The experience of European hospital-based health care workers on following infection prevention and control procedures and their wellbeing during the first wave of the COVID-19 pandemic.

BACKGROUND: Working under pandemic conditions exposes health care workers (HCWs) to infection risk and psychological strain. A better understanding of HCWs' experiences of following local infection prevention and control (IPC) procedures during COVID-19 is urgently needed to inform strategies for protecting the psychical and psychological health of HCWs. The objective of this study was therefore to capture the perceptions of hospital HCWs on local IPC procedures and the impact on their emotional wellbeing during the first wave of the COVID-19 pandemic in Europe.
METHODS: Participants were recruited in two sampling rounds of an international cross-sectional survey. Sampling took place between 31 March and 17 April 2020 via existing research networks and between 14 May and 31 August 2020 via online convenience sampling. Main outcome measures were behavioural determinants of HCWs' adherence to IPC guidelines and the WHO-5 Well-Being Index, a validated scale of 0-100 reflecting emotional wellbeing. The WHO-5 was interpreted as a score below or above 50 points, a cut-off score used in previous literature to screen for depression.
RESULTS: 2289 HCWs from 40 countries in Europe participated. Mean age was 42 (±11) years, 66% were female, 47% and 39% were medical doctors and nurses, respectively. 74% (n = 1699) of HCWs were directly treating patients with COVID-19, of which 32% (n = 527) reported they were fearful of caring for these patients. HCWs reported high levels of concern about COVID-19 infection risk to themselves (71%) and their family (82%) as a result of their job. 40% of HCWs considered that getting infected with COVID-19 was not within their control. This feeling was more common among junior than senior HCWs (46% versus 38%, P value < .01). Sufficient COVID-19-specific IPC training, confidence in PPE use and institutional trust were positively associated with the feeling that becoming infected with COVID-19 was within their control. Female HCWs were more likely than males to report a WHO-5 score below 50 points (aOR 1.5 (95% confidence interval (CI) 1.2-1.8).
CONCLUSIONS: In Europe, the COVID-19 pandemic has had a differential impact on those providing direct COVID-19 patient care, junior staff and women. Health facilities must be aware of these differential impacts, build trust and provide tailored support for this vital workforce during the current COVID-19 pandemic.

Introduction

Health care workers (HCWs) provide direct treatment and care for patients with coronavirus disease 2019 (COVID-19), as well as for those requiring ongoing care not related to COVID-19. This role exposes them to occupational hazards that may impact their health and wellbeing, including increased exposure to severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2), burnout, and stigma [1]. Protecting the physical and psychological health of HCWs is a key priority. Not only is there a moral obligation to support those willing to provide medical care in a public health emergency, this support is also vital for ensuring sufficient levels of skilled staff and continued functioning of health facilities during and after the COVID-19 pandemic [2]. Importantly, the exact need for support is heterogeneous and could vary depending on aspects such as healthcare institution location, or type, but also on HCWs’ personal characteristics, such as seniority level, job role or gender. Studies published in the first months of the COVID-19 pandemic highlighted increased signs of depression, anxiety, insomnia and distress in HCWs [3-8], with a differential impact on women [3,9]. United Nations Women stressed the importance of attention to potential gender differences when researching the impact of the COVID-19 pandemic, as this information is needed to inform policy responses [10].

While HCWs can acquire COVID-19 through many different routes, including via infected family members or through general community transmission [11], their work in health facilities clearly places them at increased risk of exposure to SARS-CoV-2 [2,12-14]. Standardized and robust infection prevention control (IPC) procedures are the primary approach to reducing transmission in health facilities. Effective implementation of IPC procedures requires engagement and commitment from those administering health facilities. This includes ensuring that local policies are developed and made available; systems and processes are set up for recommended procedures; sufficient and ongoing supply of materials are accessible; staff have access to training and support materials; and processes for monitoring staff-level adherence to local policies are in place.

