is the third one to be documented in the past twenty years [1].Human-to-human transmission of SARS-CoV-2 occurs through close contact with an infected individual via respiratory droplets generated by symptoms (such as coughing), talking or singing [3].Transmission can also occur through direct contact with infected individuals through infected secretions or indirect contact through touching surfaces that have been contaminated by respiratory droplets or secretions from the infected individual [3].There is also increasing evidence for the airborne spread of SARS-CoV-2 with enclosed environments with poor ventilation of particular concern [4][5][6].
Africa's rst recorded case of COVID-19 was in Egypt on 14 February 2020 [7].South Africa reported its rst case of COVID-19 on 5 March 2020 in a 38-year old male who had returned to South Africa after a trip to Italy [8].South Africa's daily COVID-19 case numbers started increasing signi cantly from mid-March 2020 reaching the highest daily recorded number of cases of 13 944 on 25 June 2020 [9].By 31 October 2020, South Africa had recorded 723 682 con rmed COVID-19 cases and 19 230 COVID-19 deaths which represents over 40% of all con rmed COVID-19 cases and approximately 45% of all COVID-19 deaths in Africa [9].However, excess deaths data for South Africa suggest that the number of COVID-19 deaths in South Africa is substantially higher [7].There has been a signi cant number of COVID-19 deaths among health workers globally.It was reported in early September that the number of COVID-19 deaths among health workers worldwide was at least 7000 [10].The countries that were estimated to have the most deaths of health workers were Mexico (1320), the United States of America (1 077) and the United Kingdom (649) [10].South Africa with 240 estimated deaths at the time was seventh on the list.[10] Infection prevention and control at healthcare facilities is critical in limiting transmission of SARS-CoV-2 to health workers and patients.The World Health Organization (WHO) has identi ed a number of strategies to reduce the risk of transmission of SARS-CoV-2 in health settings including isolation of suspected cases, the application of standard precautions to all patients, and the implementation of additional precautions for suspected COVID-19 cases [11].Administrative controls should be implemented and engineering and environmental controls should be utilised to limit transmission in health facilities [11].This is echoed by South African guidelines [12].Health workers are crucial in successful implementation of infection prevention and control strategies.The aim of our study was, therefore, to determine SARS-CoV-2 infection prevention and control knowledge and attitudes of frontline health workers in four provinces of South Africa.In addition, we explored some elements of health worker and health facility infection prevention and control practices.

Study design
A cross-sectional study design was utilised with both descriptive and analytical components.The KAP survey was part of a rapid appraisal of the COVID-19 occupational health and safety response in four provinces in South Africa.

Study setting
The study was conducted in public sector (government-run) facilities in four of the nine provinces of South Africa viz.Gauteng Province, Limpopo Province, Mpumalanga Province, and North-West Province.
The public sector facilities comprised district, regional, tertiary, central, and specialised psychiatric hospitals as well as community health centres.

Study population and sampling
The study population comprised frontline health workers within the four provinces that are based in casualty, outpatient departments, and entrance points of health facilities.This included both clinical and non-clinical staff.The health facilities from which participants were drawn were conveniently sampled.
At each facility, the target was to invite at least one health worker from each of six categories of staff to participate viz.medical doctors, nurses, cleaners, porters, security personnel and clerks.Clinical associates (similar cadre to physician assistants) were also invited to participate but are not employed at all facilities.Health workers were selected at each facility based on their availability at the time of the rapid appraisal.This was done to minimise disruption to normal service delivery.

Measurement tool and data collection
A structured questionnaire with closed-ended questions in four sections (socio-demographic characteristics, knowledge items, attitude/perception items and practice items) was utilised for data collection.The knowledge items of the KAP survey were based on the WHO guidance [11].For the knowledge items, participants were provided with a statement and had to indicate if they agreed, disagreed or were unsure.The attitude and perception items used a ve-point Likert response scale.The practice items measured both individual and facility practices with the WHO guidance being used as the basis for most of the items [11].As not all practice items were applicable to all categories of health workers, a 'not applicable' option was provided and these responses were not included in the data analysis.The questionnaires were self-administered with a researcher or trained research assistant being in the vicinity to address any queries.Physical distancing, wearing of medical masks and hygiene measures were employed to reduce the risk of transmission of SARS-CoV-2 during the data collection process.

