An-Najah National University Faculty of Graduate Studies COMPLIANCE WITH COVID-19 PROTECTIVE MEASURES AMONG HEALTH CARE PROVIDERS IN MATERNITY WARDS AND REVIEWING THE RELATED HOSPITAL POLICIES AND GUIDELINES IN WEST BANK GOVERNMENTAL HOSPITALS, 2021 By Duaa Bsharat Supervisors Dr. Mariem Al -Tell This Thesis is Submitted in Partial Fulfillment of the Requirements for the Degree of Master of Public Health Management, Faculty of Graduate Studies, An-Najah National University, Nablus - Palestine. 2022 III Dedication Idedicate this thesis To my beloved homeland "palestine" To my mother and father, may God preserve them... Without them, I would not have existed in this life.... From them I learned to love my life.... Challenge difficulties... and achieve the impossible. To my brother and sisters... who did not hesitate for a moment to support and assist me in completing my educational career To my honorable professors.... From them, I learned the letters..... and learned how to pronounce words..... and formulate phrases.... They showed me the path of science and knowledge. To my friends and colleagues... companions of my path... .. .. good companionship... the fragrance of love... and the roses of friendship To them,idedicate my thesies IV Acknowledgment At the beginning of my speech, I must first thank my God Almighty, who enabled me to reach this high scientific level and helping me through all the difficulties . My beloved father, my dear mother, my brother and sisters ......I cannot forget your support for me and what you have given for me. You have all my love, and no matter how many words of thanks I say to you, I will not give you what you deserve . I would like to extend my sincere thanks to my supervisor, Dr. Maryam Al-Tall, who made this work possible, and who gave me of her precious time and a sea of information and extensive experience, which constituted a great addition to the research work, as her guidance and advice were the beacon that I used in my entire research work,I ask my God, the mighty, to reward her with the best reward I would also like to thank the members of my committee for making my defense an enjoyable moment, and for your wonderful comments and suggestions, thank you. VI List of Contents Dedication ........................................................................................................................... III Acknowledgment ................................................................................................................ IV Declaration ......................................................................................................................... V List of Contents ................................................................................................................... VI List of Tables ....................................................................................................................... X List of Figures ..................................................................................................................... XI Abstract ............................................................................................................................. XII Chapter One: Introduction .................................................................................................... 1 1.1 Background ..................................................................................................................... 4 1.1.1 COVID-19.................................................................................................................... 4 1.1.1.1 Definition of COVID ................................................................................................ 4 1.1.1.2 Transmission of COVID -19 ..................................................................................... 4 1.1.1.3 Signs, symptoms, and complications of COVID-19 ................................................. 4 1.1.1.4 Types of COVID-19 diagnostic tests ........................................................................ 5 1.1.1.5 Preventive measures of COVID-19 .......................................................................... 5 1.1.2 Standard precaution ..................................................................................................... 5 1.1.2.1 Definition of standard precautions ............................................................................ 5 1.1.2.2 Types of Standard precautions .................................................................................. 6 1.1.2.2.1 Gown ...................................................................................................................... 7 1.1.2.2.2 Gloves .................................................................................................................... 7 1.1.2.2.3 Facial protection ..................................................................................................... 7 1.1.2.2.4 Face masks and respirators : .................................................................................. 8 1.1.2.2.5 Respiratory hygiene and cough etiquette (WHO .2021c) .................................... 11 1.1.2.2.6 Injection safety practices: .................................................................................... 12 1.1.2.2.7 Safe waste management ....................................................................................... 12 1.1.2.2.8 Proper linens: ....................................................................................................... 12 1.1.2.2.9 Environmental cleaning: ...................................................................................... 13 1.1.3 Vaccine of COVID-19 ............................................................................................... 13 1.1.3.1 Definition of vaccine ............................................................................................... 13 VII 1.1.3.2 Facts about vaccinations ......................................................................................... 13 .1.3.3Types of vaccinations ................................................................................................ 14 1.1.3.3.1 Complete virus vaccine ........................................................................................ 14 1.2 Literature review ........................................................................................................... 15 1.3 Epidmiolgy .................................................................................................................... 22 1.4 Measures that have been taken by the Palestinian Ministry Of Health (MOH) ........... 23 1.5 Statement of problem .................................................................................................... 26 1.6 Variables definitions ..................................................................................................... 27 1.7 Study Objectives ........................................................................................................... 29 1.7.1 Goal of the study ........................................................................................................ 29 1.7.2 Aim of the study......................................................................................................... 29 1.7.3 Specific objectives ..................................................................................................... 29 1.8 Study significance ......................................................................................................... 29 1.9 Study Hypothesis (Null hypothesis) ............................................................................. 30 Chapter Two: Methodology ................................................................................................ 31 2.1 Study design .................................................................................................................. 31 2.2 Study population ........................................................................................................... 31 2.3 Sample and Sampling method ...................................................................................... 32 2.3.1 Inclusion criteria ........................................................................................................ 32 2.3.2 Exclusion criteria were .............................................................................................. 33 2.4 Tool of data collection .................................................................................................. 33 2.4.1 Questionnaire parts: includes four sections, annex (A),page (73) ............................. 33 2.5 Validity and Reliability ................................................................................................. 34 2.6 Statistical analysis ......................................................................................................... 34 Chapter Three: Results ....................................................................................................... 37 3.1 Socio-Demographic data ............................................................................................... 37 3.2 Distribution of participants regarding their compliance about COVID -19 (IPC) measures .................................................................................................................... 39 3.3 Distribution of participants regarding the individual factors domain about COVID -19 (IPC) measures : ........................................................................................................ 40 3.3.1 Distribution of participants regarding the level of Knowledge about IPC measures for COVID-19 ............................................................................................................ 40 VIII 3.3.2 Distribution of participants regarding their Attitude about COVID -19(IPC) measures .................................................................................................................... 41 3.3.3 Distribution of participants regarding their clinical practice about COVID -19 (IPC)measures ........................................................................................................... 42 3.4 Distribution of participants regarding their institutional support for COVID -19 (IPC) measures .................................................................................................................... 43 3.5 Distribution of participants according their attitude of vaccine for COVID -19 .......... 44 3.6 Means of compliance and associated factors score of participants regarding IPC measures for COVID-19............................................................................................ 45 3.7 Results of hypothesies……………………………………………………………...46 3.8 Review the hospital policies and guidelines related to COVID-19 protective measures that issued during the pandemic ................................................................................ 47 3.8.1 Updating the quarantine protocol for those infected and in contact with Covid-19 disease protocol ......................................................................................................... 47 3.8.2 The outbreak of the COVID-19 epidemic the fifth wave, recommendations for the next stage, and the protocol for work in hospitals ..................................................... 48 3.8.3 Sampling protocol update .......................................................................................... 48 3.8.4 Receiving vaccinations against the Corona virus ...................................................... 48 3.8.5 Handbook of policies and work procedures for combating and controlling infection with the Covid-19 virus in hospitals .......................................................................... 