Informational and structural barriers to uptake of preventive behaviours among Healthcare workers working in both isolation and non-isolation sitesduring COVID 19 in Zambia

1) Project background, context and needs addressed Countries all over the world areimplementing different strategies to prepare for expected increase in numbers of patients who test positive for COVID-19.The rising number of positive COVID-19 cases puts healthcare workers(HCW) at increased risk of infection,posing a serious threat to the epidemic chain as healthcare workers are the frontliners helping in controlling the pandemic.(1) As the numbers of positive patients increase, the risk to Healthcare also increases, putting a strain on supply of Personal protective equipment (PPE) as shortages of PPE are being noted in most health facilities around the world.(2) Other factors that put healthcare workers at risk includedelayed recognition of COVID-19 symptoms and lack of experience in dealing with respiratory pathogens,exposure to large numbers of patients in long shifts with inadequate rest periodsand lack of measures to prevent the spread in hospitals.(3)Thus, the World Health Organisation WHO recommends training and support for HCWs including to recognize respiratory diseases occurring in hospital settings even as it attempts to ensure consistent supply and distrubition of PPE(3,7). Countries have systematically implemented various infection preventionand control measureswith good results - for example, using refined management theory,a general hospital in China ensured zero hospital-acquired COVID-19 infections among hospital staff.They formulated prevention and control measures and standards for non-isolation areas in the hospital,infrared temperature screenin was performed on all entering the hospital those with high fever were escorted to fever outpatient. They also ensured that rapid hand sanitizer stations were at all entrances. All outpatients were scheduled, to control patient flow and surfaced were wiped every 4 hours. For inpatient education material was placed in strategic areas with emphasis on hand hygiene, wearing masks correctly and reducing the number of visitors. Systematic training was also used to continuously give staff on the latest COVID-19 information(4) The Korean government ensured that HCWs received training in diagnostic testing for COVID-19, how to wear protective clothing, and in management of novel infectious diseases in screening clinics.(5) Singapore having learnt from the 2003 Severe Acute Respiratory syndrome (SARS) has begun to prepare for new pandemics by establishing a 330 bed facility and stockpiling PPE and barrier equipment. Other measures such as having strict staff management polices in place has also helped reduce infection. These include 14-day compulsory leave of absence for staff who traveled overseas, twice daily temperature screening for all clinical and nonclinical staff, separation of teams into those who care for COVID-19 patients and those who do not, and designated clean areas.(6)Staff with respiratory symptoms are also not allowed to come to work until symptoms completely resolve . In Italy, organizations such as Médecins Sans Frontières (MSF) helped separate wards that could be contaminated from wards less at risk and monitoring of patient and staff flow.They are also helping to increase knowledge of healthcare staff on how to protect themselves and better manage patients.(8) Zambia reported its first two confirmed COVID-19 cases on Wednesday, 18 March 2020.9 Of the76 confirmed COVID-19 as of 24 April 2020,15 are HCWs, of whom at least 5 were working in isolation wards.10This raises questions about the training, systems, and PPE available and used by HCWs to prevent and controlCOVID-19 infection among HCWs in both non-isolation and isolation facilities. Establishing what HCWs know, their perceived threat of COVID-19 and their ability to practice preventive behavioursdissagregated by those directly working with and those not working with COVID-19 patients is important to design interventions that help control the spread of infection among HCWs including and not limited to training, system changes, practice and policy. 2) Aims or research questions being addressed This exploratory research aims to gather HCWs'perspectives on their knowledge and skills needs, their attitudes towards, and their ability to practice preventive behaviorsin the context of COVID-19 in Zambia.This perspectives will help inform interventions that reduce the risk of COVID-19 transmission in health care settings.The research questions we hope to answer are as follows: 1. What information do healthcare workers need to better protect themselves and their patients from the risk ofacquiringCOVID-19? 2. How do HCWs feel handling patients who present with respiratory illness in the time of COVID-19? 3. What are the motivators, facilitators and barriers to the uptake ofinfection prevention practices to avoid contracting COVID-19? How do these differ between HCWs in both isolation and non-isolation facilities? 