Data management and analysis
Data entry was done on Microsoft Excel and imported into STATA version 16 (v15 (Statacorp; http://www.stata.com)for analyses.Proportions were calculated for each of the variables.For the knowledge items, 'unsure' and non-responses were treated as being incorrect and were included in the denominator when calculating the proportion of correct responses.The number of questions answered correctly were added to give a score out of 10.Participants were classi ed as having adequate knowledge if they answered six or more questions correctly and good knowledge if they answered 8 or more questions correctly.Logistic regression was utilised to determine factors associated with a good knowledge score.Socio-demographic and employment variables with a p-value less than 0.25 on univariate logistic regression were included in the initial multivariate logistic regression model.The nal multivariate model was developed by dropping variables from the initial model using a backwards stepwise approach.

Results
Socio-demographic characteristics of participants A total of 286 health workers from 47 health facilities participated in the survey.The health facilities comprised 4 community health centres, 22 district hospitals, 11 regional hospitals, 7 tertiary hospitals, a central hospital, and 2 specialised psychiatric hospitals.The socio-demographic and employment characteristics of the participants are displayed in Table 1.The majority of participants were aged between 30 and 49 years (62.9%) and the median age was 39 years.There was substantially more female (59.6%) than male (40.4%) participants.A large proportion of participants (46.6%) did not possess a diploma or degree.Except for clinical associates (1.8%), the different occupational categories of frontline staff were well represented.The 'other' category included various occupational categories such as allied health professionals, pharmacists, and pharmacy assistants.As would be expected based on the facilities selected, the largest proportion of participants (45.1%) worked at district hospitals.

Health worker knowledge
The proportions of health workers who responded correctly to each of the knowledge items are shown in Table 2.More than 90% of participants provided correct answers on each of the two items related to the mechanism of transmission of SARS-CoV-2.Just over half of participants (52.1%) knew that droplet and contact precautions were required for both con rmed cases of COVID-19 and for suspected cases.The lowest proportion of correct responses (6.6%) was obtained for one of the questions related to the appropriate personal protective equipment (PPE) to be used in the routine care of COVID-19 patients.In total, there were three items where the proportion of correct responses fell below 50%.Medical doctors attained the highest or joint-highest proportion of correct responses on eight of the ten items.The mean score on the 10 knowledge items was 6.3 (SD=1.6)(Table 2).Medical doctors had the highest mean score of 7.9 (SD=1.2) followed by nurses with a mean score of 7.0 (SD=1.4).The difference between doctors and nurses was statistically signi cant (p=0.002).Cleaners, clerks and security personnel all had mean scores below 6.Approximately two-thirds of participants (67.4%) answered six or more questions correctly while less than a quarter of all participants (24.1%) managed to score eight or more.The majority of participants in all but one of the health worker categories answered six or more of the questions correctly.With the exception of medical doctors, the majority of participants in each of the health worker categories failed to achieve a minimum of eight correct responses.
The nal multivariate model for factors associated with a knowledge score of ≥ 8 is shown in Table 3.
The initial model consisted of sociodemographic characteristics with p<0.25 following univariate logistic regression viz.age, education, occupation, years of experience and type of facility where employed.
Health workers aged 40 years and older had lower odds of getting 8 or more of the knowledge items correct.Medical doctors and nurses had higher odds of scoring 8 or more as did health workers employed at tertiary hospitals.