49 3.8.6 Central quarantine and home quarantine policy no (38) ............................................ 49 1.8.7 Epidemiological survey by phone .............................................................................. 49 3.8.8 Putting on and taking off personal protective equipment in case of complete barrier isolation / level one .................................................................................................... 50 3.8.9 Rational use of PPE for COVID-19/coronavirus ....................................................... 51 3.8.10 Ambulance disinfection and cleaning policy when transporting a suspected or confirmed case of COVID-19 virus,policy no (26) ................................................... 51 3.8.11 Policy for cleaning and disinfecting reusable equipment for the COVID-19 patient ,no (25) ...................................................................................................................... 51 3.8.12 The mechanism of disposal of medical waste resulting from the provision of health care to Covid-19 patients,policy no(27) .................................................................... 52 3.8.13 Criteria for sampling related to COVID-19,policy no (23) ..................................... 52 IX 3.8.14 Policy of cleaning and disinfecting personal protective equipment in the event of re- use .............................................................................................................................. 53 3.8.15 Treatment protocol for covid-19 patients,no (16) .................................................... 53 Chapter Four: Discussion .................................................................................................... 54 4.1 Introduction ................................................................................................................... 54 4.2 Socio-demographic data ................................................................................................ 54 4.3 Compliance of participants regarding IPC measures for COVID-19 comparision with other studies ............................................................................................................... 55 4.4 Individual factors of participants regarding IPC measures ........................................... 56 4.4.1 knowledge of participants regarding IPC measures for COVID-19 comparision with other studies ............................................................................................................... 56 4.4.2 Attitude of participants regarding IPC measures for COVID-19 comparision with other studies ............................................................................................................... 57 4.4.3 Practice of participants regarding IPC measures for COVID-19 comparision with other studies ............................................................................................................... 57 4.6 Atittude of health care providers toward vaccine ......................................................... 59 4.7 Associations between compliance and other factors with socio-demographic factors 60 4.8 Associations between compliance and associated factors with other studies ............... 61 4.10 Conclusion and recommendation ................................................................................ 62 4.10.1Conclusion ................................................................................................................ 62 4.10.2 Recommendations .................................................................................................... 62 List of Abbreviations .......................................................................................................... 64 References ........................................................................................................................... 65 ب ................................................................................................................................... الملخص X List of Tables Table 2.1: Name of hospital and the number of health care providers in maternity departments in them ....................................................................................... 32 Table 3.1: Distribution of participant's percentage according to their demographic data .. 37 Table 3.2: Distribution of the percentage of participants according to their workplace/hospital ......................................................................................... 38 Table 3.3: Distribution of participants regarding their compliance to IPC measures for COVID -19 .................................................................................................... 39 Table 3.4:Distribution of percentage participants regarding their attitude to IPC measures for COVID -19 ............................................................................... 41 Table 3.5: Distribution of percentage participants regarding their practice to IPC measures for COVID -19 ............................................................................ 42 Table 3.6: Distribution of participants percentage of the institutional support for IPC measures of COVID-19 ................................................................................. 43 Table 3.7: The responses of participants according to COVID-19 vaccine ...................... 44 Table 3.8: Distribution of participants regarding to the means of compliance and other associated factors score for COVID-19 IPC measures ................................. 45 Table 3.9: Distribution of participants regarding their compliance and associated factors scores of IPC measures for COVID -19 .......................................... 45 Table 3.10: Differencies between means of scores of compliance and their age (ANOVA test) ................................................................................................................ 86 Table 3.11: Differencies of participants compliance means of scores and their occupation (ANOVA test) ................................................................................................ 87 Table 3.12:. Differences between means of scores of compliance and their educational level (ANOVA test ) ...................................................................................... 87 Table 3.13: post hoc test of educational level ..................................................................... 88 Table 3.14: Diffrencies between means of scores of compliance and participants length of work experience (in years) (ANOVA ) ......................................................... 88 Table 3.15: Distribution of participants length of working experince according to post hoc test .................................................................................................................. 89 Table 3.16: diffrencies of participants compliance means of scores and their their working hours/ week (ANOVA) test ............................................................. 89 XI List of Figures Figure 1: The World Health Organization (WHO) in (2009), focusing on guidelines known as the "Five Moments for Hand Hygiene (Toney et al., 2020) ............................... 6 Figure2: FFP (Filtering Face Piece) mask with valve .......................................................... 8 Figure3: FFP mask without valve ……………………………………………………….. 8 Figure 4: Homemade face mask for everyday use ................................................................ 9 Figure 5: Surgica ................................................................................................................... 9 Figure 6: N95 respirator ...................................................................................................... 10 Figure 7: KN95 respirator …………………………………………………………...….. 11 Figure 8: distribution of the participant's correct answers regarding the knowledge about IPC measures for COVID-19. ............................................................................... 40 Figure 9: ……………………………………………………………………...……..……50 Figure 10: Steps to wear full PPE ..................................................................................... 50 Figure 11: Step s to remove full PPE .................................................................................. 92 Figure 12: Rational use of PPE for COVID-19/corona virus ............................................. 93 XII List of Appendices Appendix (A):questionner .................................................................................................. 74 Appendix (B):Approval of IRB ......................................................................................... 83 Appendix (C): Approval of faculty of graduate studies scientific research board at An- Najah National University. ................................................................................................. 84 Appendix (D): Consent form of questionner……………………………………….……..84 Appendix (E): Table ........................................................................................................... 86 Appendix (F): Figurs........................................................................................................... 92 XII COMPLIANCE WITH COVID-19 PROTECTIVE MEASURES AMONG HEALTH CARE PROVIDERS IN MATERNITY WARDS AND REVIEWING THE RELATED HOSPITAL POLICIES AND GUIDELINES IN WEST BANK GOVERNMENTAL HOSPITALS, 2021 By Duaa Bsharat Supervisors Dr. Mariem Al -Tell Abstract Background: Coronavirus disease 2019 (COVID-19) emerged as most arguable worldwide danger facing global health at present time .Healthcare workers (HCWs) particularly nurses, midwives, and doctors are at higher risk of infection from occupational exposure in different healthcare settings . Following standard precautions(SPs) in all situations would be one of the most effective ways to reduce cross-transmission, regardless of whether the patients are suspected or confirmed to be infected Objectives: The study aimed at evaluating the compliance with COVID-19 Infection prevention and control (IPC) measures and identifying associated factors among health providers in maternity wards in west bank hospitals Methodology: A cross-sectional study was conducted in maternity departments at 12 west bank governmental hospitals. Data were collected from 267 participants using a convenient sampling method. Using a pre-validated questionnaire developed from combining the contents of 3 different literature questionnaire .The Statistical Package for Social Sciences (SPSS) version 22was used to analyze data and the study hypotheses were examined at the level of statistical significance (a ≤0.05) Results: The results showed that the majority (85.1%)of the participants had a high level of compliance regarding IPC (infection prevention and Control ) measures for COVID-19.The results found no significant differences in IPC measures between compliance ,sociodemographic factors ,individual factors and institusional factors . XIII Conclusions: Despite that the majority of the participants had high level of compliance of IPC measures for COVID-19.Good compliance came from avaliabilty of suffiecient supplies for hand washing and availability of Personal Protective equipments ( PPEs ). However , Complete non-compliance among healthcare providers was due to IPC guidlines and protocols for COVID-19 in the maternity wards were not clear,not always known by them ,and there were no always monitoring and evaluation of it. More observational studies are recommended to evaluate the adherance of IPC measures for COVID-19 and holding regular training courses about current and any up dated information of IPC measures for COVID-19 to inform the health care providers of all that is new and assure compliance through rigorse monitoring Keywords: Compliance, health