Compliance and barriers to the use of infection prevention and control measures among health care workers during COVID‐19 pandemic in Qatar: A national survey

Abstract Aim To assess health care workers' compliance with infection prevention and control measures in different health care sectors in Qatar during COVID‐19 pandemic. Background Being the first line of defence against COVID‐19 infection, health care workers are particularly at increased risk of getting infected. Compliance with infection prevention and control measures is essential for their safety and the safety of patients. Methods A web‐based national survey was conducted between November 2020 and January 2021 targeting all health care workers in governmental, semi‐governmental and private health care sectors. Results Of 1,757 health care workers, 49.9% were between 30 and 39 years of age; the majority (47.5%) were nurses. Participants reported a significant increase in the median self‐rated compliance scores during the pandemic compared with before it (p < .001). During the pandemic, 49.7% of health care workers were fully compliant with personal protective equipment (PPE) use; 83.1% were fully compliant with hand hygiene. Overall, 44.1% were fully compliant with infection prevention and control measures (PPE and hand hygiene). Nationality, health sector, profession and frequency of interactions with suspected or confirmed COVID‐19 cases were significantly associated with compliance with overall infection prevention and control measures. The most reported barriers were work overload and shortages of PPE and handwashing agents. Conclusions Compliance of health care workers with infection prevention and control measures needs further improvement. Implications for Nursing Management Frequent quality checks, provision of adequate supplies and behaviour change interventions are recommended strategies for hospital and nursing administrators to improve health care workers' compliance.

Conclusions: Compliance of health care workers with infection prevention and control measures needs further improvement.
Implications for Nursing Management: Frequent quality checks, provision of adequate supplies and behaviour change interventions are recommended strategies for hospital and nursing administrators to improve health care workers' compliance. Health care workers-the first line of defence in the fight against COVID-19-are particularly at risk of getting infected while taking care of infected patients (Gholami et al., 2021). A recent systematic review and meta-analysis showed that the percentage of health care workers who tested positive for COVID-19 among 28 studies was 51.7%, with a 15% rate of hospitalization and a 1.5% death rate (Gholami et al., 2021). In Qatar, the rates of COVID-19 infection and hospitalization among health care workers are 10.6% and 11.6%, respectively (Alajmi et al., 2020). Standard precautions such as proper Low compliance with infection prevention and control measures may have negative consequences for workers, patients and institutions such as the occurrence of occupational accidents, health careassociated infections and institutional damage (Askarian et al., 2004;I. Jeong et al., 2008;Oliveira et al., 2009;World Health Organization [WHO], 2011). Health care-associated infections can result in prolonged hospital stays, long-term disability, massive additional costs for health systems and organizations, and unnecessary deaths (WHO, 2011). Compliance with PPE among health care workers during COVID-19 pandemic varied among different studies, ranging from 54% to over 95% (Ashinyo et al., 2021;Darwish et al., 2021;Michel-Kabamba et al., 2020;Neuwirth et al., 2020).
According to current evidence, the SARS-CoV 2 virus is transmitted between people through respiratory droplets and contact routes.
Transmission can occur by direct contact with infected people and indirect contact with surfaces in the immediate environment Huang et al., 2020;Li et al., 2020;Liu et al., 2020). The World Health Organization (WHO) recommended droplet and contact precautions (including the use of a medical mask, eye protection (goggles) or facial protection (face shield), a clean, non-sterile, longsleeved gown and gloves) for health care workers caring for suspected or confirmed COVID-19 patients, and airborne precautions using N95 respirator or equivalent in addition to contact precautions for settings in which aerosol generating procedures (AGPs) are performed. It also emphasized the importance of practicing hand hygiene (WHO, 2020a). Qatar formulated national infection prevention and control guidelines for COVID-19 in accordance with the WHO and Centers for Disease Control's (CDC) recommendations.
To the best of our knowledge, studies assessing compliance with the proper use of infection prevention and control measures among health care workers during this pandemic are limited, particularly in the Middle East. This is the first national study in Qatar to address this issue. It is expected that compliance with the use of PPE and hand hygiene practices changes after an epidemic, as this was evident from previous infectious outbreaks when significant improvements in compliance were noted (G. Jeong et al., 2016;Wong & Tam, 2005). So, addressing the changes in compliance during the current pandemic is worth investigating. We aimed to assess health care workers' compliance with the proper use of PPE and hand hygiene practices in different health care sectors in Qatar (governmental, semi-governmental and private sectors) during COVID-19 pandemic and explore the barriers to the proper use of such measures.