Health facility and health worker practices
Participant responses to questions related to their own practices as well as that of their health facility are shown in

Discussion
Our study examined the knowledge, attitudes and practices (KAP) of frontline health workers across occupational categories.We included both clinical and non-clinical personnel.The expectation was that knowledge of SARS-CoV-2 infection prevention and control would differ by occupational category and we, therefore, strati ed our analysis of the knowledge items by occupation.When comparing mean scores, clinical personnel (doctors and nurses) fared better on their overall knowledge than non-clinical personnel.This was con rmed by our multivariate model with doctors and nurses having signi cantly higher odds of obtaining eight or more knowledge items correct.Doctors fared signi cantly better than nurses in our study with respect to mean knowledge scores.A study in Greece found a larger proportion of physicians received high scores on their knowledge of SARS-CoV-2 preventative practices in comparison to nurses [13].A COVID-19 KAP study of healthcare workers in China found similar knowledge scores among doctors and nurses [14] while a COVID-KAP study among clinical personnel in Uganda found no signi cant difference in the level of COVID-19 knowledge of the different clinical cadres [15].A survey of generic infection prevention in Ethiopia found physicians were signi cantly less knowledgeable with respect to infection prevention than nurses [16].
In addition to occupational category, we found that a good knowledge score was also signi cantly associated with age and type of facility where employed.Older health workers had lower odds of achieving a good knowledge score than younger health workers.This nding corresponds to the nding of Olum et al [15] who used a similar cut off of 80% for knowledge items and reported signi cantly lower odds of achieving this in their participants older than 40 years.Two other COVID-19 KAP studies in health workers that have used knowledge scores have not shown a relationship between knowledge scores and age [13,17].Olum et al [15] speculate that the higher knowledge scores seen in younger health workers may be related to their utilisation of a diversity of information sources.Infection prevention knowledge has been linked to years of experience but we did not nd that to be a statistically signi cant association in our study [16].In our study, health workers employed at tertiary hospitals had higher odds of achieving a good knowledge score.Tertiary hospitals in South Africa provide specialist, subspecialist and intensive care services with many involved in training of health professionals [18].The higher knowledge scores obtained by health workers at tertiary hospitals may re ect the greater focus on infection prevention and control at this level.Based on a similar argument, one would expect health workers from central hospitals to also perform well but we are unable to draw any conclusions on this as there was only one central hospital in our sample.
With respect to the individual knowledge items, there appeared to be an understanding of the mode of transmission of SARS-CoV-2 across health worker categories.Possibly the most concerning of the knowledge items, was that almost half of the participants did not know that droplet and contact precautions were needed for both con rmed and suspected cases of COVID-19.Worryingly, this included almost 40% of nurses.Participants also struggled with the question related to hand hygiene with the majority of participants indicating alcohol-based hand rubs are always preferred over soap and water.This is not the case as the WHO recommends soap and water if hands are visibly soiled [11].Contrary to the WHO's guidance, an overwhelming majority of participants indicated boots, coveralls and aprons were needed in the routine care of COVID-19 patients.The WHO recommends a medical mask, eye protection, non-sterile long-sleeved gown and gloves [11].A majority of participants indicated that suspected COVID-19 cases should be given N95 respirators to prevent transmission to health workers while the WHO recommends they be given medical masks [11].
Though the survey was conducted during the early stages of the epidemic in South Africa, the large proportion of participants who felt they were not adequately prepared to deal with COVID-19 was concerning.On a positive note, the health workers displaying attitudes and perceptions that would put themselves or others at risk were in the minority.Approximately 12% of health workers indicated they would choose not to wear the required PPE if it were uncomfortable.This is higher than a healthcare worker KAP survey on healthcare-associated tuberculosis where 6.2% of participants indicated they would not wear a mask if it were uncomfortable [19].As health worker and health facility practices are intertwined, we asked our participants about both.
Appropriate training has been shown to improve both infection prevention knowledge and practices [16] but only just over half of our participants had undergone infection prevention and control training.Given the important role that PPE plays in the prevention of transmission of SARS-CoV-2, it was concerning that more than 40% of participants had not received training on the correct use of PPE.The availability of infection prevention guidelines has also been associated with improved infection prevention knowledge and practices [16] and more than 70% of participants indicated these were available in their departments.
It was concerning that not all participants had access to medical masks and gloves in their departments given that these should be routinely available.While the case numbers were low in South Africa at the time of the survey, these were expected to increase and lack of access to PPE would put these health workers at risk.Given the potential for SARS-CoV-2 to be transmitted by direct and indirect contact, the results for hand hygiene practices were encouraging.Our results differed markedly from the much lower 47% hand hygiene compliance rate after patient contact reported by Erasmus et al [20].

