0 SCHOOL OF PUBLIC HEALTH COLLEGE OF HEALTH SCIENCES, UNIVERSITY OF GHANA, LEGON ASSESSMENT OF THE IMPLEMENTATION OF COVID-19 PREVENTION PROTOCOLS IN SELECTED HEALTH FACILITIES IN THE KASSENA NANKANA DISTRICT OF GHANA. BY ENOS KWOPIA DANIEL SEKWO (10875963) THIS DISSERTATION IS SUBMITTED TO THE UNIVERSITY OF GHANA, LEGON IN PARTIAL FULFILMENT OF THE REQUIREMENT FOR THE AWARD OF THE MASTER OF SCIENCE PUBLIC HEALTH MONITORING AND EVALUATION DEGREE. March 2022 University of Ghana http://ugspace.ug.edu.gh i DECLARATION I, Enos K. Daniel Sekwo hereby declare that apart from specific references made which have been duly acknowledged, this research work is my independent work undertaken under the supervision of Prof. Paulina Tindana. I also declare that no part of this proposal has been submitted for the award of any degree in this University or any University elsewhere. Enos K. Daniel Sekwo 15-02-2023 (Principal Investigator) (Signature) Date Prof. Paulina Tindana 15-02-2023 (Supervisor) (Signature) Date University of Ghana http://ugspace.ug.edu.gh ii DEDICATION This work is dedicated to the CEBioGen team especially the ELSI-core of the project and to all who died from COVID-19. University of Ghana http://ugspace.ug.edu.gh iv ACKNOWLEDGEMENT Thanks, Thanks be to the Lord our God! I wish to acknowledge the following people for all their efforts and contributions to make this work a success. My supervisor, Prof. Paulina Tindana, Dr. Raymond Aborigo, the Navrongo Health Research Centre, my research assistants, my family and friends, and the good people of Paga and Navrongo. God bless you all for playing diverse roles in making this work a success. Special thanks to the United States National Institutes of Health/National Human Genome Research Institute (NIH/NHGRI) for funding the H3Africa CEBioGen project which supported my masters training at the University of Ghana School of Public Health and my research project at the Kassena-Nankana districts. University of Ghana http://ugspace.ug.edu.gh v ABSTRACT Background: In 2020, World Health Organization declared COVID-19 a global pandemic and recommended key preventive protocols, such as proper and frequent handwashing, physical distancing, and wearing of face masks, to contain the spread of the disease. Effective implementation of these protocols faced several challenges for health workers and non-healthcare workers. Aim: The study assessed the implementation of COVID-19 prevention protocols in selected health facilities in the Kassena-Nankana districts. Method: The study employed a hospital-based cross-sectional study design, using a quantitative and qualitative research approach including observations, surveys, facility assessments, and in- depth interviews to answer the research questions. Qualitative data were coded and analyzed thematically using NVivo 12 qualitative analysis software while bivariate analysis and a multivariate logistic regression model were used to determine the actual factors associated with adherence to COVID-19 protocols. Results: Overall, adherence to prevention protocols was low with about 61.1% of participants having low adherence. Participants had adequate knowledge of COVID-19 prevention protocols (60.7%) but health facilities struggled to make available the prevention protocol materials. Knowledge and enforcement were found to be the factors that influence low adherence as participants with inadequate knowledge were two times more likely (2.30) (p-value; <0.001) to have low adherence and participants who were not reminded about the protocols being six times (5.78; p-value; <0.001) more likely to have low adherence. Implementation challenges included logistics, implementer motivation, facility environment, and finance. University of Ghana http://ugspace.ug.edu.gh vi Conclusion: The study concludes that adequate knowledge of COVID-19 in the district did not positively reflect adherence, as expected. Health facilities in the district lack prevention protocol materials to effectively implement the protocols. Inadequate knowledge and poor enforcement significantly influence low adherence and the key challenges of logistics, finance, lack of cooperation, the burden of work, security challenges, and the hospital environment impede the implementation of the prevention protocols in the health facilities within the KND. Lessons learned in this study should guide. University of Ghana http://ugspace.ug.edu.gh vii Table of Contents DECLARATION ................................................................................................................................ 2 DEDICATION.................................................................................................................................... 3 ACKNOWLEDGEMENT ................................................................................................................. iv ABSTRACT ....................................................................................................................................... v LIST OF TABLES ............................................................................................................................ xii LIST OF FIGURES ......................................................................................................................... xiii LIST OF ABBREVIATIONS ......................................................................................................... xiv CHAPTER ONE: INTRODUCTION ................................................................................................ 1 1.1 Background of the study ........................................................................................................ 1 1.2 Problem Statement ................................................................................................................. 4 1.3 Objectives of the study ........................................................................................................... 5 1.3.1 Aims ................................................................................................................................ 5 1.3.2 Specific Objectives .......................................................................................................... 5 1.3.2 Research Questions ......................................................................................................... 6 1.4 Justification ............................................................................................................................ 6 1.5 Conceptual Framework .......................................................................................................... 8 CHAPTER TWO: LITERATURE REVIEW ................................................................................... 11 2.1 Introduction .......................................................................................................................... 11 2.2 Background information on COVID-19 .............................................................................. 11 2.4 COVID-19 Prevention Protocols ......................................................................................... 15 2.4.1 Face Masks .................................................................................................................... 16 2.4.2 Social/Physical distancing ............................................................................................. 17 2.4.4 Hand hygiene through washing and use of sanitizers ................................................... 18 2.5 The concept of adherence .................................................................................................... 19 University of Ghana http://ugspace.ug.edu.gh viii 2.6 Factors that influence adherence to COVID-19 prevention protocols. ................................ 20 2.6.1 Socio-demographic factors that influence adherence/compliance with prevention protocols ................................................................................................................................. 20 2.6.2 non-healthcare worker-related factors that influence adherence to prevention protocols21 2.6.3 Health worker-related factors ........................................................................................ 22 2.6.4 Facility-related factors ................................................................................................... 23 2.7 Challenges of the implementation of prevention protocols ................................................. 24 2.8 Summary .............................................................................................................................. 26 CHAPTER THREE: METHODOLOGY ......................................................................................... 27 3.1 Introduction .......................................................................................................................... 27 3.2 Research Design ................................................................................................................... 27 3.3 Study Location ..................................................................................................................... 27 3.3.1. Health infrastructure of the Kassena-Nankana Districts .............................................. 30 3.4 Target Population ................................................................................................................. 31 3.5 Study Population .................................................................................................................. 31 3.5.1 Inclusion criteria ............................................................................................................ 31 3.5.2 Exclusion criteria........................................................................................................... 31 3.6 Sample Size .......................................................................................................................... 32 3.7 Sampling Techniques ........................................................................................................... 33 3.7.1 Quantitative ................................................................................................................... 33 3.7.2 Qualitative ..................................................................................................................... 34 3.8 Source of Data...................................................................................................................... 34 3.9 Methods of Data Collection ................................................................................................. 34 3.9.0 Pretest of data collection tools .......................................................................................... 35 3.9.1 Facility Assessment ....................................................................................................... 35 University of Ghana http://ugspace.ug.edu.gh ix 3.9.2 Observation of facility users; healthcare workers and non-healthcare workers ............ 35 3.9.3 Quantitative Survey ....................................................................................................... 37 3.9.4 Qualitative (IDIs) .......................................................................................................... 37 3.9.5 Variables, terms, and operational definitions ................................................................ 38 3.10 Data Management and Analysis ........................................................................................ 40 3.10.1 Quantitative ................................................................................................................. 40 3.10.2 Qualitative ................................................................................................................... 