care providers, COVID-19, protective measures, west bank 1 Chapter One Introduction Coronavirus disease 2019 (COVID-19) emerged as most arguable worldwide danger facing global health at present time (Amanya et al., 2021). The first case of COVID-19 was discovered in December of 2019, in Wuhan city of China. The virus that causes Covid-19 is associated with extreme acute respiratory syndrome and is called coronavirus 2 (SARS-CoV-2), It is a new virus that causes respiratory disease in humans and may be transmitted from person to person through respiratory droplets when someone with COVID-19 sneezes, coughs or speaks, droplets are released (El Zowalaty et al., 2020). Recent evidence also suggests that Covid-19 infection has been spread with a risk of causing asymptomatic infection to healthcare workers (Lee et al., 2020). On March 11, 2020, the World Health Organization (WHO) declared the COVID-19 virus a global pandemic (Wong et al., 2021). Healthcare workers (HCWs) particularly nurses, midwives, and doctors, are at higher risk of infection from occupational exposure in different healthcare settings than the general public, and following standard precautions in all situations would be one of the most effective ways to reduce cross-transmission, regardless of whether the patients are suspected or confirmed to be infected. (Verbeek et al., 2019) In the fight against COVID -19, health care providers are placing themselves in grave danger. COVID -19 infected and killed many healthcare personnel, and many of them were isolated to prevent the sickness from spreading (Nagesh et al., 2020). The purpose of standard precautions is to ensure that the minimal measures used are followed in healthcare. It was changed and updated in response to changing hazards of exposure among healthcare workers (HCWs); to ensure the sufficiency and timeliness of standard precautions ; to promote healthcare workers and patients well-being (Wong et al., 2021). Many governments throughout the world imposed various restrictions to reduce Covid- 19-related morbidity and mortality. However, only a few countries were successful in halting the spread of the disease, with many developing countries, notably those in Sub- 2 Saharan Africa, failing to do so (Atnafie et al ., 2021). On the other hand, the Chinese government Mandated HCWs to strictly enforce uniform preventive measures and strengthen protective measures against droplet isolation, touch isolation, and air isolation to effectively reduce the risk of COVID-19 transmission in healthcare institutions and standardize HCW behaviors. Hand hygiene, medical masks, personal protective equipment (PPE), sterilization of patient-care equipment and linen, and other (IPC) interventions are all recommended by the WHO (Lai et al., 2020). World Health Organization (WHO) recommends keeping a physical distance of a minimum of 1 meter (3 ft) between people to avoid infection (WHO, 2021a). In addition to proposing standard precautions, the WHO proposes a series of infection control measures in the workplace, both at the individual and organizational level, to protect healthcare professionals (Beyamo, et al., 2019) and improve the response of healthcare systems to COVID -19 ( Wong et al ., 2021). Current pandemic crisis has modified the routine of healthcare practices, as new issues have emerged; they have impacted obstetric and childbirth healthcare services, which cannot be discontinued. Because Covid-19 infection in pregnancy is a new virus with limited evidence, therefore decisions about preventive, diagnostics, and treatment should be based on prior experience with clinical judgment, and common sense while dealing with viral illnesses (Poon et al., 2021). Already immunization has been recognized as the foremost effective strategy of avoiding episodes and lessening morbidity and mortality, particularly for healthcare laborers. (Huynh et al., 2021) . One of the most prominent goals of vaccinations of all kinds is to vaccinate the largest number of people around the world and to produce community immunity against the Coronavirus. (WHO .2021b, Huynh et al., 2021). Benefits of vaccines includes: protecting people against COVID-19, prolonging lives, and preventing widespread social disruption,it can help patients and caregivers avoid out-of-pocket therapeutic costs, and misfortunes in compensation by preventing bouts of preventable infection. (Arindam et al,. 2020) 3 Also, COVID-19 vaccinations should not be withdrawn from pregnant women, according to a new recommendation of the Centers for Disease Control (CDC) and Prevention in collaboration with the American College of Obstetricians and Gynecologists and the American Academy of Pediatrics (Shimabukuro et al,. 2021). Although, COVID-19 immunization in pregnancy are still constrained and, hence, most restorative social orders and organizations prompt that an immunization ought to be advertised to pregnant ladies after examining the dangers and benefits and the need for security information( Bookstein Peretz et al., 2021)After conducting many studies on the effectiveness of vaccines for pregnant and lactating women. The Pfizer vaccine has proven to be effective and safe after giving it to pregnant and lactating women (WHO.2021b). Concerning maternal coronavirus infection during pregnancy, two critical parameters have been underlined. First, the coronavirus (SARS-CoV and SARS-CoV-2) cannot be transferred vertically from mothers to newborns. Second, SARS or COVID-19 infection in the mother should not be an indicator of impending labor. The mother's respiratory stituation if she require for oxygen supplementation , heightening of ventilator ,confinement of chest extension ,and existing of any obstetric indications should be the only determinants of when and how she gives birth (Trevisanuto,2020). Despite a large increase in preparedness and progress as a result of previous epidemics, HCWs' compliance with ideal practices is still insufficient in general, and compliance rates differed across different parts of the (SPs ) (Kim & park,2020, Lim et al., 2021).The prevention of Coved -19 infection in health care workers necessitates a multi- coordinated approach that incorporates Occupational Health and safety (OHS) measures and also (IPC). Also, incorporating appropriate clinical measures at personnel levels is recommended to ensure the transmission of infection related to healthcare services ( lai et al ., 2020). The purpose of the study is to assess the compliance level of health care providers in the maternity wards to COVID-19 protective measures, identify factors affecting the health care provider compliance to COVID-19 protective measures, and review the hospital policies and guidelines related to COVID-19 protective measure that issued during the pandemic 4 1.1 Background 1.1.1 COVID-19 1.1.1.1 Definition of COVID COVID-19 is an illness caused by the SARS-CoV-2 virus. COVID-19 causes modest symptoms in the majority of people, but it can cause serious illness in others. Although the majority of patients with COVID-19 recover within weeks after becoming unwell, some people develop post-COVID symptoms. It is more prone to cause serious illness in the elderly and individuals with specific underlying medical disorders. (WHO.2021a) 1.1.1.2 Transmission of COVID -19 COVID-19 transmits through the air when an infected person exhales virus-containing droplets and very minute particles. Other people's eyes, nostrils, and mouths may be irritated by these drops and particles. These beads and particles can be breathed in by other individuals or arrive on their eyes, noses, or mouth. In a few circumstances, they may contaminate surfaces they tou ch. Individuals who are closer than 6 feet from the tainted individual are most likely to urge contaminated (WHO.2021a, CDC.2021a , Wu et al., 2020). 1.1.1.3 Signs, symptoms, and complications of COVID-19 Pneumonia was the first clinical symptom of the SARSCoV2 linked disease COVID19 that enabled case discovery. Theaverage incubation duration is five days to 7 days and the median incubation period is three days (range: 0–24 days). Fever, cough, nasal congestion, tiredness, and other upper respiratory tract infection symptoms usually appear after less than a week in symptomatic patients. (WHO.2021a, CDC. 2021a,Velavan et al., 2020, El Zowalaty et al,. 2020). If a fever or cough is accompanied by difficulty breathing or shortness of breath, or dyspnea and severe chest symptoms suggesting pneumonia chest discomfort or pressure, or loss of speech or movement, people of all ages should seek medical assistance immediately. (Velavan et al., 2020, WHO.2021a). In rare situations, children can have aserious infection situation a few weeks after infection.About 15% become extremely ill and need oxygen,and 5% necessitating 5 immediate medical attention.Respiratory failure, severe respiratory difficulty problem, sepsis and septic shock, thrombo-embolism, and/or multi-organ failure, including damage to the heart, liver, or kidneys, are all potential causes of mortality.. (Velavan et al., 2020, WHO.2021a, CDC.2021) 1.1.1.4 Types of COVID-19 diagnostic tests − In most cases, an atomic test is used to confirm SARS-CoV-2 infection.The most often used atomic test is the Polymerase Chain Reaction (PCR).Swabs are used to collect samples from the nose and/or throat.As a result, the atomic test is used to confirm the presence of an active infection, which occurs a few days after exposure and around the time symptoms mainfest. (WHO .2021a ,CDC.2021a) − Rapid antigen testing (also known as fast symptomatic tests) was used to identify viral proteins (known as antigens).Also ,swabs is applied to take samples from the nose and/or throat.These tests are less expensive than PCR and will provide results faster, however they are generally less exact.When there are a lot of viruses circulating in the population and a sample is taken from a person when they are at their most contagious, these tests perform best. (WHO .2021a ,CDC.2021a) 1.1.1.5 Preventive measures of COVID-19 Simple preventive measures from COVID -19 such as: Physical distancing ,wearing a mask, keeping rooms well ventilated ,avoiding crowds and close contact , and frequently wiping your hands, and coughing into a bent elbow or tissue (WH.2021a, CDC.2021a, lee et al., 2020). 1.1.2 Standard precaution 1.1.2.1 Definition of standard precautions Standard precautions were previously called Universal Precaution. Defined as "the bare minimum of infection prevention procedures that should be implemented to all patient care" regardless of whether the patients' infection status is suspected or confirmed, and are utilized in any situation where health care is provided. (CDC. 2021b). 6 These safety measures ought to be implemented at any site where health services are conveyed and always affecting blood, body liquid, discharges, and excrements of the patients have infectivity possibilities (CDC.2007, Al-Faouri et al., 2021). 1.1.2.2 Types of Standard precautions − Perform hand hygiene (WHO .2009, CDC .2011) It could be a major component of standard safety measures and one of the foremost viable strategies to stop the transition of pathogens related to wellbeing care (CDC .2011). − Hand washing (40–60 sec): moisten hands and apply cleanser to cover all zones of the hands; rub all surfaces; flush hands and dry altogether with a single utilized towel; utilize a towel to turn off the faucet.(WHO.2009,CDC.2011). Figure 1 The World Health Organization (WHO) in (2009), focusing on guidelines known as the "Five Moments for Hand Hygiene (Toney et al., 2020) − Use PPE. Standard Precautions for All Patient Care, (CDC .2021c) Personal protective equipment (PPE) refers to a group of protective equipment which includes: clothing, protective caps, gloves, confront shields, goggles, facemasks and/or respirators or other hardware planned to ensure the wearer from harm or the spread of disease or infection.PPE is commonly utilized in wellbeing care settings such as hospitals, doctor's workplaces, and clinical labs.