| Study procedure
A web-based self-administered survey was developed using Microsoft Forms software. Because of the low response rate generally encountered in web-based surveys and in order to improve the external validity of our study, we invited all eligible health care workers in PHCC (representing a major part of the governmental sector), semigovernmental and private facilities to take the survey. They were contacted via e-mail with an information letter and a link to the electronic version of the questionnaire. The letter stated the purpose of the study, and that the participation is voluntary. Taking the survey implied informed consent, and participants were free to terminate the survey at any time they desired. The survey was anonymous, and confidentiality of information was assured. Weekly reminders were sent to maximize the response rate.

| Study questionnaire
We developed a questionnaire that was adopted from different surveys (Chia et al., 2005;Majeed, 2018;Schwartz et al., 2014;Shimokura et al., 2006;WHO, 2020c) in English. Face and content validities were assured by experts in the field. It consisted of three sections. The first one addressed the socio-demographic data for the participants (age, gender, nationality, profession, clinical experience and health care facility), in addition to general COVID-19-related information such as having a friend or a relative infected with COVID-19, the status of training on proper use of PPE and hand hygiene practices, and the frequency of dealing with suspected or confirmed COVID-19 cases. The second and third sections assessed health care workers' compliance with the proper use of infection prevention and control measures (PPE and hand hygiene) using a checklist adopted from WHO risk assessment tool for health care workers in the context of COVID-19 (WHO, 2020c), and the barriers to the proper use, respectively.

| Study variables
To assess the compliance of health care workers with infection prevention and control measures, they were asked about the frequency of using each PPE item when dealing with suspected or confirmed cases or while performing an AGP for a suspected or confirmed case using a five-point-Likert scale (always as recommended, often, sometimes, seldom, never). And were asked about the frequency of performing hand hygiene (using similar Likert scale) at five moments that are as follows: before touching a patient, before any clean or aseptic procedure is performed, after exposure to body fluid, after touching a patient and after touching patient's surroundings. Health care workers who answered all the questions as 'always as recommended' were considered as fully compliant. We also asked the participants to rate their overall perceived compliance with proper use of PPE and hand hygiene before and during the pandemic on a ten-point scale (from 0 to 9, on which 0 indicates no compliance, and 9 indicates full compliance). Barriers to the appropriate use of infection prevention and control measures as recommended were assessed by asking health care workers to select one or more options from a list of barriers for PPE and hand hygiene separately. They were also able to specify other barriers that were not listed.

| STATISTICAL ANALYSIS
Data analysis was performed using IBM SPSS Statistics for Windows, Version 26.0. Armonk, NY: IBM Corp. Descriptive statistics were presented as frequencies and percentages for categorical variables. Continuous not normally distributed variables were presented as medians and interquartile ranges. Chi-square test was used to determine the differences between categorical variables. The Wilcoxon signed rank test was used to test the differences in the self-rated compliance with infection prevention and control measures before and during COVID-19 pandemic taking into consideration the self-rated compliance on the ten-point scale as an ordinal dependent variable.
Rank biserial correlation was calculated to measure the effect size for these comparisons (small 0.10 to <0.30, medium 0.30 to <0.50, large ≥0.50). Three multivariable logistic regression models were executed to determine the predictors of full compliance with infection prevention and control measures, one for appropriate use of PPE, one for hand hygiene, and one for overall infection prevention and control measures (both PPE and hand hygiene). The associations between risk factors and outcomes were presented as adjusted odds ratios (ORs) and 95% confidence intervals (95% CIs). Goodness of fit was assessed using Hosmer-Lemeshow test. p values less than .05 were considered significant.

| Ethical approval
This study was performed in line with the principals of Declaration of Helsinki. Approval was obtained from the relevant health institutions under protocol ID PHCC/DCR/2020/07/073.