41 3.11. Data quality control/assurance .......................................................................................... 42 3.12 Ethical Considerations ....................................................................................................... 43 3.12.1. Ethics approvals and permissions .............................................................................. 43 3.12.2. Informed consent ........................................................................................................ 43 3.12.3. Privacy and confidentiality ......................................................................................... 44 3.12.4. Risks and benefits ....................................................................................................... 44 3.12.5. Voluntariness .............................................................................................................. 44 3.12.7. Funding ....................................................................................................................... 44 3.12.6. Conducting research under COVID-19 measures ...................................................... 45 CHPATER FOUR: MONITORING AND EVALUATION ISSUES ............................................. 46 4.1 Introduction .......................................................................................................................... 46 4.2 Description/concept of the program ..................................................................................... 46 4.3 Type of evaluation ............................................................................................................... 47 4.4 Logical framework ............................................................................................................... 48 4.4.1 Narration for the logical framework .............................................................................. 49 4.5 Definition of indicators and measurement ........................................................................... 50 CHAPTER FIVE: RESULTS ........................................................................................................... 52 5.0. Introduction ......................................................................................................................... 52 University of Ghana http://ugspace.ug.edu.gh x 5.1 Socio-demographic characteristics of study participants ..................................................... 52 5.2 Adherence to COVID-19 prevention protocols ................................................................... 53 5.2.1 Level of adherence to COVID-19 prevention protocols ............................................... 55 5.2.2 Knowledge of COVID-19 prevention protocols ........................................................... 56 5.2.3 Level of knowledge about COVID-19 prevention protocols ........................................ 57 5.3 Availability of COVID-19 prevention protocol materials at vantage points ....................... 59 5.3.1 Level of adherence to COVID-19 prevention protocols by observation among HCW 60 5.3.2 Level of adherence to COVID-19 prevention protocols by observation among NHCW62 5.3.3 Availability or non-availability of COVID-19 prevention protocol materials .............. 63 5.4 Factors influencing the adherence to COVID-19 prevention protocols .............................. 68 5.4.1 Association between factors and level of adherence to COVID-19 prevention protocols among non-healthcare workers in PDH ................................................................................. 70 5.4.2 Factors influencing low adherence to COVID-19 prevention protocols among non- healthcare workers in WMH .................................................................................................. 72 5.4.3 Factors influencing low adherence to COVID-19 prevention protocols among non- healthcare workers in WMH .................................................................................................. 73 5.4.4 Factors influencing low adherence to COVID-19 prevention protocols among non- healthcare workers in PDH .................................................................................................... 74 5.5.0 Results from the qualitative arm of the study ................................................................... 76 5.5 Background information of qualitative study participants (Healthcare workers) ................ 76 5.6 General implementation of COVID-19 prevention protocols at the facilities ..................... 78 5.7 Implementation processes/strategies by facilities ................................................................ 80 5.8 Successes with implementation at the facilities ................................................................... 82 5.9 Challenges with the implementation of the prevention protocols in facilities ..................... 86 5.10 Recommendations to improve implementation of prevention protocols at facilities ........ 97 5.11 Other interesting themes from the discussions .................................................................. 98 University of Ghana http://ugspace.ug.edu.gh xi 5.12 Summary of results ............................................................................................................ 99 CHAPTER SIX: DISCUSSION ..................................................................................................... 100 6.0. Introduction ....................................................................................................................... 100 6.1 Adherence to COVID-19 prevention protocols among healthcare workers and non-healthcare workers ..................................................................................................................................... 100 6.2 Availability of COVID-19 prevention protocols materials at vantage points in health facilities .................................................................................................................................................. 101 6.3 Factors influencing the adherence to COVID-19 prevention protocols among healthcare workers and non-healthcare workers ....................................................................................... 103 6.4 Challenges of implementation of COVID-19 prevention protocols in health facilities .... 103 6.5. Study limitations ............................................................................................................... 107 CHAPTER SEVEN: CONCLUSION AND RECOMMENDATIONS ......................................... 108 7.1 Conclusions ........................................................................................................................ 108 7.2 Recommendations .............................................................................................................. 109 REFERENCES ............................................................................................................................... 110 APPENDICES ................................................................................................................................ 118 Appendix 1: Participant Information Sheet ............................................................................. 118 Appendix 2: Consent Form ...................................................................................................... 127 Appendix 3: Data Collection Tool (Questionnaire) ................................................................. 129 Appendix 4: Ghana Health Service Ethical Approval Letter ................................................... 146 University of Ghana http://ugspace.ug.edu.gh xii LIST OF TABLES Table 3. 1: Variables, terms, and operational definitions ................................................................. 38 Table 4. 1: Logical framework for assessing the implementation of COVID-19 prevention protocols in health facilities .............................................................................................................................. 48 Table 4. 2: Definition of indicators and measurement ..................................................................... 50 Table 5. 1: Socio-demographic information of participants ............................................................. 53 Table 5. 2: Proportion of adherence to COVID-19 prevention protocols among non-healthcare workers in KND................................................................................................................................ 54 Table 5. 3: non-healthcare workers' knowledge on COVID-19 prevention protocols in KND ....... 57 Table 5. 4: Background information of observed participants within the hospital facility .............. 59 Table 5. 5:Observation of adherence to COVID-19 prevention protocol among HCW and NHCWs in KND ............................................................................................................................................. 60 Table 5. 6: Observation of availability or non-availability of COVID-19 prevention protocol materials in the HFs .......................................................................................................................... 64 Table 5. 7: Availability or non-availability of COVID-19 prevention protocol materials by departments/wards in the WMH ....................................................................................................... 65 Table 5. 8: Availability or non-availability of COVID-19 prevention protocol materials in the PDH .......................................................................................................................................................... 67 Table 5. 9: Association between factors and level of adherence to COVID-19 prevention protocols among non-healthcare workers in WMH ......................................................................................... 69 Table 5. 10: Association between factors and level of adherence to COVID-19 prevention protocols among non-healthcare workers in PDH............................................................................................ 71 Table 5. 11: Factors influencing low adherence to COVID-19 prevention protocols among non- healthcare workers in KNM ............................................................................................................. 73 Table 5. 12: Factors influencing low adherence to COVID-19 prevention protocols among non- healthcare workers in WMH ............................................................................................................. 74 Table 5. 13: Factors influencing low adherence to COVID-19 prevention protocols among non- healthcare workers in PDH ............................................................................................................... 75 Table 5. 14: Background information of qualitative study participants ........................................... 77 University of Ghana http://ugspace.ug.edu.gh xiii LIST OF FIGURES Figure 1. 1: Conceptual framework of factors influencing the implementation of COVID-19 prevention protocols ........................................................................................................................... 8 Figure 3. 1: Setting of the study area on a map of Upper East, Ghana, and Africa ......................... 29 Figure 3. 2: Navrongo HDSS coverage area in the Kassena-Nankana districts ............................... 29 Figure 5. 1: Level of adherence to COVID-19 prevention protocols by the selected hospitals in KNM, 2021 .................................................................................................................................................. 55 Figure 5. 2: Overall level of adherence to COVID-19 prevention protocols among non-healthcare workers in KND, 2021...................................................................................................................... 