While one of the main goals of IPC guidelines is the prevention of nosocomial transmission, another key aspect is that they should ensure that HCWs feel they can protect themselves from getting infected. Research conducted during the SARS epidemic in 2003 demonstrated the importance of organizational and social factors and identifed how feeling prepared and confident in their ability to deliver effective IPC was critical to protect both HCWs’ physical and psychological health [15]. At the onset of the COVID-19 pandemic, large-scale information about the perceptions of European hospital HCWs from multiple countries across Europe was not yet available. Understanding HCWs’ experiences of following locally recommended IPC procedures during COVID-19 were highly needed to inform strategies for better engaging and supporting HCWs to protect themselves and maintain their wellbeing.

The objective of this study was therefore to rapidly capture hospital HCWs’ perceptions on local IPC procedures and the impact on their emotional wellbeing during the first wave of the COVID-19 pandemic in Europe, and to explore potential differences among hospital HCWs with different seniority level, job role and gender.

Methods

Study design

We performed two sampling rounds of a cross-sectional survey among hospital HCWs in European countries during the peak of the first wave of the COVID-19 pandemic in Europe (31 March 2020–17 April 2020) and during the aftermath of the first wave (14 May 2020–31 August 2020).

Sampling and recruitment

We invited European HCWs providing medical care in hospital settings. The first sampling round was conducted during the peak pandemic wave in Europe. Because a low response rate was observed–in part due to competing clinical pressures during this time—a second round of data collection was performed in which we adapted our approach to recruitment and performed online convenience sampling. For the first sampling round, we recruited participants through two European hospital research networks: Combatting Bacterial Resistance in Europe (COMBACTE) and the Spanish Biomedical Research Networking Center (CIBER). For the second sampling round, we recruited participants via newsletters in research networks, clinical networks and social media channels by distributing an online study flyer.

Survey tool

A data collection tool was rapidly developed for a generic World Health Organization (WHO) protocol to meet the aims of the study (see S1 File) [16]. Experts in the Social Science and IPC Working Group, under the COVID-19 Research Roadmap, identified a pool of items based on WHO IPC interim guidance published in March 2020 [17]. These items were developed to capture theoretically informed influences on HCWs’ motivation, opportunity, and ability to follow general IPC precautions. Items were designed for responses on a 7-point Likert scale, ranging from ‘Strongly disagree’ to ‘Strongly agree’. Once identified, the Theoretical Domains Framework (TDF), previously used for studying clinician behaviour, was used to inform the selection of the items [18-20]. Based on a previously validated measure, HCWs’ trust in the institution where they worked was assessed by capturing three dimensions of institutional trust (competence, honesty, act in best interests of staff) [21]. Finally, the WHO-5 Well-Being Index (WHO-5) was included, a validated short and generic global rating scale measuring subjective wellbeing during the last two weeks [22]. Information was also collected on participant demographics, including experience of caring for patients with suspected or confirmed COVID-19 infection. Due to the time constraints under which this tool was developed, pre-testing, reliability tests, and validation could not be conducted prior to data collection. As a result, data collected in the first sampling round of this study were used to investigate the psychometric properties of the survey tool and refine the items for data collection in the second sampling round.

Electronic data collection

The survey was only available in English. The electronic data capturing (EDC) systems Castor v2020.1.9 and Qualtrics survey platform (Provo, Utah) were used for data collection in the first and second sampling round, respectively.

Statistical analyses

As participation was anonymous, we could not prevent HCWs participating in both survey rounds. Therefore, respondents from round 2 with identical demographic information as HCWs from round 1 (age, gender, country and specialism) were excluded from further analyses (n = 16 exclusions).

Descriptive statistics were used to describe HCWs’ perceptions of IPC procedures. Absolute numbers of respondents were provided alongside percentages, as denominators differed slightly per survey item due to respondent in-survey drop out. To quantify HCWs’ emotional wellbeing, responses to the five WHO-5 statements were summarised into a total raw score and multiplied by 4 to produce an individual total score from 0 to 100, with the higher end of the scale representing best possible wellbeing [23]. Interpretation of the WHO-5 Well-Being score considers that a cut-off score of <50 is used when screening for clinical depression [23]. Differences in WHO-5 scores were assessed for gender, job role, European region and providing COVID-19 care by independent sample T-test or one-way ANOVA, depending on the number of groups compared. To assess differences in wellbeing between male and female HCWs we estimated the independent effect of gender on a WHO-5 Well-Being Index below 50 points using logistic regression, including predefined control variables for age, living situation (i.e., living alone or sharing a household), European region, job role, hospital type and providing COVID-19 patient care.