( WHO.2009). 7 The sort of PPE utilized will differ based on the level of safety measures required, such as standard and contact, bead, or airborne contamination segregation safety measures. The strategy for putting on and evacuating PPE ought to be custom-made to the particular sort of PPE. PPE Sequence. (CDC.2021c) 1.1.2.2.1 Gown It is dress wearing to protect your skin and avoid getting your clothes soiled during activities that are likely to result in sprinkles or spraying of blood, body fluids, emissions, or excretions .Health Care Providers (HCPs ) should not utilize more than one isolation gown at a time when caring for patients with suspected or confirmed SARS-CoV-2 infection, and reusable gown ought to not be reused sometime recently washing since reuse gown dangers for conceivable transmission of microbes among HCPs and patients that likely exceed any potential benefits according to CDC. (WHO.2007,CDC.2021c) 1.1.2.2.2 Gloves − when coming into contact with blood, any body fluids, secretions, excretions, mucous membranes, or non-intact skin − After interaction with any potentially infectious substances, switch between duties and procedures on the same patient. − Remove after each use, before touching non-infected materials or surfaces, and before moving on to the next patient. After you've removed your gloves, wash your hands quickly When caring for suspected or confirmed COVID-19 patients, the WHO does not suggest using double gloves (WHO .2007) 1.1.2.2.3 Facial protection Protection for the eyes, nose, and mouth during actions: − Wearing a surgical or strategy veil and eye assurance (eye visor, goggles) or (2) a confront shield to ensure mucous films of the eyes, nose, and mouth amid exercises that are likely to produce sprinkles or sprays of blood, body-liquids, discharges, and excretions. 8 − Wearing safety glasses with extensions to cover the sides of the eyes (e.g., trauma glasses HCP who may be at an increased risk of severe illness from SARS-CoV-2 infection, such as those of severe resource constraints when eye protection is unavailable (WHO.2002, CDC.2021c) 1.1.2.2.4 Face masks and respirators : Face-covering protection gear. They're made to protect both the person wearing them and the local area from breathing contaminants (such respiratory toxins or bacterial/viral pathogens. Distinctive covers can be classified. FFP (filtering face piece)masks are available with or without a valve (Figs. 2 and 3). FFP masks having valves allow air to move from within the mask to the outside.An example :N95 masks, make breathing easier.The findings demonstrated that the preventive effect was enough against the viruses tested, which included influenza and rhinovirus. Figure2 FFP (Filtering Face Piece) mask with valve Figure3 FFP mask without valve 9 Masks for everyday usage (permanent cloth masks, for example; Fig.4:These masks offer no protection against infection to the user.These masks should not be worn in healthcare institutions, although they are widely recommended for the general public.MNP (medical mouth–nose protection;( Fig.5) is very often known as a "surgical mask."The filtering effectiveness is similar with those of common use masks, and it is designed to keep patients safe.They were licensed for usage by medical personnel and guarantee only patient protection against aerosols.Whereas a full coverage covers the complete confront, a half-mask fits from beneath the chin to over the nose, a quarter cover fits from the beat of the nose to the best of the chin. ( Matuschek et al., 2020) Figure 4 Homemade face mask for everyday use Figure 5 Surgica 10 − Healthcare respirators or medical respirators: It is a device that protects you from inhaling potentially harmful substances like chemicals and infectious particles. There are various types of respirators, each with its own set of cautions, limitations, and usage restrictions. Some respirators must be tested to ensure a secure fit on the face, and they should not be worn if the wearer has facial hair (CDC .2021c) . Most respirators have been tested and evaluated in accordance with the standards.KN95 respirators are perhaps the most generally accessible internationally accepted respirators.The N95 respirator is really a filtering facepiece respirator (FFR) it has at most 95% filtering effectiveness according to the US National Institute for Occupational Safety and Health (NIOSH).Its most commonly used N95 types in hospitals are the 3M 1860, 8210, and 8511.They are made up of three layers: external, filter, and interior layers (Fig 6).( Yim et al., 2020) KN95 respirators are followed by Chinese requirements .Although some of these provide equal filtration to the N95 respirator, they are not NIOSH recommended. In response to worries about an inadequate amount of N95 respirators during the COVID- 19 epidemic, the FDA issued an umbrella Emergency Use Authorization (EUA) for KN95 respirators.External, filtering, cotton, and inner layers make up KN95 respirators (Fig 7). ( Yim et al., 2020) Figure 6 N95 respirator 11 Figure 7 KN95 respirator What you should know about international respiratory protection: − They're made to meet criteria that don't always include a quality criterion. − Based on the standard these are created to accommodate, they filter different level of particulates in the air. − When properly adjusted, they form a tight seal around your face. − Because not all respirators fit the same, it's critical to choose one that suits the face and seal well. ( Yim et al., 2020) Wearing international respirators is not recommended: − If there are any exhaust valve, vent, or any other apertures, they should be used. − If it's difficult to breathe during wearing them, discard them. − Whether they're dirty or filthy, don't use them. − Various masks or respirators are accessible. − As an alternative for National institute for occupational safety (CDC.2021c, Yim et al., 2020) 1.1.2.2.5 Respiratory hygiene and cough etiquette (WHO .2021c) A set of disease strategies aimed at limiting the spread of respiratory infections via droplets or airborne pathways. 12 Patients who may have undiscovered highly infectious respiratory infections are the focus of the strategies. − Anyone who is showing signs of disease, such as coughing, congested, a stuffy nose, or an increase in respiratory droplets. Measures to Control Respiratory droplets : − When sneeze or cough, cover your mouth and nose with the a tissue. − After using tissue, discard of them in the nearest garbage receptacle. − After coming in respiratory droplets or infected items or materials, wash your hands. − Encourage persons who are suffering from signs to stay much further away from those people as feasible. (WHO .2021c) 1.1.2.2.6 Injection safety practices: − Avoidance of needle adhere and wounds from other sharp equipment − Utilize care when: − Handling needles, surgical blades, and other sharp equipment or devices − Cleaning utilized instruments − Disposing of utilized needles and other sharp types of equipment (WHO .2002) 1.1.2.2.7 Safe waste management − Treat garbage sullied with blood, body liquids, discharges, and excretions as clinical garbage according to local controls. − Human tissues and lab waste that's straight forwardly related to samples preparation ought to moreover be treated as clinical garbage. − Dispose of single utilize things properly (WHO.2009, CDC.2007) 1.1.2.2.8 Proper linens: Holder, transport, and handle utilized material in a way which: − Avoid skin and mucous film exposures and defilement of clothing. 13 − Avoids exchange of pathogens to any patients and or to the surrounding environment (WHO.2009, CDC.2007). 1.1.2.2.9 Environmental cleaning: Ascertain that cleaning and disinfection processes are carried out regularly and correctly. Cleaning environmental surfaces using water and cleaners, as well as disinfectants routinely used in hospitals (such as sodium hypochlorite), is a safe and effective method (WHO.2021c) 1.1.3 Vaccine of COVID-19 1.1.3.1 Definition of vaccine A subestance that stimulates a person's immune system to build immunity to a specific disease, therefore protecting them from it.Vaccines are administered through different routes :needle injections, orally and via nasal spray.(WHO .2021b). 1.1.3.2 Facts about vaccinations − The COVID-19 vaccine will not make a person sick.The COVID-19 vaccine teaches our immune systems how to recognize and fight the infection that causes COVID-19. − This substance may induce negative effects such as fever in some people.These side effects are common and indicate that the body is strengthening its defenses against the COVID-19 virus ( (WHO .2021b) According to WHO, at least seven different vaccinations have been administered in many countries as of February 18, 2021, and healthcare workers (HCWs) are the greatest priority for vaccination. In addition, more than 200 other vaccines are in the works, with more than 60 of them in clinical testing (WHO.2021b).Although giving different vaccinations the same result, there are many differences in the characteristics of these vaccinations :( WHO .2021d) 14 .1.3.3 Types of vaccinations 1.1.3.3.1 Complete virus vaccine Whole virus technology relies on making a vaccine that contains certain parts of the virus or a complete copy of the virus, which can be divided into two parts:Live attenuated vaccines and inactivated Vaccines,in these types stimulate the immune system's response, but without causing pathogenic symptoms.An example of this technology is the Chinese-origin Sinopharma and Sinovac vaccines, which are based on the use of an inactivated version of the Covid-19 virus.( WHO .2021d, Han et al ., 2021) 1.1.3.3.2 DNA Vaccine The technology to produce a vaccine using messenger RNA virus (messenger RNA) is a modern technology, When the body is injected with this vaccine, depends on the use of the immune-stimulating part inside the genetic material of the modified genetic material of the virus to produce proteins on the cell surface and thus identify these parts in the event of exposure to the Coronavirus . (WHO .2021d, Kyriakidis et al ., 2021, Han et al ., 2021). Examples of this technique include Pfizer-BioNTech the German-American Pfizer vaccine which is the first vaccine that has been used. Moderna: the American Moderna vaccine is produced using the same technology used to produce the Pfizer vaccine, but it is distinguished by its tolerance of higher temperatures during storage and distribution. (WHO.2021b, Kyriakidis et al ., 2021). 1.1.3.3.3 Viral vector vaccine This method relies on the use of a genetically modified and inactivated vector virus, which carries the genetic code of the COVID- 19 virus responsible for the production of a specific type of virus surface proteins, and thus recognition and resistance in the event of infection with the Coronavirus. An example of this technology: Johnson: the American Janssen vaccine. Sputnik vaccine in Russia,and AstraZeneca: the British- origin AstraZeneca-Oxford vaccine. Despite concerns that this vaccine may cause blood clots in some people, the vaccine has not been proven to cause this, and 15 therefore it is still used as an effective vaccine to date. (Kyriakidis et al ., 2021, Han et al ., 2021) Despite the different vaccinations produced to fight corona virus infection , the side effects associated with these vaccines are generally mild symptoms, and usually disappear within a day or two after vaccination, and the following symptoms include: − General fatigue in the body. − Pain in various muscles of the body. − Pain, swelling, and redness where the vaccine was given. − headache. − A slight rise in temperature and chills. − The vaccine may cause an allergic reaction (anaphylaxis) in some rare cases, whose symptoms appear immediately after receiving the vaccine.