56 Figure 5. 3: Level of knowledge of non-healthcare workers about COVID-19 prevention protocols in KND, 2021 ................................................................................................................................... 58 Figure 5. 4: non-healthcare workers' level of knowledge about COVID-19 prevention protocols by the selected district hospitals in KND, 2021 .................................................................................... 58 Figure 5. 5: Overall adherence to COVID-19 prevention protocol by observation among HCW ... 61 Figure 5. 6: Level of adherence to COVID-19 prevention protocol by observation among HCW .. 61 Figure 5. 7: Level of adherence to COVID-19 prevention protocol among NHCW ....................... 62 Figure 5. 8: Level of adherence to COVID-19 prevention protocol by observation among NHCW63 University of Ghana http://ugspace.ug.edu.gh xiv LIST OF ABBREVIATIONS Abbreviation Meaning CDC Centre for Disease Control CEBioGen Community Engagement in Biobanking and Genomics DHMT District Health Management Team HCW Healthcare worker HMT Hospital Management Team KND Kassena Nankana District MOH Ministry of Health NHDSS Navrongo Health and Demographic Surveillance System NHRC Navrongo Health Research Centre NHCW Non-Healthcare worker NIH National Institute of Health PDH Paga District Hospital PI Principal Investigator PPE Personal Protective Equipment WHO World Health Organization WMH War Memorial Hospital University of Ghana http://ugspace.ug.edu.gh 1 CHAPTER ONE: INTRODUCTION 1.1 Background of the study Coronavirus disease 2019 (COVID-19) is an infectious disease caused by coronaviruses, specifically, severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). The disease was first reported in the Wuhan Province in China in December 2019 and has affected more than eighteen million people globally, with over six hundred thousand deaths (Kamel Boulos & Geraghty, 2020). The World Health Organization (WHO) declared COVID-19 a pandemic on 11th March 2020 when it had spread across almost all the continents of the world (WHO, 2020e). COVID-19 is a highly transmissible disease with a basic reproductive number estimated to be higher than that of severe acute respiratory syndrome (SARS), which only affected 26 countries and caused about 8,000 deaths in 2002 (Rocklöv et al., 2020). COVID-19 is transmitted from person to person through small droplets from the nose or mouth, which are expelled when a person with the disease coughs, sneezes, or speaks, and also via contact with fomites (Aylward & Liang, 2020; WHO, 2020b). The virus has been shown to survive outside a host for durations that depend on the nature of the surface. It is reported to survive in the air for up to 3 hours, on copper surfaces for up to 4 hours, on cardboard for up to 24 hours, and plastic and stainless steel, for up to 72 hours (Van Doremalen et al., 2020). Common symptoms of COVID-19 include fever, cough, colds, headaches, and difficulty in breathing. Available evidence suggests that the pathogenicity of SARS-COV2 depends on host factors such as age and other comorbidities (Atri et al., 2020; Kraemer et al., 2020; Rothan & Byrareddy, 2020; Wu et al., 2020). There is, currently, no approved treatment for COVID-19 and the symptoms keep varying from person to person (Aylward & Liang, 2020). University of Ghana http://ugspace.ug.edu.gh 2 The first two cases of COVID-19 in Ghana were reported on 12th March 2020 (Ghana Health Service, 2020). By April 19th, 2020, m o r e than 1,000 confirmed cases of COVID-19 and nine deaths had been reported (Ghana Health Service, 2020). It is not clear when the first case of COVID- 19 was recorded in the Kassena Nankana Districts but by the 25th of January 2021, about 17 healthcare workers and 10 patients were infected with one death of a nurse in line of duty (Ghana Health Service, 2020). To reduce person-to-person transmission of the virus, the Government of Ghana adopted and promoted the WHO’s recommendations (safety prevention protocols) (WHO, 2020d), which include avoiding or limiting physical contact (including handshake and other forms of body contact), regular handwashing with soap under running water, rubbing of hands with alcohol-based sanitizers with up to 70% alcohol strength, wearing of a facemask to cover nose and mouth, reducing/limiting large gatherings among the general populace, as well as coughing into the elbow or tissue and disposing it immediately into a bin. The government and the ministries concerned also adopted and localized some preventive behavioral change messages that are being disseminated through the media (radio, television, social media, and print media), nationwide (WHO, 2020d). Emphasis has been placed on ensuring adequate handwashing and social distancing in all public places, including hospitals, markets, and transport terminals (Ghana Health Service, 2020; WHO, 2020d). This is partly because the majority of rural and urban-dwelling Ghanaians rely on open markets for groceries and public transportation for daily commuting. Public transportation stations in many parts of Ghana including the Kassena Nankana Districts (KND) are usually not spacious and are characterized by high vehicular and human density, especially on market days or during rush- hours (Bonful et al., 2020). Also, Primary health care facilities (PHCs) in many parts of Ghana including the Kassena Nankana Districts (KND) are the first point of call for many residents who may University of Ghana http://ugspace.ug.edu.gh 3 feel sick or in need of one health service or the other whether the health facility and the staff are well prepared or not to deliver such services. Transmissions of the coronavirus remain high across many districts in the country, putting healthcare workers (HCWs), who are directly in contact with patients at a high risk of getting infected in the healthcare setting (Afulani et al., 2020). By the end of January 2020, the WHO and CDC (Centers for Disease Control and Prevention) had published recommendations for the prevention and control of COVID-19 for HCWs (CDC, 2019; WHO, 2020a). The WHO also initiated several online training sessions and materials on COVID- 19 in various languages to strengthen the preventive strategies, including raising awareness, and enhancing HCWs' preparedness (WHO, 2020c). Several instances point that a misunderstanding of the virus and the need to follow these laid down protocols by HCWs and patients delay the efforts to control or to provide necessary treatment (Hoffman & Silverberg, 2018), thereby implicating rapid spread of infection in hospitals (McCloskey & Heymann, 2020; Selvaraj et al., 2018) and putting the patients' lives at risk. With the advent of vaccines and appeals for all to be vaccinated, the United States Centres for Disease Control (US CDC) has stated emphatically that a person who obtains a COVID-19 vaccine should continue to observe the safety protocols to prevent breakthrough infections (CDC, 2020b). The basic means of reducing infection, morbidity, and mortality from the virus remains the right behavior towards the virus. The right behavior may include but is not limited to social distancing, wearing a nose mask in a public setting, and proper hand hygiene (CDC, 2020a). The spread of new variants of the virus in 2021 could be linked to the inconsistent avoidance of harmful behaviors among the world’s population despite the general awareness of the safety precautions and the impact of the disease on the world (O’Connell et al.,2021). University of Ghana http://ugspace.ug.edu.gh 4 In this regard, the COVID-19 pandemic offers a unique opportunity to assess the implementation of COVID-19 prevention protocols in selected health facilities and explore the challenges in implementing the COVID-19 protocols during this peak period. 1.2 Problem Statement Globally, little evidence exists on transmission patterns of COVID-19. As a novel virus, scientists and governments across the world are still learning the genetics of the virus and how to overcome it. There are uncertainties regarding who is likely to catch the disease, its potential severity, and management (Jin et al., 2020). The WHO-the lead organization of the world’s health has depended on the available information about the virus, to set out certain recommendations that could reduce or prevent infection or transmission of the virus. These recommendations to prevent infection include proper and frequent handwashing, physical and social distancing, wearing of nose masks, and limiting social gatherings (staying at home) (WHO, 2020e). While the virus and its devastating effects looked farther from Ghana, Ghana confirmed the first case of COVID-19 on March 12th, 2020, barely four months after the outbreak in Wuhan and a day after the WHO declared the virus a pandemic. Since then, the case incidence in Ghana has risen sharply despite the adoption and promotion of the WHO safety protocols in Ghana (Ghana Health Service, 2020). Healthcare facilities around the world and for that matter in Ghana have been largely hit by the virus especially as they are the first point of call for many patients. Most patients have not heeded the recommendation from the WHO to call in for directions before reporting to the facility, therefore, causing more spread and implicating healthcare workers who fail to increase clinical suspicion (WHO, 2020d). Healthcare workers and patients at the facilities are at risk of either University of Ghana http://ugspace.ug.edu.gh 5 contracting or transmitting the virus (Afulani et al., 2020) In several instances, lack of knowledge, poor adherence, and compliance with the preventive measures of the infectious disease implicate rapid spread of the virus and put both the patient and health worker at high risk (McCloskey & Heymann., 2020). While the government of Ghana adopted and promoted the safety precautions for the Ghanaian population, (“Coronavirus,” 2020), reports of the upsurge of infections across various districts leaves much to be desired and in KND in particular, where there are about four deaths, and over 21 patients in the major referral facility of the district. (Bonful et al., 2020; Ghana Health Service, 2020). This situation could be linked to the inability of the population to follow the safety precautions religiously (O’Connell et al., 2021). This breeds a research interest to understand how well the protocols are implemented and followed in rural districts of Ghana. Also, no studies have been conducted to assess the implementation of COVID-19 prevention protocols in health facilities in the Kassena-Nankana district since Ghana recorded its first case. Hence to facilitate outbreak management of COVID-19 in Ghana and the KND, there is an urgent need to understand adherence to COVID-19 prevention protocols among health facility users (largely healthcare workers and non-healthcare workers) including the challenges in implementing the COVID-19 protocols at this critical moment. 1.3 Objectives of the study 1.3.1 Aims The general aim of this study was to assess the implementation of COVID-19 prevention protocols in selected health facilities in the Kassena-Nankana district. 1.3.2 Specific Objectives To achieve the general objective of this study, the study addressed the following specific objectives: University of Ghana http://ugspace.ug.edu.gh 6 1. To assess the level of adherence to COVID-19 prevention protocols among healthcare workers and non-healthcare workers in selected health facilities 2. To assess the availability of COVID-19 prevention protocol materials at vantage points in health facilities 3. To determine the factors influencing adherence to COVID-19 prevention protocols among non-healthcare workers 4. To explore the views of health workers on challenges in implementing the protocols 1.3.2 Research Questions 1. What is the level of adherence to COVID-19 prevention protocols among healthcare workers and non-healthcare workers in health facilities? 