Multivariable regression was performed to examine the association between prespecified behavioral determinants and HCWs’ perceived sense of control over getting infected with COVID-19. The association between the feeling of control over getting infected and a WHO-5 Well-Being score <50 was investigated using the same model as for the effect of gender, adding the sense of control statement. From the Likert-scale questions, we conducted principal component analysis to examine correlation matrices and construct indices from the first principal component for the following measures: beliefs about effectiveness of PPE, availability of PPE at the respondent’s institution, and skills for preparedness for dealing with COVID-19 (see S2 File). The index constructed from the first principal component for each of these measures was then included as an explanatory variable in the multivariable analysis. This allowed us to test, for example, for the independent effect of availability of PPE at the respondent’s institution, on the dependent variable, HCWs’ perceived sense of control over getting infected with COVID-19, while controlling for other regression model covariables. For each of the constructed indices, Cronbach’s alpha scores for the Likert-scale components exceeded 0.75.

For all analyses, a two-tailed P value < .05 was considered statistically significant. There was no formal sample size calculation before the start of this study. Surveys with completion of only demographic and basic IPC training information (corresponding to survey completion of <58%) were excluded. All analyses were performed with Statistical Package for Social Sciences V.25.0.2 (SPSS, Chicago, Illinois, USA) and R Version 3.4.1.

Ethics

This study was conducted in accordance with the EU GDPR (General Data Protection Regulation) and the principles of the Declaration of Helsinki [24]. The Medical Research Ethics Committee of the University Medical Center (UMC) Utrecht waived the need for extensive ethical review (IRB correspondence number 18-574C). Electronic individual informed consent for participation was obtained at the start of the survey.

Results

Study population

In total, 2289 hospital HCWs participated (round 1: n = 190, round 2: n = 2099). HCWs worked in 40 European countries, the majority in Southern Europe (n = 1244, 54%) (S1 Table). Forty-eight percent (n = 1088) had experience working in a clinical setting during a previous epidemic with a novel respiratory virus such as SARS, MERS-CoV or H1N1. Sixty-eight percent (n = 129) and 75% (n = 1570) had personally cared for a patient with suspected or confirmed COVID-19 in the first and second sampling round, respectively. Detailed demographic information is provided in Table 1.

Table 1

Demographic information of all participating hospital health care workers (HCWs).

	Hospital HCWs N = 2289 (%)a
Age, mean (±SD)	42 (11)
Female	1509 (66)
Region1    Southern Europe    Western Europe    Northern Europe    Eastern Europe	1244 (54)658 (29)329 (14)57 (3)
Living with others	1916 (85)
Informal care responsibilities for any other adults	614 (27)
Academic hospital	1570 (70)
Medical specialty    Acute care (anaesthesiology, ER, ICU)    Internal medicine    Surgery    Paediatrics    Other	748 (33)506 (22)226 (10)144 (6)665 (29)
Job role    Junior nurse    Senior nurse    Senior medical doctor    Junior medical doctor    Junior allied health professional    Senior allied health professional    Other	240 (11)657 (29)803 (35)269 (12)31 (1)66 (3)223 (10)
Daily patient contact	1844 (81)
Direct COVID-19 patient care	1699 (74)

COVID-19, coronavirus diseases 2019; ER, emergency room; HCW, health care worker, ICU, intensive care unit; IQR, interquartile range; SD, standard deviation.

a Sub division of Europe adapted from the United Nations; for the current study, Cyprus, Israel and Turkey were categorized as Southern Europe [25].

