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 filled 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).
Table 1: General profile of study participants
Variables
|
n (%)
|
Age (years)
|
18-24
|
8
|
25-35
|
82(85.4)
|
> 35
|
6
|
Sex
|
Male
|
61 (63.5)
|
Female
|
35 (36.5)
|
Religion
|
Orthodox
|
44 (45.8)
|
Protestant
|
36 (37.5)
|
Muslim
|
15 (15.6)
|
Other
|
1
|
Marital status
|
Married
|
52 (54.2)
|
Single
|
44 (45.8)
|
Current education level
|
Degree
|
67 (69.8)
|
Master/Specialist
|
27 (28.1)
|
PhD
|
2
|
Years spent in healthcare setting
|
< 5 Years
|
73(76)
|
5 -10 Years
|
19(19.8)
|
> 10 Years
|
4
|
Knowledge of respondents about hand hygiene by alcohol-based hand sanitizer
Outbreak of COVID-19 is a global health crisis of our time and become the greatest challenge faced since World War II. Current evidence indicates that the COVID-19 virus is transmitted through respiratory droplets or contact. Due to no drug or vaccine has been found, WHO recommended different prevention techniques 2,19. So in the present study, the study participants were using hand washing using water and soap 93(96.9%), ABHS 92(95.8%), non-pharmaceutical equipments (such as mask, goggles) 78(81.3) and social distancing 87(90.6%).
The HH by either ABHS or hand washing using water and soap is more critical. Commonly, most study participants relatively preferred ABHS15. According to this study, the majority (90(93.8%)) of the respondents had good knowledge about HH by ABHS to prevent spreading of COVID-19 (table 2). This result agrees with studies conducted in Dubti Referral Hospital, Northeastern Ethiopia (2018)20 and in Lagos University Teaching Hospital, South-West Nigeria (2011)17.
Table 2: Knowledge of respondents on hand hygiene by alcohol-based hand sanitizer to prevent COVID-19
Statement about hand hygiene by ABHS
|
Responses n (%)
|
Knowledgeable
|
not knowledgeable
|
HH is necessary even if gloves are used when touching patients.
|
88(91.7)
|
8(8.3)
|
When hands are visibly dirty, ABHS alone cannot be used for HH.
|
79(82.3)
|
17(17.7)
|
Removal of dirt can increase the effectiveness of ABHS
|
82(85.4)
|
14(14.5)
|
Both hands should be dried before using ABHS
|
85(88.5)
|
11(11.4)
|
The minimal time needed for ABHS to kill COVID-19 virus on your hands is 20 seconds.
|
75(78.1)
|
21(21.9)
|
Using ABHS for HH is less time-consuming, at least as efficient, and convenient than hand washing with soap and water
|
70(72.9)
|
26(27.1)
|
Poor adherence to HH practice is a primary contributor to COVID-19
|
84(87.5)
|
12(12.5)
|
ABHS causes skin dryness more than hand washing with water & soap
|
74(77.1)
|
22(22.9)
|
Knowledge of respondents on alcohol-based hand sanitizer storage condition
Due to the environmental condition affects the quality, safety and effectiveness of ABHS, the WHO recommends standard storage conditions15. According to this study results less than 75% of the study participants know the recommended storage condition.
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%).
Potential risk factors related to lack of knowledge
In the current study, univariate (binary logistic regression) analysis indicated that HCWs knowledge about HH by ABHS was not statistically associated with difference in sex (COR 0.552; 95% CI 0.105-2.894; P= 0.482) and years spent in healthcare setting (COR 0.618; 95% CI 0.068-5.580; P =0.668). Multivariate analysis showed that HCWs who took training on COVID-19 prevention techniques had more than three times knowledgeable than untrained (AOR 3.65; 95% CI 0.41-32.56; P= 0.246) (table 5).
Attitude of respondents towards hand hygiene by alcohol-based hand sanitizer
In the current study, almost majority 71(74%) of the respondents had a good attitude towards their knowledge and practicing HH mainly by ABHS and requirement of ABHS for them in their work area. Similar finding has been reported by a study done in a tertiary hospital, South West Nigeria (2011)17. This positive attitude towards HH by ABHS exhibited by the respondents may be attributed to their knowledge of the consequences of poor HH on transmission of COVID-19 virus.