2. Are prevention protocol materials provided at vantage points in the health facilities? 3. What are the factors influencing adherence to COVID-19 prevention protocols in selected health facilities? 4. What are the views of facility users on the challenges in implementing the COVID-19 protocols? 1.4 Justification Understanding the situation of adherence to COVID-19 prevention protocols is necessary for the revision and implementation of safety protocols. This study provides information regarding the adherence to COVID-19 prevention protocols among healthcare workers and non-healthcare workers in selected health facilities in the Kassena Nankana District. The study also provides information on the availability of COVID-19 prevention protocol materials at vantage points in health facilities, the factors influencing the adherence to COVID-19 prevention protocols among University of Ghana http://ugspace.ug.edu.gh 7 healthcare workers and non-healthcare workers, and their views on challenges in implementing the protocols. The findings of this study could enable policymakers in the MOH, Ghana Health Service, and their collaborating agencies to design innovative strategies that would help improve the implementation of COVID-19 prevention protocols in health facilities. The results of this study may also serve as a baseline for more research in the future regarding the gap between establishing prevention protocols, implementation of the prevention protocols, and adherence/compliance with the prevention protocols, as well as the challenges therein. University of Ghana http://ugspace.ug.edu.gh 8 1.5 Conceptual Framework Figure 1. 1: Conceptual framework of factors influencing the implementation of COVID-19 prevention protocols Source: Author’s construct, 2021 University of Ghana http://ugspace.ug.edu.gh 9 1.5.1 Narration of conceptual framework In figure 1, the adherence to COVID-19 protocols is the outcome of the study. The framework illustrates a relationship between the various factors and how they interrelate to influence the outcome variable (Adherence). The socio- demographic factors of a person such as age, sex, educational status, occupation, and religion will directly affect his/her knowledge and perception of the COVID-19 protocols and will influence his/her adherence as explained in literature (Ashinyo et al., 2021; Piché-Renaud et al., 2021). The health facility is supposed to be the implementing body with the ability of the structure and the systems within it to directly influence its users in terms of ensuring or enforcing the protocols. The health facility-related factors such as the availability of COVID-19 cue to action at vantage points, constitute some form of health education or awareness for both healthcare workers and non-healthcare workers and indicate attempts of implementation. As in other studies, an educated person who is within the age range of 30-39 would most likely notice cue to action on display and may already have prior knowledge of the COVID-19 prevention protocols. Such a person is influenced by the interaction between his or her demographics and the facility related factors to be adherent with the prevention protocols. This directly impacts facility users’ knowledge of the protocols and their likelihood to adhere (Abeya et al., 2021; Fenerty et al., 2012) Again, the availability of prevention protocol materials such as veronica buckets, soap, tissue, and hand sanitizer at vantage points in the health facility affects the belief/perception of both patients and health workers as the facility’s portrayed seriousness with the virus would make users appreciate what is at stake For instance, a person may only acknowledge that there is a health emergency when they notice the seriousness within the facility. When they notice that things are done differently within the health facility, and they have already been exposed to some knowledge or University of Ghana http://ugspace.ug.edu.gh 10 education of the COVID-19 pandemic based on their demographics or the facility related factors, then they may be more likely to adhere. (Abeya et al., 2021). University of Ghana http://ugspace.ug.edu.gh 11 CHAPTER TWO: LITERATURE REVIEW 2.1 Introduction This chapter reviews relevant literature on the topic to highlight the gap and the depth of the research questions. The literature review is drawn from writings and theories of scholars who have contributed knowledge to the subject matter under review. The literature review is divided into subtopics to include COVID-19, response to the COVID-19 pandemic, the COVID-19 prevention protocols, the concepts of adherence, factors that influence adherence/compliance with COVID-19 prevention protocols including socio-demographic factors, non-health worker- related factors, health facility- related factors, health worker-related factors, and challenges of implementation of protocols. 2.2 Background information on COVID-19 The coronavirus disease is the world’s most devastating issue of recent time that is causing so much havoc to health systems around the world (O’Connell et al., 2021). The world woke up to the devastating news later in the year 2019 and nothing has been the same for any sector, especially for health systems around the world that continue to experience the greatest impact. (WHO, 2020e, Zhu & Cai, 2020)). The coronavirus disease otherwise known as SARS-CoV-2 is a respiratory infection caused by a newly discovered coronavirus that affects the lungs of infected persons, causing mild to moderate respiratory illness. Depending on factors of the host such as age, comorbidities including diabetes, cardiovascular disease, cancer, or chronic respiratory disease, a person may suffer more serious illness and may require treatment or medical attention to recover (Jin et al., 2020). The COVID-19 virus spreads from person to person through droplets of saliva or discharge from the nose of an infected person, with a mean infection incubation period estimated at 5.2days. While University of Ghana http://ugspace.ug.edu.gh 12 there are several speculations as to the actual source of the virus, bats are likely an important source of SARS-CoV-2 (Jin et al., 2020). There is still no specific treatment for the virus and steps must be taken to curtail the viral infection (Jin et al., 2020). The most current issue around the virus is the development and deployment of vaccines to stop the spread and protect the world’s population (COVID-19 Vaccines, n.d.). This venture is however yet to be assessed for success in middle or low-income countries in Africa (Gidudu et al., 2020) and in some parts of the West where the available vaccines are characterized by complex adverse events (“AstraZeneca Vaccine,” 2021). Globally, over 3,330,000 people have fallen ill with morbidity cases becoming mortalities. The current morbidity and mortality rates of the virus remain an important issue for the World Health Organization and its partners (WHO, 2020d). In Africa, the virus has wrecked more havoc on the already unstable health systems. While the impact of the virus in the Western countries cannot be compared to that of Africa, especially in terms of morbidity and mortality, the region has had a fair share of the impact which has affected every sector of the economy including agriculture, education, and above all health (Exploring the Impact of COVID-19 in Africa, n.d.). The situation in a vast continent such as Africa can even be more complex as many countries in the continent have insufficient testing and limited data on tests to understand the true reflection of the virus on the ground. (“COVID-19 in Africa,” 2021). The region has seen a significant increase in new cases and COVID-19 related mortalities. As at 2021, the Africa CDC reported that there were about 4,587,568 cases in Africa with a total death toll of about 122,969 (“Africa CDC - COVID-19 Daily Updates,” n.d.). With the presence of the vaccine in a multifaceted and complex continent characterized by poverty, political instability and other inherent frailties, the African population across various countries have worries over the inadequacy University of Ghana http://ugspace.ug.edu.gh 13 of the vaccine for the entire population, and the general potency of the vaccine and what the potential risk and harm may be (“COVID-19 in Africa,” 2021). To demystify the fears and misconceptions around the vaccine, the Africa CDC, the public health agency of the African Union, released a statement assuring Africans that the vaccine is safe and potent for the fight against the virus (“Statement to African Union Member States on the Deployment of the AstraZeneca COVID- 19 Vaccine to the Continent and Concerns about Adverse Event Reports Coming from Europe,” n.d.) The situation in Ghana is not very different from other countries in Africa. Ghana has since the inception of the pandemic been applauded for the strategies taken to contain the virus. Even though the testing capacity of the country may be inadequate, the Ghana government continues to work with the health partners to ensure that information about the virus is available to all (Quakyi et al., 2021). The case count in Ghana as of 2nd May 2021 stood at 1,583 active cases with a death toll of about 783. The Upper East region is one of the regions that continue to record cases of the virus partly due to the presence of an active testing center. The morbidity and mortality situation of the region has not been stable as different points in time reflect either high or few infections. The Kassena Nankana District, one of the few vibrant districts in the region has also had a fair share of the community spread to the extent of losing some healthcare workers and many indigenes. The War Memorial Hospital (WMH) has had to close down certain wards in the facility at certain points to contain the spread (Coronavirus, 2021; COVID-19, n.d.; Upper East Region Records 3 COVID-19 Related Deaths This Month, n.d.). University of Ghana http://ugspace.ug.edu.gh 14 2.3 Response to the COVID- 19 pandemic After declaring the coronavirus disease, a pandemic, the WHO took the forefront to support and assist governments and agencies around the world to take action against the virus. Little understanding of the virus through the efforts of the WHO and all the other scientific bodies that work together generated information that informed the prevention protocols that are widely adopted across the globe. Apart from the prevention protocols, the WHO has facilitated the manufacturing and supply of PPEs, the development, and deployment of vaccines, and the availability of experts as a way to respond to the pandemic (WHO, 2020e). The effort in Africa has not been any different since the first recorded case in Egypt. According to the CDC, sub-Saharan Africa reported its first case in February 2020 in Nigeria. Since then, Africa has dwelt on the experiences of the Ebola epidemic to fight the current pandemic. With efforts including lockdowns and restrictions to movement and social gatherings, intensified case finding and testing, as well as other public health and social measures such as self-isolation and the establishment of centers for quarantining cases, crowned with the frequent and transparent communications around the virus in most countries of the region, Africa appears to be responding quite well to the pandemic even though these efforts are largely derailed by poverty and inadequate health access (Ihekweazu & Agogo, 2020; The COVID-19 Pandemic in Africa, n.d.). The response in Ghana has been recognized as one of the best in Africa (CDC, 2020b). Centered on four main goals; thus, to slow and stop transmission, prevent outbreaks and delay spread, provide care for all patients, and minimize the impact of the pandemic on the health system, social services, and economic activity, the government of Ghana in consultation with relevant stakeholders set out to achieve these goals through the implementation of some strategies. Firstly, there were budgetary allocations for several sectors including health and support for the production and distribution of University of Ghana http://ugspace.ug.edu.gh 15 PPEs. Lockdowns, closure of schools and bans on social gatherings, adoption, and enforcement of WHO’s recommended safety protocols, enhanced contact tracing, hospitalization, and treatment of cases have all been implemented in Ghana quickly in response to the pandemic. Health facilities and health workers have been provided with PPEs and a commitment to give incentives to health workers for their efforts has also been met. Other actions in other sectors include tax waivers and support for small and medium scale industries. These measures were implemented both at the national and local level with emphasis on districts to tailor these measures for easy adoption at the district level. Interestingly, there is a gap in knowledge on the impact as well as the implementation of these measures at the district level (Dwomoh et al., 2021; Ghana, 2020; Hoffman & Silverberg, 2018; Quakyi et al., 2021). 