Wellbeing

There were 2180 (95%) HCWs who completed all questions about emotional wellbeing. Overall mean WHO-5 Well-Being Index was 56.3 (±19.3) and was slightly higher among HCWs that participated in the second sampling round than in the first round (56.7 ±19.0 versus 51.9 ±22.0, respectively). Scores differed per region, being lowest in Eastern Europe (52.7 ±19.9) and highest in Western Europe (62.1 ±17.8) (P value < .001). Junior nurses and medical doctors had lower scores compared to their senior counterparts (P value < .05) (Table 2). Overall prevalence of a WHO-5 Well-Being Index below 50 points was 38% (95% confidence interval (CI) 36%-40%). Mean WHO-5 was 59.6 ±19.3 for male and 54.5 ±19.0 for female HCWs (P value < .001). In multivariable logistic regression, female HCWs had higher risk of a WHO-5 score below 50 points compared to males (aOR 1.5 (95% confidence interval (CI) 1.2–1.8) (S3 Table).

Table 2

WHO-5 emotional Well-Being Index per subgroup.

	Mean (±SD)	P value
Gender
Male    Female	59.6 (19.3)54.5 (19.0)	< .001
Job role    Junior nurse    Senior nurse    Junior medical doctor    Senior medical doctor    Junior allied health professional    Senior allied health professional    Other	54.0 (18.2)57.5 (19.3)54.8 (17.8)56.9 (19.8)57.5 (17.2)51.0 (21.2)55.7 (19.8)	.04
Regiona    Eastern Europe    Southern Europe    Northern Europe    Western Europe	52.7 (19.9)53.4 (19.5)56.0 (18.8)62.1 (17.8)	< .001
COVID-19 direct patient care    HCWs with COVID-19 patient care    HCWs without COVID-19 patient care	56.0 (19.5)57.0 (18.7)	NS

COVID-19, coronavirus disease 2019; HCW, health care worker; NS, not significant; SD, standard deviation; WHO, World Health Organization.

a Sub division of Europe adapted from the United Nations; for the current study, Cyprus, Israel and Turkey were categorized as Southern Europe [25].

A large proportion of HCWs reported concerns about the risk for themselves of becoming ill (1568, 71%) and about the risk to their family related to COVID-19 as a result of their job role (1809, 82%) (Fig 1). Thirty-two percent (n = 527) of HCWs directly caring for patients with COVID-19 reported being afraid of looking after these patients. Significant additional strain to their workload due to following recommended IPC procedures was reported by 86% (n = 1463) of these HCWs. HCWs that participated in the second sampling round less often agreed that the risk of getting infected with COVID-19 was part of their job, compared to HCWs from the first sampling round (69% versus 84%, respectively).

Fig 1

Perceptions of hospital healthcare workers on recommended IPC procedures, perceived skills, intentions and environmental resources.

HCWs, health care workers; IPC, infection prevention and control; PPE; personal protective equipment. NB. Individual statements were abbreviated for readability of this figure (see S1 File for all complete statements used in the surveys).

Sense of control in getting infected

Overall, 40% (869/2199) of HCWs indicated that they felt that that getting infected with COVID-19 was outside of their control. This feeling was more prevalent in junior than in senior HCWs (46% versus 38%, P value < .01), and was significantly associated with a WHO-5 score below 50 points (aOR 2.1, 95% CI 1.7–2.6). In multivariable regression, factors that were positively associated with a perceived sense of control over getting infected with COVID-19 were having received sufficient COVID-19 IPC training, having greater confidence in using PPE and perceived institutional trust (Table 3).

Table 3

Ordered logistic regression for the effect of perceived skills, self-reported environmental context, social influences and institutional trust on a positive sense of control over getting infected with COVID-19.

	aOR	95% CI		P value
Having received general training for IPC procedures for communicable diseases	0.98	0.90	1.06	NS
Having received sufficient training in IPC practices for COVID-19	1.11	1.02	1.20	.01
Feeling confident in ability to correctly use PPE	1.08	1.00	1.17	.045
Index of PPE availability	1.05	0.96	1.15	NS
Feeling encouraged and supported by senior medical/nurse staff to apply recommended IPC measures	1.03	0.96	1.11	NS
Trust that health facility is competent, honest and acts in best interest of its staff	1.34	1.24	1.45	< .0001

aOR, adjusted odds ratio; COVID-19, coronavirus disease 2019; CI, confidence interval; IPC, infection prevention and control; PPE, personal protective equipment; NS, not significant.

a This model was adjusted for age, gender, living situation, European region and providing direct care for COVID-19 patients.