( WHO .2021d, Kyriakidis et al ., 2021, Han et al ., 2021) 1.2 Literature review Many studies have examined the relationship between compliance with Covid -19 protective measures and associated factors such as socio-demographic factors including age, sex, education level, occupation, working hours and work experience, and knowledge, attitude and institutional factors, and others. Covid -19 is a very universal disease affecting millions of people around the world; therefore, it is important to clarify the factors affecting healthcare workers' compliance with Coved -19 preventive measures. A quasi-experimental study was carried out by Amira et al,. 2021. The study aimed to see how an educational program for maternity nurses affected their knowledge of preventive measures in the labor unit during the pandemic of COVID 19. A convenient sampling of total nursing (90 nurses) using an online meeting was held at the Benha University Hospital's Obstetrics and Gynecological Department. It used a structured questioner including three parts. The results showed a strong statistically significant difference between pre-and post-program p value=0.001, 41.1 percent of nurses had bad knowledge pre-program compared to 80 percent of nurses who had good knowledge post-program. In terms of overall attitude, 32.2 percent had a negative attitude 16 (definition in annexes) before the program and 90 percent had a good attitude thereafter, with substantial variations. And there is significant difference in all other aspects of attitude between before and after the program (p value=0.001). Furthermore, 32.2 percent of nurses indicated bad self-reported practices before the program, but 90% reported excellent practices thereafter. A study was conducted by Amanya et al,. 2021 an online cross-sectional descriptive study, aimed to assess the knowledge and compliance with Covid-19 infection prevention and control rules amongst health care workers in territorial, referral hospitals in northern Uganda. Data were gathered from 75 health workers using a self- administered, structured, online questionnaire. The study showed most health workers had adequate knowledge 69%, sufficient compliance 68% with Covid-19 IPC. Sufficient compliance was associated with practicing in Covid -19 IPC p=0.039, getting to Covid-19 IPC at workstations p=0.039, and having powerful institutional support p=0.031. but, there was no statistically significant relationship between knowledge and compliance with IPC p= 0.07. Also, No statistically significant association between Covid-19 IPC knowledge or compliance and the socio-demographic factors of health workers, including age, sex, education level, occupation, working hours, and work experience. Another online cross-sectional study was done by Wong et al., 2021 aimed to assess the extent of compliance with the infection prevention and control practices among health care workers in various health care settings and its relationship with their views on the environment of workplace infection during the COVID-19 pandemic. It was done on 16,500 nurses; they fill out an online self-administered questionnaire.The study results showed the respondents were discontented with work infection and prevention measures .Their compliance was comparatively low once having correct patient handling (54%) and implemented invasive procedures (46%). A statistical method model established that the standard of compliance of the quality precautions was completely related to the satisfaction on infection prevention , the highest level of compliance was conjointly considerably related to operating in the selected team and having the chronic condition of the respondents among risky and inpatients clusters. 17 Also, A descriptive cross-sectional study was carried out by Ashinyo et al., 2021 aimed to evaluate compliance of healthcare workers with IPC measures in Ghana’s COVID-19 treatment centers, it was conducted on 424 participants of healthcare workers in four COVID-19 treatment centers situated in Greater Accra Data were gathered using WHO COVID-19 risk assessment questioner. Results showed compliance of IPC through healthcare communications was 88.4% for hand cleanliness and 90.64% for PPE use; IPC compliance for hand hygiene was 97.5 percent and for PPE use was 97.5 percent when directing aerosol-generating procedures. Compliance with hand hygiene was substantially lower among midwives (OR:0.29; 95 percent ) and pharmacists (OR:0.15; 95 percent) than among registered nurses. Lower adherence was found in healthcare employees who were separated/divorced widowed (OR:0.08;95 percent ), those with secondary level training (OR:0.08;95 percent ), non-clinical personnel (OR0.1695 percent ), cleaners (OR:0.16;95 percent) pharmacists (OR:0.07;95 percent), and those who suffer from shortage PPEs (OR:0.33;95%). Moreover, a descriptive study was conducted by Kabasakal et al., 2021. The study's goal is to see if there's a link between COVID-19 anxiety and healthcare personnel' and service sector employees' preventive efforts during the epidemic. A total of 735 participants were included in the study including healthcare workers (n=426) and service sector personnel (n=309). Snowball sampling was utilized, results showed the services sector's Fear of COVID-19 scale (FCV-19S) median was 14 and also the healthcare sector's was 17.In the services sector's , there was no relationship among occupational categories and the FCV-19S score. however in the healthcare sector,midwives had such a median FCV-19S score of 21, which was higher than other occupational categories.The healthcare workers believed thay they found greater mean FCV-19S scores than others who had COVID-19 manifestations due to anxiety . Also, a study was carried out by Ali et al., 2021 The goal of this study was to find out how well HCWs followed SPs for COVID-19 prevention and what factors were involved. In nine different tertiary care institutions, an analytical cross-sectional study was undertaken on 877 HCWs. Universal sampling was used to obtain HCWs. A self- reporting questionnaire was used to obtain the data. Results indicated several HCWs indicated that several roadblocks prevent SPs from the following protocol while caring for patients. Accidents/emergencies, prioritizing patient care to save lives while giving 18 SPs less importance were among the challenges. The healthcare system, on the other hand, faces significant challenges due to the limited or non-availability of PPE. Another hurdle to HCWs complying with SPs is that PPE often obstructs their ability to conduct nursing skills. Across-sectional study was conducted by Tang et al,. 2021 in higher education institutions/universities in Hong Kong and Putian, China. It aimed to look at the relationships between demographic variables, perceived threat, perceived stress, coping mechanisms, and adherence to COVID-19 prevention measures among Chinese Healthcare students. Using convenience and snowball sample of 2706 students aged 18 or older who were enrolled in a healthcare program were recruited. They filled out a questionnaire that had six scales for participants. Results showed both social distance and personal hygiene measures were reported to be highly adhered to by the subjects. Compliance with distance and personal hygiene measures was directly predicted by confidence in one's ability to control the current circumstance, wishful thinking, and sympathetic responses. The data imply that male students who are familiar with Hong Kong, have greater clinical experience, and have a low level of confidence in their ability to manage the threat are less likely to follow the COVID-19 preventive measures A study was conducted by Shah et al ., 2021. Between May and June 2020, an electronic survey was used to conduct a multinational cross-sectional study. The purpose of the study was to see if there are any differences in mental health, knowledge, Attitudes, and practices (KAP) of COVID-19 prevention strategies between healthcare professionals and non-healthcare professionals . A multi-national poll was sent by social media and electronic mail to 36 nations. Participants were 21 years old and worked in healthcare and non-healthcare-related fields. Results found that when compared to non- healthcare professionals. healthcare professionals had a considerably better understanding of personal cleanliness (AdjOR 1.45, 95 percent CI -1.14 to 1.83) and social distancing (AdjOR 1.31, 95 percent CI -1.06 to 1.61). They were 1.5 times more ready to participate in the contact tracing app and had a more positive attitude toward personal hygiene. Personal cleanliness and social distance measures were observed to be highly adhered to. HCPs with high compliance were 1.8 times more likely to thrive and have a strong sense of emotional CI (1.44 to 2.61), social CI (1.55 to 2.78), and psychological CI (1.59-2.85) well-being. 19 Across -sectional study was conducted by Shekhar et al., 2021. The study aimed to think about attitudes of health workers regarding the COVID-19 vaccine to better address the obstacles to universal vaccination acceptance. An English questionnaire that can be completed online was used. Results showed 6 percent of respondents said they would take the vaccination as before as it became accessible, whereas 56% said they were unsure or would wait for further information. Only 8% of health care workers do not intend to obtain the vaccine. Vaccination acceptance expanded as people got older, were more educated, and got more money. Female (31%) HCWs, Black (19%) HCWs, Latinx (30%) HCWs, and rural (26%) HCWs were less likely than the general study group to require the vaccine before long. Vaccine acceptability was higher among direct medical workers (49 percent ). The most prominent concerns for the COVID-19 vaccine were safety (69%), effectiveness (69%), and pace of development/approval (74%) in our survey. A study was conducted by Huynh et al., 2021. The cross-sectional study aimed to see how well healthcare laborers were accepting the COVID-19 vaccine in two general hospitals in Vietnam. A convenient sampling method was used on 410 healthcare laborers. Using a self-administered questionnaire. It found 76.10 percent of 410 healthcare personnel were willing to be vaccinated. Indicators of acknowledgment were decided that the gather detailing as “vaccine acceptance” was more likely to be positive towards the seen defenselessness and seriousness of COVID-19, seen benefits of immunization, and prompts to activity, but less likely to have the seen boundaries to inoculation compared with the no acknowledgment bunch. Other than that, individuals who had great information concerning the severity of sickness were 3.37 times more likely to have recognized as vaccine acknowledgment P<0.05. The statistic components were moreover related to readiness to get the immunization, with members who were staff and gotten COVID-19 data from relatives were less likely to acknowledge the vaccine over those who were specialists and not getting data from relatives. A study was conducted by Michel-Kabamba et al., 2020. In the Democratic Republic of the Congo . It evaluated healthcare workers (HCWs) knowledge, attitudes, and practices (KAPs). A cross-sectional study was carried out in 23 referral hospitals in three DRC towns (Lubumbashi, Kamina, Mbuji-Mayi). The World Health Organization's (WHO) "Exposure Risk Assessment in the Context of COVID-19" questionnaire was used to 20 interview a total of 613 HCWs. Doctors (27.2%) and other types of HCWs were among those who took part in the study (72.8 percent ). It found Attitudes and practices, on the other hand, scored poorly. Only 27.7% of HCWs were eager to acquire a