2.4 COVID-19 Prevention Protocols The WHO has outlined some simple precautions to contain the spread of the virus worldwide and keep individuals safe. These safety precautions include the practice of regular handwashing with soap under running water, the use of a mask to cover the nose and mouth, and physical distancing. Other recommendations from the WHO also include coughing into a bent elbow or tissue, and the habit of keeping rooms well ventilated. The WHO also admonishes individuals to listen and follow all laid down recommendations from local health authorities and governments (Advice for the Public on COVID-19 – World Health Organization, n.d.). The various precautions from the WHO have been widely adopted and implemented by governments across Africa. The Africa Center for Disease Control and Prevention has taken and promoted these prevention protocols. They have narrowed these recommendations to the regional level to guide African governments and health systems, and have established guidelines based on the WHO recommendations on how to use or execute efficiently, each of these safety precautions (CDC, University of Ghana http://ugspace.ug.edu.gh 16 2020b). In Ghana, the Ministry of Health, the Ghana Health Service, and the Government of Ghana have collaborated to adopt and promote these prevention protocols. Ghana aims to stop the spread of the virus by reducing new infections, morbidity, and death through the enforcement of the WHO recommendations. To this end, the Ghana government has put in place further restrictions to control the community's spread of the virus (Ghana, 2020). Little has however been considered for the health facilities in the country in terms of supporting or assessing the implementation of the protocols in the facility setting. The various safety precautions are discussed in detail in subsequent paragraphs. 2.4.1 Face Masks According to the CDC, a nose mask is a loose-fitting and single-use device that covers the nose, mouth, and chin. A nose mask provides a physical barrier against potentially infectious droplets and is a simple and low-cost non-pharmaceutical individual intervention for protecting oneself and preventing the spread of respiratory infections (Center for Disease Control and Prevention [CDC], 2019). The World Health Organization recommends the use of nose masks to prevent the spread of respiratory infections including but not limited to COVID-19 (CDC, 2019; Centre for Health Protection [CHP], 2020; World Health Organization [WHO], 2020). The nose mask is expected to be used at all times by every individual, especially at enclosed places such as markets, offices, public transport, and health facilities (Dzisi & Dei, 2020). A simple cloth covering should be enough for individuals who may not have access to a surgical mask since the idea is to protect an individual’s droplets from getting out onto other people (Greenhalgh et al., 2020). University of Ghana http://ugspace.ug.edu.gh 17 While the use of a facemask may be quite basic, the safety precaution has met increasing resistance to compliance by many Ghanaians with issues of discomfort, loss of mimical communication including an inability to see the smiles of loved ones, and forgetfulness. It takes authorities at various departments to get some people to comply even though a lot of people agree and acknowledges the mask is protection for themselves and the people around them (COVID‐19: Face Masks and Human‐ to‐human Transmission - Liu - 2020 - Influenza and Other Respiratory Viruses - Wiley Online Library, n.d.; Howard et al., 2020). 2.4.2 Social/Physical distancing According to WHO, the practice and enforcement of social distancing are as critical as all the other measures because the virus only spreads from person to person and an effort to break the chain of transmission by being distant from others should be a concern for every person in the world (WHO, 2020d). According to the US CDC, limiting face-to-face contact with others remains the best way to curtail the spread of coronavirus disease (CDC, 2020a). Social distancing is a public health practice aimed at preventing sick persons from coming in contact with healthy people, especially in infectious disease situations, to reduce the risk of disease transmission. The practice ranges from large-scale measures such as canceling large gatherings as instituted by authority or personal decisions to avoid crowds (Mar 13 & 2020, 2020). There is currently a transition in terminology to refer to this practice as “physical distancing” instead of “social distancing”. Proposers of the transition argue that the practice aims to physically distance people who could be socially connected virtually. A change in the terminology will reduce the impact of quarantine and isolation on the mental health of people (Should We Say “Physical” Distancing Instead of “Social” Distancing? n.d.). University of Ghana http://ugspace.ug.edu.gh 18 Some of the steps to practice social distancing as outlined by the CDC include avoiding hugs and handshakes, avoiding mass gatherings, and maintaining a distance of about 6feet or 2 meters from other people (CDC, 2020c). In Ghana, the government in consultation with the ministry of health and the Ghana Health Service outlined some restrictions to help Ghanaians maintain social distance, especially at the peak of the virus. These steps include further restrictions and bans on public gatherings, demarcation of places including pharmacies, health facilities, banks, and offices to show the allowable distance that users of such facilities could be away from the other person, and the use of virtual mode for all activities including school and worship (“Coronavirus,” 2020; Dzisi & Dei, 2020; O'Connell et al., 2020). 2.4.4 Hand hygiene through washing and use of sanitizers Regular and proper handwashing is considered the most important hygienic principle. It is the one single determinant of the relevance of all other protocols such as wearing a mask or social distancing. It will not be very prudent to wear a mask the entire day and then take it off and touch your face or eyes with unwashed hands (Welle (www.dw.com), n.d.). Before the pandemic, the WHO and the CDC already established some guidelines for hand hygiene among healthcare workers. The situation of the pandemic has caused an extension of this practice to include every user of health facility. The merits of regular handwashing with soap under running water, especially in times of an infectious disease cannot be overemphasized (CDC, 2020d). To ensure compliance with handwashing within facilities in Ghana, the use of veronica buckets has become popular. Every health facility, transport station, market, and other open places are required to provide functional veronica buckets with constant water supply, soap, tissue, and dustbins at vantage points for use by individuals who visit (Bonful et al., 2020; Dzisi & Dei, 2020). University of Ghana http://ugspace.ug.edu.gh http://www.dw.com/ 19 Several studies have identified handwashing as the most simple, easy, and effective preventive measure for IPC. Handwashing is arguably the simplest protocol to comply with and it is practiced by both healthcare workers and non-healthcare workers (Azene et al., 2020; Banerjee, 2020; Fuls et al., 2008). 2.5 The concept of adherence The novel coronavirus disease that continues to cause mild to severe disease in the human population around the world has no potent treatment yet despite the development and deployment of some vaccines. The arm against the battle remains a behavioral change to include improved hygiene and exercises (CDC, 2020a; Quakyi et al., 2021; Xie et al., 2020). Despite the consensus that adherence to the preventive protocols is the only way to defeat the virus, studies have shown inadequate adherence in communities and transport systems (Azene et al., 2020; Bonful et al., 2020) The concept of adherence has been studied extensively in medical research. A lot of the studies done around adherence are on patient adherence to medication for some diseases or healthcare workers' adherence to some procedure or work protocols (Bissonnette, 2008; Chatio et al., 2015; “Measuring Adherence to Behavioral and Medical Interventions | Request PDF,” n.d.). Most of the studies however do not have a unified scale of measurement for adherence, hence authors operationally define their measurements of what adherence or compliance with the phenomenon under study would mean (Bargain & Aminjonov,2020; Roma et al., 2020; Saechang et al., 2021). University of Ghana http://ugspace.ug.edu.gh 20 2.6 Factors that influence adherence to COVID-19 prevention protocols. The factors that influence adherence generally depend on several things. Knowledge around the subject matter, the individual beliefs around the phenomenon, social demographic issues such as age, gender, and educational level as well as institutional factors including laws and cues to action. These factors have been broadly categorized by other authors in other scientific fields as socio-demographic factors, non-healthcare worker-related factors, healthcare worker- related factors, and facility-related factors (Piché-Renaud et al., 2021; Xie et al., 2020). 