Behavioural influences on following IPC guidance

The majority of HCWs had received training related to general IPC procedures and indicated that there were clear policies and protocols for everyone to follow related to COVID-19 IPC procedures, namely 75% (n = 1725) and 80% (n = 1785), respectively (Fig 1). Twenty-three percent (n = 391) of HCWs that cared for COVID-19 patients indicated they had not received sufficient training in IPC practices specific to COVID-19.

Most HCWs (1814, 79%) felt that following IPC recommendations would protect them from becoming ill with COVID-19, and almost all (2134, 96%) intended to always use recommended PPE when taking care of patients with suspected or confirmed COVID-19, when having access to these. HCWs reported positive social influences at work, such as colleagues regularly following IPC measures and encouragement by senior medical/nurse staff to follow recommended procedures (Fig 1). Trust in their health facility to be competent, honest with staff, and act in the best interest of its staff when managing the response to COVID-19 differed per region, being 61%, 67%, 79%, 81% for Eastern, Southern, Northern and Western European HCWs, respectively.

Use and availability of personal protective equipment

Based on self-reported use of PPE at last contact with a patient suspected or confirmed with COVID-19, HCWs reported good compliance with PPE recommendations as provided by the WHO (Fig 2). A larger proportion of HCWs reported limited access to PPE materials at work during the first sampling round compared to the second survey round, namely 28% (52/183) versus 14% (293/2048), respectively. Overall, PPE that was most often reported to be in limited or no supply during the HCWs’ most recent clinical shift were N95 respirators (30%), fluid-resistant gowns (25%) and eye protection (i.e. goggles) (21%) (S1 Fig).

Fig 2

Self-reported adherence to recommended IPC proceduresa used during most recent clinical contact with COVID-19 case.

a Recommended infection prevention and control (IPC) procedures during direct medical care with suspected or confirmed COVID-19 patients according to WHO interim guidance document (6 April 2020) [26] on the rational use of personal protective equipment (PPE) at the time of data collection: (A) contacts with aerosol-generating procedures (e.g. tracheal intubation, non-invasive ventilation, cardiopulmonary resuscitation): Gloves, N95 mask or equivalent, eye protection (i.e. goggles or face shield), and fluid-resistant long-sleeved gown. (B) Contacts without aerosol-generating procedure: Gown, gloves, medical mask and eye protection (goggles or face shield). Hand hygiene was part of recommendations during all contacts. b Of those respondents (n = 60) that did not use an N95 respirator, 58 (97%) used another type of face mask, such as surgical mask (categorized in this figure as ‘no’). c Of those respondents (n = 44) that did not use either a fluid-resistant gown or full-body suit, 26 (59%) used a disposable plastic apron (categorized in this figure as ‘no’). d Of those respondents use either a gown or full-body suit (n = 120), 68 (57%) used a disposable plastic apron. e Of those HCWs that used a face mask (n = 802), 69% used an N95 mask (n = 557) and 31% (n = 245) used another type of mask, such as a surgical mask.

Discussion

In this study, we found that European hospital HCWs reported low levels of emotional wellbeing while providing hospital care and following local IPC recommendations during the start of the COVID-19 pandemic, with particular concerns for those providing direct COVID-19 patient care, junior staff and women.

There is more evidence emerging on the psychological strain on HCWs working during the first wave of the COVID-19 pandemic [3,7,27]. A systematic review and meta-analysis investigating the psychological impact during the first months of COVID-19 predominantly in Asia, identified high levels of depression among medical staff [3]. Across Europe, we similarly identified psychological strain in hospital HCWs. Not only were there high levels of concern about HCWs’ own risk of COVID-19 infection, almost all respondents were worried about the risk to their families due to their job role. One-third of HCWs reported fear of looking after COVID-19 patients. Further, when quantifying emotional wellbeing using the WHO-5 Well-Being Index, we found that more than one-third of HCWs had a score below 50 points, indicative of depression symptoms [23]. These findings reiterate worrisome findings of other studies performed during the start of the COVID-19 escalation in Europe [28-31].