Table 3: Attitude of respondents towards hand hygiene by alcohol-based hand sanitizer
Attitudes
|
Response, n(%)
|
Strongly Disagree
|
Disagree
|
Neutral
|
Agree
|
Strongly Agree
|
You have sufficient knowledge about HH
|
5
|
6
|
3
|
48(50)
|
34(35.4)
|
You work in a health facility where HH is encouraged
|
4
|
3
|
7
|
56(58.3)
|
26(27.1)
|
You feel competent on using ABHS in accordance with WHO recommendations
|
5
|
8
|
15(15.6)
|
48(50)
|
20(20.8)
|
You believe that you are the front-line professional to create
awareness on HH practice
|
3
|
5
|
12(12.5)
|
49(51)
|
27(28.1)
|
You believe that you are one of the most accessible HCWs to patients
|
2
|
11(11.5)
|
12(12.5)
|
45(46.9)
|
26(27.1)
|
The frequency of HH required does not make it difficult to carry out ABHS as often as necessary.
|
8
|
41(42.7)
|
16(16.7)
|
26(27.1)
|
5
|
There is no time pressure for not to attend HH courses
|
5
|
21(21.9)
|
17(17.7)
|
36(37.5)
|
17(17.7)
|
Your HH practice can be further improved
|
4
|
8
|
12(12.5)
|
50(52.1)
|
22(22.9)
|
If ABHS is provided, it is not difficult for
you to use it even if ABHS
|
residual is not pleasant
|
3
|
16(16.7
|
13(13.5)
|
48(50)
|
16(16.7)
|
irritates your skin
|
2
|
25(26)
|
11(11.5)
|
41(42.7)
|
17(17.7)
|
is not easy to use
|
5
|
7
|
8
|
54(56.2)
|
22(22.9)
|
Potential risk factors related to poor attitude
According to this study results, univariate or multivariate statistical analysis (accordingly) showed that study participants differences in sex (p=0.96), age (p=0.39), years spent in healthcare setting (p=0.57) and current education level (p=0.35) did not have a statistically significant association with their attitude towards HH by ABHS (tablet 5). Even if it is not statistically significant the respondents considered as knowledgeable had better attitude towards ABHS use than not knowledgeable (COR 0.676; 95%CI 0.118-4; P= 0.676).
Compliance of respondents to WHO recommended alcohol-based 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 settings15. 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 finding is in line with different study14,15.
Compliance for ABHS use of the WHO identified five 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 concern21, 22. According to this study, majority 73(76%) of the study participants were compliant to the five moments of HH recommended by the WHO. This should be due to improved HCWs awareness of COVID-19 infection control techniques. This study finding shows more compliance to ABHS use than with other study conducted in University of Gondar teaching hospitals23 and in a tertiary university hospital in Istanbul24. This variation might be due to sample size, study time and outbreak of COVID-19.
Table 4: Compliance of respondents to hand hygiene using alcohol-based hand sanitizer
Compliance evaluation: When to use ABHS?
|
Frequency of use, n (%)
|
Always
|
Often
|
Sometimes
|
Seldom
|
Never
|
Before touching a patient
|
70(72.9)
|
11(11.5)
|
15(15.6)
|
-
|
-
|
Before clean/aseptic procedure
|
70(72.9)
|
14(14.6)
|
9(9.4)
|
1
|
2
|
After body fluid exposure risk
|
80(83.3)
|
9(9.4)
|
6(6.3)
|
-
|
1
|
After touching a patient
|
82(85.4)
|
7(7.3)
|
6(6.3)
|
-
|
1
|
After touching patient surroundings
|
80(83.3)
|
8(8.3)
|
6(6.3)
|
1
|
1
|
Most of the study participants 63 (65.6%) are compliant to ABHS duration of hand rub recommended by the WHO (20-40 seconds)15. The others were noncompliant to the WHO recommendation (<20 sec= 29(30.2), >40 sec= 4(4.1)).