2.6.1 Socio-demographic factors that influence adherence/compliance with prevention protocols Most studies around COVID-19 employed descriptive analysis without actually uncovering factors that influence adherence to preventive protocols. The socio-demographic characteristics of people including healthcare workers and non-healthcare workers play a very big role in how they perceive and relate to issues. The gender of a person, the level of education, age, occupation, and other socio- demographic characteristics have been referred to as the basis for the formation of other variables (Ashinyo et al., 2021; Piché-Renaud et al., 2021). A study in Ethiopia revealed that the socio-demographics of participants in the study such as their age or educational level showed a high likelihood for adherence to safety protocols. (Azene et al., 2020). Similar studies for healthcare workers in Canada and Ghana also revealed that the socio- demographics of healthcare workers influenced their attitude to personal protective equipment and their general compliance with preventive protocols (Ashinyo et al., 2021; Piché-Renaud et al., 2021). University of Ghana http://ugspace.ug.edu.gh 21 2.6.2 non-healthcare worker-related factors that influence adherence to prevention protocols There are factors that cause non-healthcare workers (patients or their relatives to either comply or refuse to comply with preventive protocols. Several studies have identified that the knowledge level of non-healthcare workers and their perception about the virus determines their attitude towards adherence or compliance. A study in Ethiopia revealed that the likelihood for non-healthcare workers to comply with prevention protocols was directly dependent on the level of their knowledge of the protocols, and their perceived risk of infection (Azene et al., 2020). A similar study in China among non- healthcare workers also showed that non-healthcare workers' knowledge and perceptions of the virus and protocols influence their ability or willingness to comply (Xie et al., 2020) while arguing that non-healthcare workers in the facility setting are likely to emulate the example of healthcare workers. This assertion is however different in another study which explains that while non- healthcare workers including patients may likely remember elements of their experiences in the facility, patients are likely to remember actions that were carried out on them or some things that were required of them such as asking for stool samples or listening to their heartbeat, but may not be able to recognize or notice the other technical aspects of clinical care such as healthcare workers washing their hands or respecting their privacy (Aujla et al., 2021). A study by Azene et al, (Azene et al, 2020) reported that a negative attitude towards the prevention protocols for COVID-19 is fueled by a lack of knowledge, misconceptions around the virus, and the perception of not being at risk of infection. Most non-healthcare workers who have not had the opportunity to see infected persons still doubt if the virus affects everybody and think of it as a stigmatized disease for the aged and people of a certain class. University of Ghana http://ugspace.ug.edu.gh 22 2.6.3 Health worker-related factors The reasons why healthcare workers may or may not comply with COVID-19 prevention protocols are not very different from that of non-healthcare workers. Within an outbreak setting, perceptions and confidence in prevention control measures influence healthcare worker adherence. Inconsistent use of materials due to inadequate logistic supply, lack of training to improve knowledge among others are outlined as the healthcare-related factors that influence adherence or otherwise with COVID-19 prevention control in Canada (Piché-Renaud et al., 2021). While healthcare worker compliance may be generally high, a study revealed that this compliance varied across factors including the type of healthcare worker, knowledge of virus, perceptions, and beliefs about virus and protocols, as well as other socio-demographic factors of healthcare workers (Ashinyo et al., 2021). Studies around the healthcare worker as a factor to adherence or compliance with COVID-19 protocols have shown that the workload of healthcare workers affects their ability to practice or comply with COVID-19 protocols, especially handwashing (Felice et al., 2020). Healthcare workers in the studies report that it is difficult to keep washing hands from patient to patient as the volume of work increases. The impact of workload on the mental health of healthcare workers in the pandemic situation is crucial and countries like Italy are providing psychological support for healthcare workers (Felice et al., 2020). In the case of a COVID-19 outbreak, adherence to all severe occupational requirements by healthcare workers is crucial because they are the occupational categories most at risk of contracting the virus during the pandemic (World Health Organization, 2020a). In Italy, because they were not promptly provided with self-protective equipment such as gowns, gloves, N95 University of Ghana http://ugspace.ug.edu.gh 23 masks, goggles, and so on, or given sufficient IPC (infection prevention and control) training, healthcare workers in life-threatening healthcare settings, with longer duty hours, are more exposed to the pandemic and need support to consistently comply with prevention protocols while on duty (Carlucci et al., 2020) 2.6.4 Facility-related factors Facility-related factors are the circumstances or situations at the health facility that either promote or impede adherence to COVID-19 prevention protocols. For facility users to be compliant with safety precautions, the Joint Commission on Accreditation of Healthcare Organizations posits that there should be clearly labeled materials and demarcations for people to follow. Clear labels improve facility internal non-verbal communication and remind users to adhere (Abeya et al., 2021; Fenerty et al., 2012; n.d.). One key role of the health facility is infection control. The importance of infection control in healthcare facilities has become more important, especially with the presence of the pandemic. A study posits that the ability of health facility managers to give training to the staff and improve the ability of staff to practice safe and proper hand hygiene can influence general adherence to the facility. Technology and other functional materials also available at the facilities increase the likelihood of compliance as compared to instances where these are not available (Abeya et al., 2021). Other opinions support this assertion that the presence of a water management system to support hand hygiene and well-ventilated spaces to reduce infections will go a long way to improve adherence to these facilities. University of Ghana http://ugspace.ug.edu.gh 24 2.7 Challenges of the implementation of prevention protocols Different users of healthcare facilities face different challenges at different points in time. Even though there may be more general challenges within the facility that affects every user including managers and other healthcare workers, the major challenges that healthcare workers face may differ from the challenges of non-healthcare workers within the health facility. A study of healthcare workers' challenges revealed that they are unable to fully comply with prevention protocols when they spend long hours in the facility, wearing a nose mask for a longer period and using the same logistics to care for multiple patients (Rostami & Neshati-Khorram, 2020). The healthcare workers posit that the pandemic has increased their workload because they have more patients coming in at a point in time using the same limited logistics and facilities. Apart from logistics challenges, there are also demographic and personal challenges, as well as political challenges including the will of the government to supply facilities with the needed stock supplies to improve adherence. These challenges are similar in most studies and either focus on the lack of logistics, patients’ knowledge or beliefs, health workers’ workload, and perceptions, or institutional management support systems (Amugsi et al., 2015; Arianpoor et al., 2020). The challenges which hinder the implementation of prevention protocols may include a lack of administrative commitment and support as well as community support. The implementation of COVID-19 prevention protocols is heavily reliant on administrative assistance for maintenance, involvement, and motivation of the process (Dassin & Kim, 2020). According to the WHO standards, lockdowns, and restrictions should be placed by local governments and authorities in certain places to reduce the transmission rate of the virus (WHO COVID-19 situation report, 2020). The ability and willingness of authorities and local governments to ensure that people are University of Ghana http://ugspace.ug.edu.gh 25 offered their necessities and sufficient education to support the process are however inadequate (Human rights dimensions of COVID-19 response, 2020). The pandemic has also intrinsically increased demand for drugs, immunizations, testing facilities, diagnostics, and reagents. This has resulted in a scarcity of medical facilities and products, especially at the primary health or community level. Even though medical product procurement, use, and management must be done with care, a lack of products and facilities such as PPEs can exacerbate the surge in infections; the case of China’s Wuhan city (Guan W.J. et al, 2019). Another hurdle while implementing COVID-19 preventive measures is inadequate resources to execute public health and social policies. Insufficient funding, incorrect resource distribution, lack of motivation, all contribute to a lack of resources (Yazdani & Wells, 2018). Lack of resources complicates the establishment of coronavirus isolation wards or treatment facilities, as well as the provision of critical care to patients suffering from the most severe cases of COVID-19, and the procurement and distribution of logistics to implement prevention protocols. COVID-19 infected cases may place tremendous strain on hospitals and critical care institutions, some of which may lack the necessary resources or staff to deal with the situation (Remuzzi & Remuzzi, 2020). Despite the general awareness around the COVID-19 prevention protocols, there is the challenge of lack of cooperation among the populace which may make it difficult to strictly and consistently enforce the WHO restrictions. If WHO regulations are not followed correctly, the COVID-19 pandemic will contribute more to public hazards resulting in more transmissions and deaths (Wilder-Smith, 2020; Kohli, 2020). The lack of cooperation may translate into a poor dedication to safety by the public, even though the awareness and general knowledge of the WHO regulations expected an increase in the public’s commitment to safety (WHO Coronavirus disease 2019 (COVID-19) situation report, 2020). University of Ghana http://ugspace.ug.edu.gh 26 Communication and language challenges also impede the smooth implementation of prevention protocols. Communication in all stages of the healthcare process is essential to patient care, especially in sharing patient information and discussing treatment (Coiera, 2006). Poor communication has an impact on all elements of healthcare, including teamwork, leadership, and workplace culture. Institutions with good communication methods can improve their patients' health, whilst those without effective procedures can harm their patients' well-being (Wilder- Smith, 2020). To halt the spread of COVID-19, health care experts and organizations must grasp the importance of communication in the health care sector. Furthermore, effective communication between health advisors and the general public in a language they can easily understand will encourage people to be aware of COVID-19 and to take appropriate precautions to prevent its transmission (Kholi, 2020). 2.8 Summary The literature review chapter explored relevant literature on the implementation of the COVID-19 prevention protocols in health facilities. It recognized the various prevention protocols as outlined by the WHO as well as guidelines by the government of Ghana. It also highlighted the various factors that affect adherence to the prevention protocols in health facilities notably; socio- demographic factors, healthcare worker-related factors, non-healthcare worker- related factors as well as facility-related factors. It then discussed the inherent challenges of implementing the COVID-19 prevention protocols. The review revealed a large gap in implementation assessment for the prevention protocols, especially in district hospitals as it was nearly impossible to come across literature or similar studies that have looked at the implementation of COVID-19 prevention protocols in district hospitals in Ghana. University of Ghana http://ugspace.ug.edu.gh 27 CHAPTER THREE: METHODOLOGY 3.1 Introduction The chapter describes the methods that were used in conducting the study. The chapter comprises the research design, study location, study population, inclusion and exclusion criteria, sample size and the sampling techniques, data collection approaches, study variables, and the steps by which data was analyzed and interpreted. 