COVID-19 vaccine if one became available, but 55 percent followed best practices: 49.4% used masks regularly, and, notably, only 54.9 percent employed personal protective equipment (PPE) at work and during patient contact. The usage of social media as a primary source of COVID-19-related information and the category of residency were both positively connected with knowledge level, with HCWs from towns previously afflicted by the pandemic having more positive attitudes. The majority of Congolese HCWs had enough knowledge of COVID-19, however, the majority did not adhere to consistent PPE use, according to the findings. Another study conducted by Gesser-Edelsburg et al., 2020 used the mixed-methods explanatory design consists of: (1) An online review of 242 HCWs about the utilization of the rules and PPE, and (2) Personal meetings of 15 HCWs chiefs concerning PPE deficiency and the actions they are taking to address it. This study aimed to distinguish and compare: (1) Israeli HCWs' insights concerning the application of formal COVID- 19 guidelines and their preventive value, and (2) HCWs chiefs' reaction to HWCs worry in regards to personal protective equipment (PPE) deficiency. The study showed a different distinction between the apparent applicability and preventive value was found for the vast majority of the guidelines. A portion of the rules was seen as more relevant than preventive (hand cleanliness, signage at the entrance, rubbing using alcohol sanitizers at the passageway, and using masks to connect with the symptomatic patient). Others were seen as less appropriate than preventive measures (disallowed assembling of more than 10 individuals, keeping a distance of 2 meters). Across-sectional study was conducted by Lai et al, 2020 aimed to evaluate the level of change of healthcare workers' self-reported IPC behaviors with the risk of COVID-19 emerging and increasing. It was conducted in two tertiary hospitals with a total of 1386 participants using a structured self-administered questionnaire. It showed HCWs from high-risk departments showed better self-reported experience in most IPC activity coefficients, which ranged from 0.027 to 0.149. In many IPC behaviors, HCWs in risk- affected areas showed higher self-reported compliance (coefficient ranged from 0.028 .113). Nonetheless, when HCWs are in danger of coming into touch with suspected 21 patients, their IPC habits deteriorate. This may be due to a higher workload and a lack of supplies and resources among those HCWs . Another descriptive online -cross-sectional study was conducted by Alrubaiee et al., 2020 aimed to determine the knowledge, attitude, anxiety, and fear, and preventive measures among Yemeni HCPs towards COVID-19. It was included 1231 Yemeni HCPs who provided direct healthcare services to patients. It was used a questionnaire developed from previously published studies.The results showed majority of respondents had sufficient knowledge, a hopeful attitude, a low level of anxiety, and high practices in preventive behaviors, with 69.8, 85.10 percent, 51.0 percent, and 87.70 percent, respectively, to COVID-19 Another study was done by Belayneh et al., 2020, aimed to evaluate COVID-19 prevention practices and associated characteristics among healthcare personnel in Northwest Ethiopia. A cross-sectional study was carried Between March and April 2020, 630 healthcare workers in Northwest Ethiopia were surveyed. The study participants were chosen using a multistage sampling process. Data was collected using a pretested and standardized self-administered questionnaire. it showed the total good preventive practice towards COVID-19 was (95 percent CI: 34.8, 42.5). Being a male healthcare provider (AOR = 1.48; 95 percent CI: 1.02, 2.10), having 6–10 years of work experience (AOR = 2.22; 95 percent CI: 1.23, 4.00), and having a negative attitude toward COVID-19 (AOR = 2.22; 95 percent CI: 1.03, 2.22) were all found to be significant to poor COVID-19 preventive practice among healthcare workers. Overall, healthcare personnel's compliance with COVID-19 prevention practices was determined to below . A study was conducted by (Kim & Hwang, 2020) aimed to assess the knowledge, attitudes, recognize the safe environment, and compliance level of clinical nurses, and identify the factors related to compliance with infection prevention and control practices.A cross-sectional study, using a self‐administrated questionnaire on 197 nurses was conducted. The study results found Nurses effectively answered 67.4% of the inquiries in regards to infection prevention and control information, with the lowest right scores, (55%) identified with multidrug‐resistant creatures. Attendants exhibited good mentalities toward infection anticipation and control (6.5 of 8) and ideal 22 discernments in regards to safe surroundings (7.75 of 9). The general compliance score was 87.41 of 100. Nurses' behaviors, seen safe climate, and time of clinical experience had considerable positive associations to compliance. The results demonstrate that institutional help for safe work conditions ought to be joined with continuing training for improving information and nurses’ attitudes, particularly in generic wards. Another cross -sectional study conducted by Beyamo et al ., 2019 aimed to assess health care workers compliance with standard precaution practices and associated factors in public health institutions of Dawuro zone, south west Ethiopia, 2016. Data was collected on 250 health care workers using a pre-tested questionnaire and a basic random sampling technique .It found a total of 250 health-care staff took part in this study .Out of the total respondents, 162 (or 65.0 percent) had followed normal precautionary procedures. Service years of less than or equivalent to five years, standard precaution training , proper hand hygiene, and the availability of personal protective equipment were all independent associated to standard precaution practices. Another cross-sectional study by Suliman et al., 2018 .The goal of this study was to evaluate Jordanian nurses' knowledge and practices regarding isolation precautions. A self-questionnaire and an observational checklist were developed based on the CDC's 2007 isolation precautions guidelines. It found that a total of 247 questionnaires were returned out of 400, representing a 61.7 percent response rate. The findings revealed that the majority of nurses (90%) are well-versed in isolation precautions. Only 65% of nurses, on the other hand, sai d they adhered to isolation protocols well. HCWs in both public and private hospitals had valuable expertise, and that the cause of their non- compliance is a lack of resources and a heavy workload. 1.3 Epidmiolgy Globally ,21 feburary ,2022.Over 220 nations and territories had reported the outbreak of the COVID-19 infection .Around 425 million individuals had been infected by the virus,distributed as ;males (93,428,384 ),females ; (90,192,768) .With 5.9 million people dying as a result of it,also distributed as males ;(2,080,292) ;females ;(1,586,676). 23 The world wide highest proportion of infected cases was inThe United States America (USA) of (80,087,617) followed by India of (42,838,524) ,and Brazil (28.208.212). In Arabic world ,Turkya has the highest proprtion of cases (13,504,485) followed by Iran (6,942,452).Also ,the highest rate of deaths globally was in USA of (954,412). In arabic world Turkya has the highest proprtion of deaths. WHO Coronavirus (COVID-19) Dashboard. (2022) In palestine, the number of infected cases was 636,055 distributed as:Females 50.07"%,males 49.93%. Also the number of deaths was 5,132 distributed as :males 57.69% ,females 42.3%. Global health 5050.org. (2022). Regarding health and care workers(HCWs) ,latest statisics was by WHO ,around 80 000 to180 000 health and care workers (HCWs) could had died from COVID-19 during the period between the first of January 2020 to Jun 2021.(Health and Care Worker Deaths during COVID-19", 2022) 1.4 Measures that have been taken by the Palestinian Ministry Of Health (MOH) The Government of Palestine (GOP) promptly announced an emergency when the first seven cases in Bethlehem governance, in the west bank of Palestine were discovered on 5 of march 2020 and dispatched public control measures.Despite the low number of cases, WHO has determined the danger to the Territory of Palestine as extremely high, because of lacking clinical resources in the nation contrasted with different nations. The absence of applicable resources (counting basic consideration beds and artful ventilators) significantly raises the death pace of Coronavirus. The Province of Palestine has 375 grown-up emergency unit beds (in private and government clinics) and 295 ventilators, which seriously obliges their capacity. (Abuzerr et al ., 2021) The Palestinian Authority developed an emergency plan, collaborating with all partners, trained health experts and facilities in the West Bank, and equipped them with the necessary safety equipment, medical equipment, and medicine. (Abuzerr et al ., 2021) It is controlling the viral outbreak by testing, quarantining, and imposing travel restrictions on citizens. Each governorate has a quarantine facility, and the Central Health Laboratory conducts testing. people suspected of having COVID-19 were isolated at home till symptoms appear or a positive test is obtained; in addition, all 24 inbound travelers are subjected to a two-week government quarantine. People with positive patterns or symptoms were treated at government hospitals. Each governorate has its contact and tracking unit. (Abuzerr et al ., 2021) The government quickly started a national collaborated campaign, informing individuals about public health and status updates using national and local methods such as news, Facebook, and Twitter.Agovernment COVID-19 monitoring panel was part of the program, as is a collaboration with social media pages dedicated to countering misinformation. The Palestinian Ministry of health (PMOH) is in duty of delivering health services to Palestinians who are covered by government health insurance (GHI).The GHI presently covers around 65 percent of Palestinians living in the West Bank, and all Gaza Strip residents. was offered information sessions twice a day through the national media, including updates on COVID-19 cases and government guidelines for citizens . (Abuzerr et al., 2021) Actions were done at the public and provincial level: 1. All educational institutions including schools, colleges, universities, and recreational areas for 30 days were closed, all borders were closed (goods movement is permitted), and all entering travelers (from Ben Gurion airport) were subject to a 14- day government quarantine and testing. 2. Closing of, all things considered, public foundations and government workplaces, aside from fundamental suppliers (drug stores and food), restriction of mobility between urban areas and different West Bank governorates for every citizen,and all residents were approached to remain at home, except for fundamental exercises and crises . 3. Palestinian workers who transport to Israel for working were asked not to move between the Palestinian Authority and Israel; this was meant they must either return home (and be quarantined for two weeks) or stay in Israel until the situation improves.