| Socio-demographic characteristics and general information
As shown in Table 1

| Compliance with infection prevention and control measures
When participants were asked to rate their compliance with infection prevention and control measures on a ten-point scale, before and during the pandemic, there was a significant increase in the median selfrated compliance scores during the pandemic compared with before it (median score: 7 before and 9 during, for PPE), and (median score: 8 before and 9 during, for hand hygiene), with p values < .001 and large effect sizes (r = .87 and .89), respectively. We assessed compliance with infection prevention and control measures using a checklist adopted from WHO risk assessment tool for health care workers in the context of COVID-19 (WHO, 2020c

| Predictors of compliance with infection prevention and control measures
Three multivariable logistic regression models were executed to determine the predictors of compliance with infection prevention and control measures. One for compliance with PPE (during both interactions with suspected or confirmed COVID-19 cases and while performing an AGP), one for compliance with hand hygiene at the five moments, and a third one for compliance with overall infection prevention and control measures (with both PPE and hand hygiene).
All models were of good fit and were statistically significant (p values < .001) compared to the null model. The selection of independent variables to be included in the models was based on clinical and statistical relevance. In the first model (Table 2), nationality, health sector, profession and frequency of interactions with suspected or confirmed COVID-19 cases were found to be significantly and independently associated with compliance with PPE. The following were less likely to be fully compliant: nationalities of Middle Eastern-North African origin compared to those of Asia-Pacific origin (OR 0.44, 95% CI 0.30-0.65, p < .001), pharmacists compared to physicians (OR 0.16, 95% CI 0.07-0.38, p < .001), and health care workers at the private sector compared to those at the governmental sector (PHCC). On the other hand, dentists were more likely to be fully compliant with PPE compared to physicians (OR 6.23, 95% CI 2.37-16.38, p < .001), so as health care workers who deal with suspected or confirmed COVID-19 cases frequently (every shift) compared to those who never deal with such cases (OR 1.99, 95% CI 1.18-3.36, p = .010). In the second model (Table 3), compliance with hand hygiene was significantly associated with gender, nationality, profession and previous training on hand hygiene. Males were less likely to be compliant than females (adjusted OR 0.71, 95% CI: 0.52-0.95, p = .022), as well as those with nationalities of all origins compared to those with nationalities of Asia-Pacific origin. On the other hand, allied health professionals were more likely to be compliant with hand hygiene compared to physicians (adjusted OR 2.06, 95% CI: 1.32-3.20, p = .001), and health care workers who received previous training on hand hygiene were more than two times more likely to be compliant compared to those who did not (adjusted OR 2.42, 95% CI: 1.44-4.07, p = .001). In the third model ( study, pharmacists were found less likely to be fully compliant with proper use of PPE than physicians, which is consistent with the results of Ghana study (Ashinyo et al., 2021). One explanation might be that pharmacists are less likely to have direct contact with patients in general and with suspected or confirmed COVID-19 cases. In addition, the duration of their contact is usually short and in most cases like in hospitals, patient's family or friends are the ones who attend the pharmacy for medication pick up upon discharge not the patient him/herself. Also, at almost all pharmacies in Qatar, most of the contacts happen through glass shields that might be perceived as protective by many pharmacists against countering infection. On the other hand, dentists were found more likely to be compliant with PPE and with overall infection prevention and control measures than physicians. This might be explained by the closer contact dentists have with their patients while managing them, as their job involves more contact with aerosols and droplets produced during many dental procedures that have the potential to spread the infection to dental personnel. This will force dentists to be more fully compliant with infection prevention and control measures in a step to protect themselves from getting infected. Health care workers in the governmental T A B L E 3 Determinants and predictors of full compliance with hygiene using chi-square test and multiple logistic regression analysis firmed. This finding is also supported by another finding in our study that showed that those who deal more frequently with suspected or confirmed cases were more likely to be compliant, which is also consistent with established findings in the literature (Brooks et al., 2020).
We found that lack of time, discomfort caused by certain types of PPE, shortage of PPE, and skin irritation caused by handwashing

ACKNOWLEDGMENTS
Qatar National Library (QNL) funded the publication of this article.

CONFLICT OF INTEREST
None.

FUNDING INFORMATION
This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.

ETHICAL APPROVAL
This study was performed in line with the principals of Declaration of Helsinki. Approval was obtained from the Institutional Review Board of the Primary Health Care Corporation (PHCC) under protocol ID PHCC/DCR/2020/07/073 to carry out the survey at PHCC level, and an exempt certificate was obtained from The Health Research Governance Department at Ministry of Public Health (MOPH) to carry out the survey at the semi-governmental and private sectors.

DATA AVAILABILITY STATEMENT
The data that support the findings of this study are available from the corresponding author upon reasonable request.