3.2 Research Design The study employed a hospital-based cross-sectional study design involving quantitative and qualitative approaches to gather data for the assessment of the implementation of COVID- 19 prevention protocols in selected health facilities. The study design is appropriate as it enables data to be collected on individual characteristics at a point in time, alongside information about the outcome, and the association between individual characteristics and the outcome of interest (Setia, 2016). The cross-sectional study design is used because it is simple and less expensive in terms of time and resources. 3.3 Study Location The study was conducted in the Kassena Nankana Districts located in the Upper East Region of Ghana. The researcher chose to study KND because it was one of the districts in the region that had upsurge of COVID-19 cases in 2020 (Bolgatanga Regional Health Directorate., 2020). Also, no study had been conducted in the district to assess the implementation of the COVID-19 prevention protocols even though the Navrongo Health Research Centre and the DHMT had done a number of educational campaigns in the district. The vegetation of the University of Ghana http://ugspace.ug.edu.gh 28 study area is guinea Savannah with a short rainy season from May to September and a prolonged dry season for the rest of the months. The area has an annual mean rainfall of approximately 1300 mm with mean monthly temperatures ranging from 22.88oC to 34.48oC (Oduro et al., 2012). Economically, the people in the study area are engaged in petty trading, agriculture, and tourism. The study district was selected purposively because it is a surveillance area of the Navrongo Health and Demographic Surveillance System (NHDSS) managed by the Navrongo Health Research Center (NHRC). The surveillance area is sectioned into five geographic zones (East, West, South, North, and Central) based on proximity and language. This study focused on the East and West zones (the municipal hospital and the Paga Health Centre which is now the district hospital in the west zone) of the district because the two zones are representative of the five zones, and also because of time limitation to complete work. University of Ghana http://ugspace.ug.edu.gh 29 Figure 3. 1: Setting of the study area on a map of Upper East, Ghana, and Africa Figure 3. 2: Navrongo HDSS coverage area in the Kassena-Nankana districts University of Ghana http://ugspace.ug.edu.gh 30 3.3.1. Health infrastructure of the Kassena-Nankana Districts The study area has one hospital that serves as a referral facility. In addition to the hospital, there are seven health centers of which one in the West is now a hospital, with 27 CHPS compounds with resident health workers, and several other primary health care clinics. The two hospitals in the district (War Memorial Hospital in the east and Paga District Hospital in the west) are the two major referral facilities in the Kassena Nankana districts. The two facilities are managed by the District Health Management Team (DHMT) in the west and the DHMT in the east. Both east and west get their health information from the facilities and the community radio (Oduro et al., 2012). The health infrastructure of the KNDs is largely influenced by the research activities of the Navrongo Health Research Centre NHRC). NHRC is a research institution in the district whose research activities over the years have brought great improvement to the health situation of the district. Many residents in the district have built trust in the work of the Research Centre. It is because of this trust relationship that the center has a moral imperative to act especially in times of health emergencies and misinformation. One of the projects currently being run at the NHRC is the H3Africa Community Engagement in Biobanking and Genomics (CEBioGen) project funded by the United States National Institutes of Health (NIH). The overall aim of the project is to identify effective community engagement strategies for genomics and biobanking in Africa. As a community engagement project within a health research institution, the CEBioGen team collaborated with the DHMT of the East and West zones of the district to conduct some COVID-19 educational campaigns including roadshows, radio discussions, and van announcements. These campaigns became the major educational intervention of the district in demystifying misconceptions around the COVID-19. There were also instances of donation of personal protective equipment (PEs) to the two major facilities and further health education within the facilities. The collaboration aimed to demystify misconceptions around the COVID-19 and also allow researchers to educate the community on the prevention protocols as well as the advent of possible vaccines. Following the education and intensity of campaigns in the University of Ghana http://ugspace.ug.edu.gh 31 district, it will be interesting to see how the education affected compliance and adherence and how the donations supported the facilities to implement the prevention protocols. 3.4 Target Population The target population of the study was healthcare workers and users of health facilities within the two hospitals during the period of observation. 3.5 Study Population The study population included health workers and non-healthcare workers (patients and their relatives) in the two health facilities. The Paga District Hospital (PDH) and the War Memorial Hospital (WMH) were also assessed. Healthcare workers including nurses, doctors, managers, or facility leaders were also observed and interviewed to answer objective four (4) of the study. 3.5.1 Inclusion criteria To participate in the study, a potential participant had to: ▪ Be any person within the selected facility at the period of observation including in-patients (for the observation) ▪ Be eighteen (18) years and above, who have either come to receive care or brought someone receive care and has been successfully observed, (for the exit survey) ▪ A health worker at the facility either in the ward or out department ▪ Go through the informed consent process and voluntarily agree to participate in the survey. For the qualitative arm, a health worker including managers or facility unit head had to be available and willing to grant an interview. 3.5.2 Exclusion criteria The inclusion criteria were as follows: University of Ghana http://ugspace.ug.edu.gh 32 ▪ Any person within the health facility in visible pain or an emergency at the period of observation ▪ A person 18years and above who received care from the facility but is not sane ▪ A potential participant who did not show an understanding of the study after going through the consent process was disqualified even if such a person voluntarily agreed to participate. ▪ Again, a health worker or manager, or facility in-charge who declared willingness or availability but whose attention was needed for other important issues at the facility was allowed to exit the interview at that particular time. 3.6 Sample Size The sample size was determined using single population proportion formula considering the following statistical assumptions: Confidence level (Cl), 95% Proportion = 50% (50% proportion is used because the proportion of adherence to COVID-19 prevention protocols among facility users is unknown). The margin of error is 5% Using the following single proportion formula: (Za/2)2 x P (1-P) n = (W)2 Where, n = initial sample size Z = 1.96, the corresponding Z-score for the 95% CI P = Proportion = 50% W = Margin of error = 5% = 0.05 University of Ghana http://ugspace.ug.edu.gh 33 (1.96)2 x 0.5 (1-0.5) n = (0.05)2 n = 384 Based on the fact that the study was to be conducted in two selected facilities, the sample size of 384 was used to sample non-healthcare workers for exit surveys in the two selected facilities. It implied that the daily attendance of the two facilities had to be added and averaged in respect to the calculated sample size to determine how many surveys will be carried out in each of the two facilities. The average daily attendance to the WMH is about 120 as reported by the administrator while that of PDH is 55. Adding the two figures gives a total of 175. Calculating the proportion for each facility, We had for WMH; 120÷175×384₌ 263 For PDH, we had a sample of; 55÷175×384₌ 121 By considering a 10% non-response rate for each facility, WMH expected a minimum sample of 289 surveys and PDH expected a minimum sample of 133. In all, the study expected to conduct a minimum of 422 surveys with non-healthcare workers in the two facilities. 3.7 Sampling Techniques 3.7.1 Quantitative A consecutive sampling procedure was used to sample participants for the exit survey. This sampling approach was chosen because there was no available list of non-healthcare workers and the researcher University of Ghana http://ugspace.ug.edu.gh 34 could not tell beforehand those who will be visiting the health facilities of the study area, to make randomization possible. Also, with the consecutiveience sampling technique participants were selected in the health facility (PDH and WMH) based on availability and willingness to take part in the exit interviews during the period of observation till the desired sample size was reached. The same respondents were followed till their exit interviews to determine adherence to COVID-19 prevention protocols. While the advantages of consecutive sampling cannot be overemphasized, the fact that it is prone to bias was well noted and the researcher intentionally enforced the inclusion and exclusion criteria, while ensuring a balance between males and females during recruitment (Etikan, 2016). 3.7.2 Qualitative A purposive sampling technique was used to select the participants for the study. Considering that healthcare workers in the facility setting usually have a lot of pressure and work burden, the study purposively sampled the ward or unit in-charges (male ward, female ward, OPD, laboratory, kids ward, emergency ward, COVID-19 ward, head of security) who were available and willing from the two facilities for the qualitative interviews. The researcher focused on the actual implementers of the prevention protocols in the units within the facilities (Stojan et al., 2016). 3.8 Source of Data A comprehensive literature review was conducted to augment the primary data that was gathered from the facilities through the administration of the exit survey, interviews, and observations. 3.9 Methods of Data Collection A mixed-method approach involving the use of both qualitative and quantitative methods was used for data collection. The study conducted four data collection activities within each facility visited. University of Ghana http://ugspace.ug.edu.gh 35 3.9.0 Pretest of data collection tools The testing of the data collection tools was done in Sandema district hospital to detect inconsistencies and other problems that may arise during data collection. This process was also to establish validity and reliability. 3.9.1 Facility Assessment Each hospital was assessed for the availability of COVID-19 prevention materials using an observation checklist to mark the availability and functionality of COVID-19 prevention materials including veronica buckets with soap, water, tissue, dust bins at vantage points for disposing of used tissue, hand sanitizers, available cue to action at vantage points to remind people to adhere including loud posters and comprehensible signs, spaces with demarcated seats for social/physical distancing, and rules that return healthcare workers and non-healthcare workers who do not wear a mask or wash their hands. The observation checklist for the facility assessment was developed with the CDC’s guidelines and standards for health facilities during the COVID-19 pandemic and administered to the various units of the facilities. Unit by unit, the researcher assessed the availability of these prevention materials as against the CDC standards. 