(Abuzerr et al .,2021) The (PMOH) had striven to boost the country's multi-sectored response to the COVID- 19 outbreak while sustaining principled program delivery and life-saving assistance to the extent possible. The following were the top priorities: improving the ability to 25 identify, trace, and isolate cases, with a significant requirement to enhance laboratory capacity to test for rapid detection; safeguarding health care workers and communities through training and more PPE; and assuring good case management of all cases. The (PMOH)has adopted strict steps at the primary and secondary care levels as resources are diverted to meet the expanding COVID-19-related needs. Central clinics in the West Bank, in particular, have been asked to treat only acute emergency cases. To prioritize responding to COVID-19, over 52,000 outpatient appointments (weekly) will be delayed in the West Bank. (AlKhaldi et al., 2020) Outpatient clinics and elective procedures have been banned in West Bank hospitals. As a result of the readiness measures for possible care of COVID-19 cases, around 4,500 elective procedures (monthly) are expected to be postponed. (AlKhaldi et al., 2020) According to health officials in Gaza, only seventeen of the 52 basic healthcare clinics are operational, and two of them have been converted to quarantine zones. Quarantine centers were supported by 400 doctors, nurses, and administrative personnel. Breast cancer screening is no longer available, leaving solely diagnostic services. (AlKhaldi et al., 2020) Routine Noncommunicable diseases (NCDs) patient care has been put on hold, along with early childhood development treatments, oral and dental health services, and physiotherapy. In the meantime, all Gaza hospitals have postponed elective treatments and outpatient services.4,000 patients have had their elective procedures rescheduled as a result of efforts taken to prepare for the likely management of COVID-19 cases. WHO has funded several infection prevention and control (IPC) training sessions for health workers in the West Bank and Gaza Strip and procured and supplied personal protective equipment. (AlKhaldi et al., 2020) For high-risk pregnancies, the Ministry of Health continues to provide prenatal and postnatal care. The following are some of the difficulties in providing care:Inadequate personal protective equipment (PPE) for maternal health workers, Fear prevents pregnant from attending services (some providers report up to 90 percent decrease in attendance). Access to health services is difficult due to a lack of public transportation. 26 − United Nations Population Fund (UNFPA) helped the Ministry of Health in Gaza and the West Bank distribute safety information to persons who had been freed from quarantine, including pregnant and breastfeeding mothers. UNFPA is acquiring personal protective equipment (PPE) for healthcare workers who provide maternal health services and is collaborating with the Ministry of Health and other partners to ensure that maternal health services are maintained to the maximum extent possible. (AlKhaldi et al., 2020) − UNFPA is acquiring personal protective equipment (PPE) for healthcare workers who provide maternal health services and is collaborating with the Ministry of Health and other partners to ensure that maternal health services are maintained to the maximum extent possible. (AlKhaldi et al., 2020) − WHO aided the Ministry of Health in preparing for COVID-19 in terms of maternal and neonatal health. (AlKhaldi et al., 2020) A committee has been constituted to discuss both quarantine and facility safety measures. In addition, a management plan and patient flow have been discussed, with a focus on intrapartum care and infant care for moms with COVID-19, whether suspected or confirmed. (AlKhaldi et al., 2020) 1.5 Statement of problem During my working in the maternity ward, since starting of the COVID -19 pandemic in Palestine, and the increasing number of infected cases globally, this changed the daily routine of healthcare practices followed in hospitals. Although of WHO protocols and standards to prevent the spread of infection, it was broken whether from patients who came to receive care from the hospital and their companions, they were not wearing masks, infected patients not wearing gloves, moreover health care providers have poor compliance with the use of personal protective equipment and aseptic practices The lack of compliance with Standard Precautions (SPs) among HCWs subsidizes the patients who are affected, overall treatment expenses, and hospital stays of patients who are hospitalized owing to Health-Care-Associated Infections ( HCAIs) are caused by a variety of circumstances, including the patient's age, immunological status, previous co- morbidity, and sickness vulnerability. On the other hand, an extended hospital stay increases the risk of contracting hospital-acquired infections. https://www.unfpa.org/ 27 Pregnant women are most susceptible to the development of severe pneumonia, and therefore they are more likely to contract corona, especially if they suffer from chronic diseases or pregnancy complications. Failure to use a strict method to prevent the spread of infection leads to an increase in the incidence of complications and an increase in the mortality rate So, it's important to study factors affecting compliance and identify associated factors of non – compliance among health care providers in maternity wards this will minimize the incidence and complications that result from spread infection between patients and as well as health care providers 1.6 Variables definitions The dependent variable of this study was health care workers compliance with Infection prevention and control (IPC ) measures regarding Coved -19 infection. The independent variables were including Socio-demographic factors ,individual factors (knowledge ,attitude ,and individual practices about IPC measures of COVID -19 ),and institutional factors .Table (1.1) 28 Table 1.1 conceptual and Operational definitions of variables conceptual and Operational definitions of variables Operational definition Conceptual definition Variable It is defined as adherence to a regulation, such as standard, guidelines specification, policies related to Coved-19 disease. In the study we measure the level of compliance by asking 8 questions to assess the level of compliance with IPC measures and scored as follows: 1, ‘sometimes’; and 2, for ‘rarely,3, for ‘sometimes and 4 for ‘always’, giving a possible score of 32 points compliance is defined as "the degree to which an individual's conduct taking medicine, following an eating routine, and additionally executing way of life changes-relates with concurred recommendations from a medical care providers"( Chakrabarti,2014)" Compliance the level of knowledge about Covid-19 IPC measures was scored as follows: one (1) point was awarded for each correct response and zero (0) for an incorrect response, and a correct response score of ≥80% was considered sufficient knowledge (Amanya et al,.2021) is a highly regarded state in which a person is cognizant of reality.As a result, it is a relationship.A conscious subject is on one side of the relation, and a component of reality to which the knower is directly or indirectly related is on the other.( Zagzebski, 2017) Knowledge In the study we measure the level of attitude by nine questions, one answer to be chosen; the eighteen questions has four options, this part scored as follows: 1 point for "Very dissatisfied "; 2 for "dissatisfied ";3 for "Neutral";4 for "Satisfied ";5 for "Very satisfied", total scores 65 points. An attitude can be defined as one's proclivity to use a certain evidence- based activity, either positively or negatively (EBP).This propensity is formed by one's perceptions of the repercussions or results of employing that EBP, which might be perceived as a benefit or a drawback of taking that action. (Fishman et al.,2021) Attitide We measure clinical practices related to Coved-19 preventive mesures includes four questions with options and scored as follows: 1 for "Never",2 for "Seldom",3 for "Sometimes",4" often ",5 for "Very often ", total scores 75 points (Beyamo et al,.2019) It refers to the ability to address complex nursing problems and offer appropriate care .it is a collection of psychological and physiological traits of individuals that can be used to solve clinical difficulties.it is focusin a changing nursing work environment utilizing comprehensive ways to handle complex nursing challenges and deliver high- quality nursing care.( Zeng et al., 2016). Clnical Practice We measure the level of institusional commitment by two types of questions, the first 4 questions were rated on a Likert scale (never, rarely, neutral, sometimes, and always). A scoring system was assigned as follows: 1, for ‘never,2 for ‘rarely, 3 for neutral,4for ‘sometimes, and 5 for ‘always giving a total score of 20 points. The second part includes two questions answered by yes or no(Amanya et al,.2021). The active encouragements provided by the organization in the form of policies, laws, monetary and non-monetary assistance that motivate employees to do their duties in a highly effective and productive approach .( Falola et al .,2020) Institusional factors 29 1.7 Study Objectives 1.7.1 Goal of the study To increase compliance with standard precaution related to COVID -19 diseases to decrease the related infection morbidity among patients and health care providers 1.7.2 Aim of the study The study aims at evaluating the compliance with COVID-19 prevention measures and identifying associated factors among health providers in maternity wards in west bank hospitals 1.7.3 Specific objectives 1. To assess the compliance of health care providers in the maternity room to COVID- 19 protective measures 2. To identify factors affecting the health care provider compliance to COVID19 protective measures 3. To review the hospital policies and guidelines related to COVID-19 protective measures that issued during the pandemic 1.8 Study significance − This study will be the first study done in Maternity wards in west bank governmental hospitals about the evaluation of the compliance of IPC related to Coved -19 during the pandemic. − Healthcare workers are in the first line of deveining against COVID-19 infection, in Palestine, there is no clear data about the relationship between compliance with Coved -19 IPC and the extent to get infected from Coved -19 among health care workers − The findings of the study will help the Palestinian Ministry of Health (MOH) to identify the factors that contribute to healthcare personnel's noncompliance with Coved-19 infection prevention and control (IPC) procedures in maternity wards in governmental west bank hospitals. 30 − The study emphasizes the significance of COVID -19-related IPC guidelines in the prevention of infection spread, as well as the challenges that can arise when these protocols and guidelines are implemented. − This study will evaluate the importance of the availability of the essential equipment and facilities for implementing successful IPC practices linked to COVID -19 in maternity wards in particular, as well as in public hospitals in the West Bank in general. 1.9 Study Hypothesis (Null hypothesis) 1. There are no differences between the socio-demographic factors and compliance with COVID-19 IPC measures among health providers in maternity wards in west bank hospitals. 2. There is no relationship between individual-related factors and compliance with COVID-19 IPC measures among health providers in maternity wards in west bank hospitals. 3. There is no relationship between institutional factors and compliance with COVID- 19 IPC measures among health providers in maternity wards in west bank hospitals 31 Chapter Two Methodology This chapter reviewed in detail the steps used to meet the study objectives. The study design and setting, the study population and sampling method, the data collection tool, validity and reliability,ethical considerations,field work,variables definitions ,statistical analysis, and limitations of the study are all covered in this chapter. 