It is known that health emergencies can magnify already existing structural inequities [10]. Our study highlights impacts for women in particular, who comprise the majority of all HCWs worldwide. In general, women perform the majority of care within the home, are more likely to care for family members ill with COVID-19, and may face gender bias at work [10,32]. In our study, female HCWs reported higher levels of emotional strain compared to males, echoing findings from other COVID-19 studies [9,33-36]. These results highlight the need for awareness of the differential psychological impacts on HCWs during the COVID-19 pandemic and future pandemics.

IPC recommendations aim to protect patients, HCWs, and the health system, and are therefore tied to risk perception as recommendations should ensure that HCWs feel protected during their work. Perceived lack of control is known to be an important stressor of mental health and is associated with occupational burnout [37-39]. Research during the 2002–2003 SARS epidemic suggested that the combined role of three specific institutional measures impacted HCWs’ risk perception (including avoidance of patients and acceptance of risk) and belief in the effectiveness of protective measures at work: clear policies and protocols, available specialists, and adequate training [40]. In our study, junior HCWs in particular felt that getting infected with COVID-19 was outside of their control. Risk perception is complex and multifactorial. A qualitative study among frontline HCWs who chose to respond to the West Africa Ebola virus disease outbreak in 2014–2016, showed that next to individual and social-level factors, institutional trust was a key risk attenuator [41]. Our multivariable analysis also identified organisational and personal factors that were positively associated with feelings of having control over becoming infected, including COVID-19 IPC training, confidence in the use of PPE as well as institutional trust. These aspects may therefore be important to consider in IPC implementation.

Overall, our survey suggests that institutions should adopt a multifaceted approach in IPC preparedness and training in order to best support hospital HCWs at work during an infectious diseases pandemic. Such an approach begins with recognition of the importance of preventing and mitigating adverse impacts on wellbeing, together with the explicit assurance to protect the clinical workforce. These foundations for protecting physical and mental health protection are made through ensuring safe working conditions and accessible support. We echo recommendations that local IPC guidelines should be clearly communicated, and HCWs should receive specific IPC training, have access to appropriate PPE, and feel confident in its use [42]. Crucially, we add that health facilities must be aware of, and address differential impacts and experiences, such as those of female and junior HCWs. Given the already-heavy burden and time pressures on HCWs, effective support must therefore be readily accessible and responsive to the different needs, pressures, and barriers experienced by different groups. Together, these measures should work to increase HCWs’ feelings of self-efficacy to undertake IPC behaviors and, subsequently, their perceived safety.

Previous studies have also shown the importance of managers’ support and a safe workplace culture [42]. To identify where most improvements could be made, we further suggest that health facilities rapidly assess local perceptions of their HCWs on IPC recommendations and their wellbeing using the WHO research template and data collection tool (freely available online) [16]. This would serve to identify specific key local needs that are/are not being met, enabling wellbeing support services to be better targeted and tailored, as research has shown that these are often poorly utilised by HCWs [9].

There are important limitations of the current study that should be acknowledged. First, in the first sampling round we chose to rapidly recruit HCWs from existing research networks where we could accurately describe our study base population, limiting the number of HCWs we could invite for participation. Along with data collection taking place during the first peak of the pandemic in Europe and restricting to a single reminder because of high clinical workload of HCWs, this ultimately led to small sample size. Therefore, a second sampling round was performed using convenience sampling, leading to two different sampling methods used in the current study. Notably, the target population remained the same. Second, inherent to our survey study design there is an important risk of response bias, both on the level of demographic characteristics as well as on personal views, meaning that our responding HCWs do not reflect an representative sample of the entire European hospital HCW population. The choice of survey methodology over qualitative design was, in part, driven by a need to rapidly collect data that could be used to inform operational pandemic response. Survey methods will miss more nuanced accounts that could help explain our findings which would be best captured through qualitative methods. A free text box allying respondents to add their reflections would have been helpful to enable us to capture some of these reflections. Third, this was a cross-sectional observational study using quantitative data, we therefore cannot draw strong conclusions on the direction of effects. Lastly, we were unable to triangulate responses with actual local PPE supplies and hospital infection rates.