3.9.2 Observation of facility users; healthcare workers and non-healthcare workers The researcher directly observed all persons in the facility including healthcare workers in the ward and those at the OPD using a checklist designed in Open Data Kit (ODK). The researcher also observed non- healthcare workers including inpatients and their caretakers, and outpatients. The broad categories of observation were the healthcare workers and non-healthcare workers since the focus of the study was to use adherence to COVID-19 prevention protocols to assess the implementation of the protocols in health facilities which are mainly used by healthcare workers and non-healthcare workers. Again, the focus of University of Ghana http://ugspace.ug.edu.gh 36 the study was the health facility that deals with outpatients and inpatients hence, the researcher observed compliance and adherence in the wards and whether it was any different from the users at the OPD. The observation period was four days for each facility and usually started at 7:00 am till about 2:00 pm when the facilities no longer had many people at the departments. The researcher believed observing for four days within the hours of 7:00 am and 2:00 pm gives a true reflection of what is actually on the ground than the initial plan of observing for a day. While including more days for observation could have produced a much better reflection of the ground situation, the researcher had time and other constraints which further heightened the choice of observing each facility for four days. The researcher observed the male ward, the female ward, the emergency ward, and the pediatric ward of the two facilities for the inpatient category. The researcher however added the maternity ward in the Paga District Hospital as it stands so close to the pediatric ward and was visibly busy at the time of field visits. The male and female wards were observed to give a fair balance between the sexes of the population even though the wards produced a different number of observations at the end of the day depending on the number of in-patients, caretakers, and healthcare workers in the ward at the time of observation, while the pediatric ward was observed to see how healthcare workers and caretakers were protecting the young children against the virus. The OPD, records, pharmacy, and laboratory departments of both facilities were also observed for the outpatient category. The observation checklist was designed according to the WHO standards for wearing a nose mask, social/physical distancing, and washing hands (WHO, 2020d). Two data collectors were trained to help the researcher conduct the observation. University of Ghana http://ugspace.ug.edu.gh 37 3.9.3 Quantitative Survey After the facility assessment and during the period of observation, the calculated sample for each of the facilities was used to recruit qualified non-healthcare workers for an exit survey. Exit interviews allowed the users of the facility to recount their experiences and challenges they faced while at the facility in trying to observe the prevention protocols (Aujla et al., 2021). An exit survey is appropriate for this study because it eliminates recall bias in terms of users narrating their challenges and reduces the fear of being victimized that non-healthcare workers usually have when they are being interviewed within the facility setting (MILLER FRANCO et al., 2002). To successfully conduct the exit survey under the current circumstances of the COVID-19 pandemic, data were collected using a pretested, structured, electronic interviewer-administered questionnaire designed in Open Data Kit (ODK). The importance of e-data cannot be overstated. The survey tool was adapted from a similar study in Ethiopia (Azene et al., 2020). The questionnaire was written in the English language and comprised mainly close-ended and a few open- ended questions. These questions were divided into dimensions such as socio- demographic, non- healthcare worker-related factors, health facility factors including challenges with adherence to COVID- 19 prevention protocols. Six data collectors were trained to know the objectives, the relevance of the study, and the rights of the respondents either to participate or decline, to prepare them to help the researcher with the data collection. 3.9.4 Qualitative (IDIs) Face-to-face in-depth interviews were conducted with healthcare workers including nurses, unit heads, facility managers, and security guards. An interview guide was developed and interviews were conducted to ascertain the views of healthcare workers or managers on challenges in implementing the protocols. The interview questions were constructed and conducted in English. Each interview lasted for University of Ghana http://ugspace.ug.edu.gh 38 approximately 15-55 minutes. The researcher conducted eight (8) IDIs at the WMH and Nine (9) IDIs at the PDH. As planned, the qualitative data reached a saturation point at the 5th and 6th interviews for the WMH and the PDH respectively but the researcher conducted three (3) additional interviews to confirm saturation of data (Guest et al., 2020). The interviews were conducted at the health facility (OPD, ward, and offices) at the participant’s convenient time. With the consent and permission of the participants, the interviews were audio-recorded and notes were taken as well. All these methods and approaches gathered data from consenting individuals to answer the four research questions. 3.9.5 Variables, terms, and operational definitions Table 3. 1: Variables, terms, and operational definitions Study Variables Operational Definition Data Collection Technique Dependent variable (Adherence to COVID-19 prevention protocols) Adherence is one’s ability to always observe the COVID- 19 prevention protocols because it is the right thing to do or because you are told to do so. Adherence is measured as a nominal variable (binary) using 13variables. Observation checklist/questionnaire University of Ghana http://ugspace.ug.edu.gh 39 Independent variables Socio-demographic factors including Age Sex Religion educational status occupation Ethnicity . Age is the complete years of life a person has had at the time of the study. Sex is categorized into male and female, and was reported. Religion was measured as a nominal variable (muslim, Christian, or traditionalist) Educational status was measured as a nominal variable (no formal education, primary, secondary, tertiary) Occupation was measured as a nominal variable (Unemployed, employed, self-employed) Ethnicity is measured as a nominal variable (Builsa, Ga- adangbe, kassem, Nankam, Sisala) These are factors that may influence facility users’ ability to comply or adhere to prevention protocols Questionnaire and interview guide Knowledge of COVID-19 and prevention protocols What facility users know about the virus and the preventive protocols Questionnaire and interview guide Enforcement of prevention protocols Implementers ensuring or reminding facility users about the prevention protocols Survey and interview Belief/perception about the virus and prevention protocols What facility users think about the virus and the preventive protocols Questionnaire and interview guide Work burden for healthcare workers Other responsibilities and workload of healthcare workers Interview guide University of Ghana http://ugspace.ug.edu.gh 40 Availability of materials including cue to action Functional materials with easy access to all users that have signs to remind users to use the materials Observation checklist Healthcare worker A person who has been trained to provide health services at the facility and is either a nurse, a doctor, a manager, or other supporting staff like security guards. Non-healthcare worker A person who is within the facility at a particular time either as a patient (outpatient or inpatient), or a caretaker Facility users A term that refers to healthcare workers and non-healthcare workers in a facility Source: Author’s Construct, 2021 3.10 Data Management and Analysis 3.10.1 Quantitative Data collected were exported into Microsoft Excel format, and then imported into STATA 16 for data management and analysis. Consistency and accuracy were checked based on the flow of the questions. Also, outliers were checked and resolved. Then, a composite scoring approach was used to assess adherence, enforcement, and knowledge of participants on COVID-19 prevention protocols. Discrete variables such as the age of the participant were transformed into categorical variables based on reviewed literature. University of Ghana http://ugspace.ug.edu.gh 41 Descriptive statistics like frequencies, percentages, and means/median were computed and bivariable analyses were carried out to examine the relationship between adherence and each of the factors using Chi-square test analysis. Individuals were adjudged by both observation and some variables in the survey to be adherent to COVID-19 prevention protocols. ll explanatory variables that were statistically significant at the bivariable logistic regression model at p-value <0.05 were included in the multiple logistic regression model to see the real determinants of adherence. Adjusted odds ratios with a 95% confidence interval were computed, and variables with a p-value <0.05 in the multivariate model were considered statistically significant. The results of the study were presented in tables and figures. 3.10.2 Qualitative The audio-recorded data were kept on a passworded computer and copies of such were on a compact disc to serve as backup. The recorded files were transcribed verbatim in the English language from audio to text format using the Microsoft Office Word application 2019 version. In analyzing the data, six steps method of qualitative data analysis was adapted (Creswell, 2009). The first step of this method involved data transcription. At this stage, the researcher listened to the voices over and over again to familiarize himself with the audio-recorded data before it was transcribed into text format. The second step was familiarization with the transcripts. With this step, the researcher read through all the data over and over again. This helped the researcher to get a general sense of the overall meaning of the data from the perspectives of the participants. This exercise created the opportunity for the identification of codes and themes. The third step involved coding where the researcher organized the material into segments to bring meaning to the information. These segments were labeled with codes developed in the NVivo12 software that described the data at different levels with emerged themes. The fourth step was the development of themes. The researcher developed themes that appeared as major findings and University of Ghana http://ugspace.ug.edu.gh 42 exported the various codes to these themes that were used to create headings and subheadings in the presentation and discussion of data. In respect of the last but one step, data were described- meanings and clarifications were made from the data in respect to the subject matter; challenges in implementing the COVID-19 protocols. At the final step, the researcher interpreted the meaning of the themes in line with the objectives of the study. The researcher also compared these findings with the information gathered from the literature to draw conclusions and highlight the implications of the key findings of the study. This method was useful because it helped the researcher to validate the accuracy of the information received from the participants (Creswell, 2009). Qualitative data of the study were analyzed per facility. 3.10.2.1 Triangulation Triangulation is a strategy for ensuring t