3) Study design This qualitative study will use in-depth interviews with 20 healthcare workers, 10 from the isolation centres and 10 from two health centres -- one in high and the other in low density hotspots in Lusaka, the epicenter for COVID-19 in Zambia.Ourstudy populations will includeMinistryOf Health Zambiastaff,in particular HCWsand support staff who are directly involved in triaging, screening, testing and caring for COVID-19 patients in isolation facilitesandnon-isolation sites. If the current guidelines of social distancing are still in place by the time the study starts, we will conduct In-depth interviews by phone, recruiting staff through the facility-in-charges and through the Zambia National Public Heath Institute (ZNPHI). The ZNPHI leads the national epidemic response. Staff will be contacted on phone numbersprovided by the in-charges and ZNPHI. The lead qualitative researcher (this applicant) will explain the study and emphasize voluntary participation, confidentiality and right to refuse/withdraw with no penalty. Those interested to proceed will be asked for verbal consent before the IDI. The IDIs will be conducted on a conference call to includea research assistant, who will document the conversation, engagement and emotion. The interview will be audio recordedwith participants' consent. Each interview is expected to take 1-1.5 hours and will be conducted in English.Which is predominantly spoken in Lusaka.Interviewswill then be transcribed verbatim.The computers used for data entry will be password-protected and have regularly updated anti-virus application. No personal identifiers will be noted; pseudonyms or codes will replace any identifying information arising during interviews. Asemi-structured IDI guide will be used to collect the data andwillcontain open-ended but key questionstofullyexploreparticipantexperiencesthroughthe normal flow of conversation and probes to gain deeper insight and to pursue new information. Questions will explore the Once the interviews are completed, with the participant present on phone or in-person, interviewers will review the field guide and check the availability of notes and audio recordings to ensure that nothing has been left out.The recordings will then be transcribed verbatim. Final transcripts will be reviewed for accuracy against original notes and recordings for at least two transcripts. Recorded data will be transferred on to a lockable pass-word protected computer. Once this process is done and the quality of transcripts has been assured, recordings will be destroyed. All electronic data will be stored in secure locations, with access permissions only for authorized users. At a minimum, data will be stored until the final analysis and reporting on the project are complete. Ethical Considerations Ethical approvals will be sought from University of Zambia Biomedical Research Ethics Committee (UNZABREC).Informed consent will be obtained from persons completing the interviews. Any participants showing signs of distress will be referred to appropriate care. 4) Approach used to maximise the impact of research outputs, to improve health and the research community The findings from this study will be disseminated to relevant stakeholders such as the Ministry of Health, Zambia National Public Health Institute's Epidemic Preparednessand Response team, who are mandated to ensure that national policies, plans, procedures and protocols for public health emergency preparedness and response conform with the International Health Regulations.(11)Organisations like the National Health Research Authority (NHRA) are also key stake holders, part of whose mandate is dissemination research in Zambi and knowledge translation.(12) We will aim to share our findings with Philantrophic organizations such as the Jack Ma foundation who are distributing medical supplies around the world to the most affected parts.(13) We plan to publish the findings in relevant journals and contribute to the knowledge currently being generated on prevention of COVID-19 in healthcare settings with implications for other sub-Saharan African countries. 5) Expected outcomes We hope the findings from this study can be discussed with the relevant stakeholders who can tailor training, health policy and procedures to refineemergency response toolkits or practices for HCWs to use during pandemics.The results from this study will complement current initiatives by providing recommendations on how best HCWs can reduce the risk of contracting COVID-19 in both isolation and non- isolation facilities and for future emergencies.Our rigorous qualitative method design will provide robust evidence needed to protect our frontline workers and keep pace with the dynamic COVID-19 situation in Zambia. 6) Your role in the project I will lead the project and with a research assistant, will collect, analysis and report findings.   References 1. https://www.journalofhospitalinfection.com/article/S0195-6701(20)30187-0/fulltext#secsectitle0025 2. https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(20)30644-9/fulltext 3. https://www.weforum.org/agenda/2020/04/10-april-who-briefing-health-workers-covid-19-ppe-training/ 4.https://www.sciencedirect.com/science/article/pii/S2352013220300533?via%3Dihub 5. https://www.jeehp.org/upload/jeehp-17-10.pdf 6. Feng Tan L, Preventing the Transmission of COVID-19 Amongst Healthcare Workers, Journal of Hospital Infection, https://doi.org/10.1016/j.jhin.2020.04.008. 7. https://www.who.int/news-room/detail/03-03-2020-shortage-of-personal-protective-equipment-endangering-health-workers-worldwide 8. https://www.msf.org/protecting-hospital-staff-coronavirus-covid-19-codogno-italy 9. Ministry of Health Zambia. https://www.facebook.com/mohzambia/ COVID-19 UPDATE #1 SUMMARY. 2020; 10. https://diggers.news/local/2020/04/22/zambias-covid-19-cases-surge-to-70/ 11. http://znphi.co.zm/preparedness-and-response.html 12. https://www.nhra.org.zm/ 13. https://www.jackmafoundation.org.cn/our-work/#field-medical