Potential risk factors related to poor compliance to hand hygiene by alcohol-based hand sanitizer
Compliance to HH by ABHS did not statistically vary with respondents’ age, taking training, current education level (table 5). In univariate analysis, non-compliance with HH was not associated with sex (COR 1.101; 95% CI 0.413-2.935; P= 0.848). This finding agrees with study conducted in tertiary university hospital in Belo Horizonte, Brazil (2015) 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 five 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 knowledge23. 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 identified as the most common reasons for not using ABHS as their preferred technique to prevent spreading of COVID-19. This finding 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.
Compliance and self-reported health associated risks of alcohol-based hand sanitizer
According to this study most study participants had been using (alone or alternatively) ethanol based alcohol 65 (67.7%); followed by denatured ethanol 32(33.3%) and isopropanol based 10(10.4%). During their use, most of them experienced different health associated risks; commonly 60(62.5%) skin dryness, 27(28.1%) skin irritation, 18(18.8%) unpleasant taste, 11 (11.5%) ocular irritation, 11(11.5%) Cough, 4(4.2%) gastro-intestinal disturbances and 5 (5.2) others. This results agrees with study conducted in tertiary university hospital in Belo Horizonte, Brazil (2015)25. These risks become one of the reasons for not adhering to the WHO recommended five essential moments to use ABHS by 8 (8.5%) respondents.
Table 5: Factors related to lack of knowledge, poor attitude and practice of hand hygiene
Variables
|
Knowledge
|
COR (95%CI)
|
p-value
|
AOR (95% CI)
|
p-value
|
knowledgeable
|
Not knowledgeable
|
Sex
|
male
|
58
|
3
|
1
|
|
|
female
|
32
|
3
|
0.55(0.11-2.89)
|
0.48
|
Years spent in healthcare setting
|
<5
|
68
|
5
|
0.62 (0.07-5.58)
|
0.66
|
>5
|
22
|
1
|
1
|
|
Training*
|
yes
|
38
|
1
|
1
|
|
no
|
52
|
5
|
0.27(0.03-2.44)
|
0.25
|
3.65(0.4-32.56)
|
0.25
|
Attitude
|
Good attitude
|
Poor attitude
|
|
Sex
|
male
|
45
|
16
|
|
|
|
Female
|
29
|
9
|
1.03(0.40-2.65)
|
0.96
|
Age
|
18-30
|
58
|
23
|
0.39(0.08-1.86)
|
0.24
|
2.06(0.40-10.5)
|
0.39
|
>30
|
13
|
2
|
1
|
|
|
Years spent in healthcare setting
|
<5
|
55
|
18
|
1.34(0.48-3.77)
|
0.57
|
>5
|
16
|
7
|
1
|
|
Training*
|
Yes
|
31
|
8
|
1
|
|
No
|
40
|
17
|
0.61(0.23-1.59)
|
0.310
|
Current education level
|
Degree
|
47
|
20
|
0.49(0.16-1.47)
|
0.20
|
1.73(0.55-5.44)
|
0.35
|
Masters & above
|
24
|
5
|
1
|
|
|
Compliance
|
Compliant
|
Non-complaint
|
|
Sex
|
male
|
46
|
15
|
|
|
|
female
|
27
|
8
|
1.10(0.41-2.94)
|
0.85
|
Age
|
18-30
|
60
|
21
|
0.44(0.09-2.11)
|
0.31
|
>30
|
13
|
2
|
|
|
Training*
|
Yes
|
28
|
11
|
|
|
No
|
45
|
12
|
1.47(0.57-3..79)
|
0.42
|
Years spent in healthcare setting
|
<5
|
51
|
22
|
0.11(0.01-0.83)
|
0.03
|
8.00(0.99-64.08)
|
0.05
|
>5
|
22
|
1
|
|
|
|
Current education level
|
Degree
|
47
|
20
|
0.27(0.07-1.0)
|
0.05
|
2.98(0.78-11.34)
|
0.11
|
Masters & above
|
26
|
3
|
|
|
|
Legends
- Age and current education level do not fulfill the assumption to analysis knowledge of HCWs due to inadequate sample size
- *= training taken on techniques to prevent COVID-19 virus transmission
NA: Not applicable (Only variables with p values < 0.25 on univariate were put into multivariate regression model), COR: corrected odds ratio, AOR