Conclusions

In conclusion, this international cross-sectional survey examined the perceptions of European hospital HCWs on their emotional wellbeing and local recommended IPC procedures during the onset of the COVID-19 pandemic. We advocate that hospitals should provide multifaceted IPC training that accounts for behavioural determinants and tailored support that accounts for the needs of junior and female HCWs. Such training should be inclusive and accessible to all. Further, local hospital support systems should be intensified and health facilities must be aware of, address, and provision for potential differential impacts to better care for our HCWs during the current COVID-19 and potential future pandemics.

Self-reported availability of personal protective equipment during most recent clinical shift.

(DOCX)

Click here for additional data file.

Country of work of responding hospital healthcare workers.

(DOCX)

Click here for additional data file.

Response bias assessment first sampling round.

(DOCX)

Click here for additional data file.

Multivariable linear regression for the effect of gender on WHO-5 emotional wellbeing index of hospital healthcare workers.

(DOCX)

Click here for additional data file.

Survey tools used in the current study.

(DOCX)

Click here for additional data file.

Principal component analysis.

(DOCX)

Click here for additional data file.

8 Sep 2021

The experience of European hospital-based health care workers on following infection prevention and control procedures for COVID-19

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Reviewer #1: The study benefitted from a good sample size and from addressing topical and relevant issues (e.g., healthcare staff wellbeing and infection and prevention controls). However, I felt confused throughout as to what the main goals of the study were – it felt like a mishmash of questions had been asked and statistics had been conducted. I also felt concerned as to the factor analysis which is briefly referenced and minimally described but which is of key importance to the overall study (as it was the basis for developing the main questionnaire used in the study). In general, it seemed a lot of survey questions had been asked but not enough thought had been put into making the data into a clear and cohesive study. Specific comments below:

Abstract:

1. The aims are not clear- what were the specific purposes of doing this survey? What did the authors want to learn? Were there any predictions?

2. The reason for having two ‘rounds’ is also unclear. As all the results seem to only refer to one group, were the two ‘rounds’ simply two different ways of recruiting participants and the two groups were then pooled for the purposes of the analysis?

Intro

The intro covers some relevant issues – for example, demonstrating that HCWs are at heightened risk of both catching Covid and experiencing burnout. It stresses that HCWs should be familiar with IPC procedures, and that women may be at higher risk of experiencing stress and burnout. However, there are a couple of issues with the introduction:

3. It is unclear what the gaps in knowledge are as the introduction progresses. The authors need to more clearly demonstrate what IS NOT known which the present research aimed to address

4. The aims are poorly written. They are extremely broad and do not give the reader a sense of where the analyses and results will be heading. It would be acceptable to have broad aims but to follow these up with specific objectives.

5. The use of a survey methodology also needs to be justified – both of the current aims strike me as being better suited to a qualitative study. Again, the gap in the literature that this study (using a survey approach) addresses needs to be clear

Methods

6. The section on the survey tool is confusing. It says the tool was developed ‘to capture theoretically informed influences on HCWs’ motivation, opportunity and ability to follow general IPC precautions’. There needs to be info on the number of items, how many captured each of these three things (motivation, opportunity and ability), and some example questions. There also needs to be basic info about the psychometrics of the survey once it had been developed for use in round 2 of the research (i.e., following the first round of the research). It is not sufficient to say the authors didn’t have this information to begin with.

7. The section on the survey tool is also confusing because at the end of the paragraph the authors throw in that the purpose of the first round of the survey was to develop and refine the tool which is used in round 2. This should have been clear from the abstract and the introduction. If such a tool (which is the foundation of the research) didn’t exist prior to the survey being conducted, then one of the aims of the study was surely to develop such a measure? Aside from this only one other questionnaire is used, so it is important that this is clarified.

8. The statistical analyses section refers to objectives – but these objectives are not outlined anywhere earlier in the paper. These objectives need to be provided at the end of the introduction. The methods is not the place to introduce new objectives.