Limitations
Our survey was conducted as part of a rapid appraisal of COVID-19 occupational health and safety preparedness in four provinces of South Africa.We used convenience sampling to maximise the number of facilities that could be assessed in a short period of time.While we believe that our sample provides a fair re ection of the knowledge, attitudes and practices in health facilities in the four provinces, the nonprobability sampling strategy needs to be borne in mind with respect to generalisation of the ndings.
The scienti c community's understanding of COVID-19 has been rapidly evolving since the rst cases were discovered.We developed our questions on the accepted understanding of COVID-19 at the time of the survey and analysed the results as such.With respect to an acceptable knowledge score, it is not clear-cut as to what an appropriate cut-off would be particularly with clinical and non-clinical cadres involved in our study.We, therefore, presented results for an adequate score of 60% and a good score of 80%.Health worker reporting of practices may not re ect actual practices and it is likely that the selfreported hand hygiene compliance is an overestimate.

Conclusions
The majority of participants in our study demonstrated adequate knowledge of COVID-19 infection prevention and control with approximately a quarter of participants having good knowledge.A good knowledge score was associated with occupational category, age and level of hospital.The attitudes of participants re ected a willingness to engage in appropriate SARS-CoV-2 infection prevention and control practices as well as a commitment to be involved in COVID-19 patient care.Ensuring adequate infection prevention and control training for all staff and universal access to appropriate PPE were identi ed as key areas that needed to be addressed.Interim and nal reports were provided to the provincial departments of health which identi ed key shortcomings that needed to be addressed.

Consent for publication
Not applicable.

COVID- 19 :
Coronavirus disease 19; SARS-CoV-2: severe acute respiratory syndrome coronavirus 2; WHO: World Health Organization Declarations Ethical approval and consent to participate The study received ethics approval as part of a research project titled 'A rapid appraisal of the COVID-19 OHS response by four provinces in South Africa' (Reference number: 246/2020) from the Research Ethics Committee of the Faculty of Health Sciences, University of Pretoria.The questionnaire was accompanied by a participant information lea et and informed consent document for anonymous questionnaires.This indicated that participation in the study was voluntary and informed consent was implied by submission of the questionnaire.

Table 1 .
Socio-demographic and employment characteristics of participants

Table 2 .
SARS-CoV-2 infection prevention and control knowledge items by occupational category * includes 5 clinical associates # includes 7 health workers who did not provide their occupational category

Table 3
. Factors associated with knowledge score of ≥ 8 ( nal multivariate model) (N = 261) 8%) felt they could be infected with COVID-19 at their facility regardless of the precautions they take.One-tenth of participants (10.0%) indicated they would continue to report for duty even if they had symptoms suggestive of COVID-19.More than 5% of participants (6.4%) indicated they would resign to avoid contact with COVID-19 patients.

Table 5 .
Just over half of participants (51.3%) con rmed they had undergone occupational health and safety training.Slightly more than half of participants indicated they had received infection prevention and control training (55.6%) and training on the correct use of personal protective equipment (56.2%).Less than 90% of participants indicated they had access to medical masks (85.7%) and gloves (88.7%) with approximately half of participants (51.0%) indicating they had access to medical masks in their department.The vast majority of participants indicated they practiced hand hygiene after touching a patient (97.7%) and after touching a patient's surroundings (90.3%).
Approximately 9% of the participants would treat COVID-19 patients even if the required PPE were not available indicating the vast majority of participants understood the risk of treating COVID-19 patients without PPE.It is noteworthy that 10% of participants indicated they would still continue to report for duty even if they had symptoms suggestive of COVID-19 thereby putting colleagues and patients at risk.This may indicate a failure to effectively communicate the appropriate protocols to all health workers.While the proportion of participants indicating they would resign to avoid contact with COVID-19 patients was small (6.4%), it is nonetheless signi cant in a country already struggling with health workforce shortages in government facilities.