2.1 Study design A cross-sectional study was conducted to evaluate the compliance of health providers in maternity wards(labor ,postnatal wards) in west bank governmental hospitals with Covid-19 prevention measures and identify associated factors 2.2 Study population The study population included 267 participants: midwives, nurses, and female doctors (these numbers were taken after contact with head nurses of maternity departments in each hospital table (2.1) 32 Table 2.1 Name of hospital and the number of health care providers in maternity departments in them Name of hospital Number of health care providers in the maternity and postpartum department 1. Tubas Turkey Midwifes 12 ,Nurses:1,Female doctors :1 (14) 2. Jenin (Khalil Suliman) Midwifes 28 ,Nurses:1,Female doctors :5 (34) 3. Tulkarm (Thabit Thabit) Midwifes 17 ,Female doctors :5 (22) 4. Rafidia- Nablus Midwifes 34 ,Nurses:2,Female doctors :11 (47) 5. Qalqiliya (Darwish Nazal) Midwifes :13 6. Salfit (Yasser Arafat) Midwifes :13 ,Female doctor:1 (14) 7. Palestin Medical Complex (PMC)- Ramallah Midwifes :20,Nurses:2,Female doctors :5 (27) 8. Jericho Midwifes :10 9. Beit Jala (Al Hussein) Midwifes :16 , Female doctor:1 .(17) 10. Hebron (Alia) Midwifes :26,Nurses:1,Female doctors :5 (32) 11. Yatta (Abu Alhasan Al Kassem) Midwifes :18 ,Female doctors :1 (19) 12. Mohammad Ali Al Mohtaseb- Hebron Midwifes :14 ,Nurses:2,Female doctors :2 (18) Total of staff 267 2.3 Sample and Sampling method A convenient sampling method was used, Sample size was calculated using an online raosoft calculator.The population number and margin of error E (0.05) and (50%) response distribution + (10%) drop out.The sample size calculated to be : x = Z(c/100)2r(100-r) n = N x/((N-1)E2 + x) E = Sqrt[(N - n)x/n(N-1)] where N is the population size, r is the fraction of responses that you are interested in, and Z(c/100) is the critical value for the confidence level c(0.95). 2.3.1 Inclusion criteria All healthcare workers(midwives, nurses, and female doctors) who work in the maternity departments (labor, postnatal wards) of the12 west bank governmental 33 hospitals with full-time employment and who voluntarily agreed to participate in the study by filling the online questionnaire. 2.3.2 Exclusion criteria were − Male doctors and other staff who work part-time. − Private hospitals, Palestinian Venezuelan Ophthalmic Hospital Hugo Chavez- Turmusa'yya, and Bethlehem (Psychiatric) hospital. 2.4 Tool of data collection This study was designed to collect data to evaluate the compliance with Covid-19 measures and identify associated factors among health care providers in maternity wards in west bank hospitals. Using A pre-validated and free questionnaire developed by combining the contents of questionnaires from 3 different literature (Amanya et al,.2021, Beyamo et al,.2019, and Shekhar et al,.2021), and modified to fit with aim of the study, it translates by An English language doctor who is familiar with medical terminology to fit the language of healthcare providers. 2.4.1 Questionnaire parts: includes four sections, annex (A),page (73) − The first section socio-demographic characteristics of the subjects includes 7 questions (Amanya et al,.2021, Beyamo et al,.2019). − The second section about individual related characteristics includes three parts; first part nine questions to assess the level of knowledge and understanding of the concepts of Covid-19 IPC and was scored as follows: one (1) point was awarded for each correct response and zero (0) for an incorrect response, and a correct response score of ≥80% was considered sufficient knowledge (Amanya et al,.2021). Second part ten questions about attitude related to IPC measures for COVID-19; Nine questions, one answer to be chosen; the eighteen questions has four options, this part scored as follows: 1 point for "Very dissatisfied "; 2 for "dissatisfied ";3 for "Neutral";4 for "Satisfied ";5 for "Very satisfied", total scores 65 points. The third part about clinical practices related to Coved-19 includes four questions with options and scored as follows: 1 for "Never",2 for "Seldom",3 for "Sometimes",4" often ",5 for "Very often ", total scores 75 points (Beyamo et al,.2019). The second part about the attitude toward vaccination against COVID-19 includes 4 questions; 3 questions 34 answered "yes" or " No", and in the third question if the answer was no, there were 4 choices, to choose one of them. The fourth question-answer one of four choices (Shekhar et al,.2021) − Third section: It included 8 questions to assess the level of compliance with IPC measures and scored as follows: 1for never’; and 2, for ‘rarely,3for neutral, 4 for ‘sometimes and 5 for ‘always’, giving a possible score of 40 points. Adequate compliance was set at ≥75% (Amanya et al,.2021). − The fourth section is about the perception of institutional commitment to IPC and it included two types of questions, the first 4 questions were rated on a Likert scale (never, rarely, neutral, sometimes, and always). A scoring system was assigned as follows: 1, for ‘never,2 for ‘rarely, 3 for neutral,4for ‘sometimes, and 5 for ‘always giving a total score of 20 points. The second part includes two questions answered by yes or no(Amanya et al,.2021). 2.5 Validity and Reliability To verify the validity of the questionnaire ,it was reviewed by the infection control coordinator and two academic supervisor specialists in the field of study, their comments were to add some points about the vaccine, and translate the questionnaire. The pilot study was done after developing the tool on 10% of the sample (30) which was included in the sample. And the value of Cronbach's Alpha was calculated, it was 0.875. It shows a good indication. 2.6 Statistical analysis After completing the data collection and review, they were entered into the database developed on the Statistical Package for Social Sciences (SPSS), where the respondents' answers were given according to the five-point Likert scale for each paragraph of the questionnaire. The researcher also processed the necessary statistics for the data by extracting numbers and ratios. The metrics, arithmetic means, and standard deviations of the study paragraphs, and the study hypotheses were examined at the level of statistical significance (a ≤0.05) by using the following tests: 35 1. Percentages, frequencies, and arithmetic mean averages: This command is mainly used to know the frequency of the categories of a variable, and it is useful in describing the study sample. 2. Pearson Correlation Coefficient to measure the degree of correlation: This test is based on studying the relationship between two variables, and the researcher used it to calculate the internal consistency and the structural validity of the questionnaire. 3. Cronbach's Alpha test to determine the stability coefficient of the tool 4. T-test for independent variables to see if there are statistically significant differences between two sets of independent data. 5. One-Way ANOVA to see if there are statistically significant differences between three or more groups of data. The researcher used it for the differences attributable to the variable that includes three groups or more. 6. Linear regression, a test by which the mean of a random variable or several random variables is predicted based on the values and measurements of other random variables. 7. Rely on the Likert fifth scale in data analysis. 8. 8.Post hok tests are used to determine where discrepancies between groups arose, they should only be used when there is a statistically significant difference in group averages i.e .,ANOVA one -way outcome that is statistically significant. In the same way that ANOVA was used on multiple t-tests, post hoc tests help to maintain the find a different error rate (typically alpha = 0.05). 2.7 Fieldwork The data was collected by creating an electronic link to the questionnaire after a letter was sent to facilitate a task in all government hospitals in the West Bank. All nursing directors were contacted to reach the heads of the maternity and postpartum departments, and their numbers were taken and contacted by phone. The link was sent through Whats App and Messenger, and the data collection period was from the first to the end of September to 2021. 2.8 Ethical and administrative consideration The study proposal was approved by the Institutional Review Board (IRB) annex (),page () and the scientific research committee of the Public Health department as well 36 as the faculty of graduate studies scientific research board at An-Najah National University annex (),page () . Permission to conduct the study in the west bank governmental hospitals was obtained from the Palestinian Ministry of Health (MoH). Each questionnaire included an explanatory letter for all participants that describes the purpose, relevance, confidentiality, and anonymity of the information, as well as the choice to participate (voluntary) ,consent form in annex () ,page (). Summary This was a cross-sectional descriptive study was done in governmental hospitals in West Bank.The sample consisted of (158) midwives, nurses, and female doctors. Data were collected by an online self- administered questionnaire. Then data was analyzed by using SPSS. Different statistical tests were used to calculate frequency and percentages and correlations.These tests were T-test, one-way ANOVA, and linear regression. 37 Chapter Three Results Introduction The tools that were used to help evaluate data and produce the results that will be displayed in this chapter were discussed in the previous chapter. The findings of the study, as well as an analysis of various demographic data for the participants, are presented in this chapter. 3.1 Socio-Demographic data Table 3.1 Distribution of participant's percentage according to their demographic data Variables Classification No % Occupation Nurse 3 1.9 Midwife 137 86.7 Doctor 18 11.4 level of education attained Certificate 1 0.6 Diploma 16 10.1 Bachelor’s degree 136 86.1 Master’s Degree 5 3.2 Marital status Single 24 15.2 Married 132 83.5 Widowed 2 1.3 Length of work experience (in years) 1-5 60 38.0 6-10 56 35.4 11-15 32 20.3 16-20 5 3.2 21+ 5 3.2 (1-34) 8.15± 5.349 Age (24-50) 30.79 ±5.022 Working hours /week (10-62) 40.80± 7.822 Table (3.1) shows that (86.7%) of participants were midwives and the mean age was (30.79±5.022). Also, (83.5%) of participants were married, (86.1%) had a bachelor’s degree. The mean work experience was (8.15±5.349), with a mean of working hours (40.08 ±7.822). 38 Table 3.2 Distribution of the percentage of participants according to their workplace/hospital Name of hospital No % 1-Tubas Turkey 14 8.9 2-Jenin (Khalil Suliman) 20 12.7 3-Tulkarm (Thabit Thabit) 16 10.1 4-Rafidia- Nablus 21 13.3 5-Qalqiliya (Darwish Nazal) 10 6.3 6-Salfit (Yasser Arafat) 10 6.3 7-Palestin Medical Complex (PMC)- Ramallah 10 6.3 8-Jericho 5 3.2 9-Beit Jala (Al Hussein) 8 5.1 10-Hebron (Alia) 19 12 11-Yatta (Abu Alhasan Al Kassem) 16 10.1 12-Mohammad Ali Al Mohtaseb- Hebron 9 5.7 Total of participants 158 100 Table (3.2) showed the working place of participants, it indicated that (13.3) were from Rafidia governmental hospital - Nablus; (12.7%) were from Khalil Suliman governmental hospital -Jenin, while (3.2%) were from Jericho governmental hospital – Jericho. 39 3.2 Distribution of participants regarding their compliance about COVID -19 (IPC) measures Table 3.3 Distribution of participants regarding their compliance to IPC measures for COVID -19 Questions about compliance Rarely Occasionall y Neutral Most of the time Always, as recommended Do you follow recommended hand hygiene practices? 1.3% 0.6% 0.0% 27.8% 70.3% Do you use alcohol- based hand rub or soap and water before touching a patient? 1.3% 19.0% 0.6% 53.2% 25.9% Do you use alcohol- based hand rub or soap and water before cleaning/aseptic procedures? 2.5% 13.3% 5.1% 47.5% 31.6% Do you use alcohol- based hand rub or soap and water after (risk of) body fluid exposure? 1.3% 2.5% 2.5% 51.3% 42.4% Do you use alcohol- based hand rub or soap and water after