9. ‘bivariate analyses for gender, job role, European region and providing COVID-19 care by

independent sample T-test or one-way ANOVA’: when were independent sample T-tests used and when were ANOVAS used? This needs to be clarified

10. The statistical analyses section also describes conducting tests relating to examining gender etc differences in wellbeing and factors relating to ‘HCWs’ perceived sense of control over getting infected with COVID-19’. Due to unclear aims and objectives earlier in the paper, these analyses seem to ‘come out of nowhere’. Really the issue here is not what is in the statistical analyses section but the foregoing information in the paper. There is a lack of build-up and explanation in the intro to prepare readers for these analyses and they are not clear in the aims/objectives of the study.

11. Halfway through a paragraph in the statistical analyses section, a factor analysis is mentioned with minimal information. If the purpose of the factor analysis is to develop the main tool which is used in the paper (which it is) I would expect much, much more information about this – the type of analysis done, the scree plot, the factor loadings etc. As it is, we don’t know from the manuscript even how many items the authors started with and the approach they used to reducing the number of items they had. This is very concerning. I would expect to see all the original items in a table with their factor loadings and then the approach used for reducing these. I’d also expect to see some kind of justification for the sample size.

12. Information about how much data was missing and how this was managed needs to be provided in the statistical analyses section

**********

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Reviewer #1: No

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17 Oct 2021

Reviewer #1: The study benefitted from a good sample size and from addressing topical and relevant issues (e.g., healthcare staff wellbeing and infection and prevention controls). However, I felt confused throughout as to what the main goals of the study were – it felt like a mishmash of questions had been asked and statistics had been conducted. I also felt concerned as to the factor analysis which is briefly referenced and minimally described but which is of key importance to the overall study (as it was the basis for developing the main questionnaire used in the study). In general, it seemed a lot of survey questions had been asked but not enough thought had been put into making the data into a clear and cohesive study. Specific comments below:

Author’s response: We would sincerely like to thank the reviewer for their valuable time and we sincerely appreciate the careful reading of our manuscript. In the following we will address all comments point by point.

Abstract:

1. The aims are not clear- what were the specific purposes of doing this survey? What did the authors want to learn? Were there any predictions?

Author’s response: The study took place at a crucial time in the peak of the first wave of the pandemic in order to rapidly respond on an international level to the needs of the healthcare workers. The primary aim of the study was to capture health worker perceptions related to key factors that are known to influence their adherence to infection prevention and control guidelines. The study was rapidly developed at the start of the pandemic, and, in response to emerging evidence of the impact of the pandemic on health worker mental health and emotional well-being, a second objective was included to capture data related to wellbeing.

Changes to the manuscript: To clarify these objectives in the abstract, we have updated the text – please see p. 2, lines 28-31 of the revised manuscript.

2. The reason for having two ‘rounds’ is also unclear. As all the results seem to only refer to one group, were the two ‘rounds’ simply two different ways of recruiting participants and the two groups were then pooled for the purposes of the analysis?

Authors’ response: This was a rapidly developed study, designed to respond quickly to emerging needs at the start of the pandemic. The first round was conducted during the first peak pandemic wave in Europe. We had a low response rate to this survey at round 1 – in part due to competing clinical pressures during this time. For the second round of data collection, we adapted our approach to enhance recruitment.. This second round of data collection was undertaken toward the end of the first pandemic wave in Europe, and we had a strong response. Importantly, the target population of both rounds were the same, only our recruitment approach changed.

Changes to the manuscript: To clarify this further, we have updated the abstract – please see p. 2, lines 32-35 and we have added information to the methods section – please see p. 6, lines 113-117.

Intro

The intro covers some relevant issues – for example, demonstrating that HCWs are at heightened risk of both catching Covid and experiencing burnout. It stresses that HCWs should be familiar with IPC procedures, and that women may be at higher risk of experiencing stress and burnout. However, there are a couple of issues with the introduction:

3. It is unclear what the gaps in knowledge are as the introduction progresses. The authors need to more clearly demonstrate what IS NOT known which the present research aimed to address

Authors’ response: We thank the reviewer for this comment. We have added more specific statements about the research gaps that our study aimed to fulfill in to the Introduction section of the paper.

Changes to the manuscript: please see p. 4, lines 68-69 and p. 5, lines 89-93 of the track changes version of the manuscript.

4. The aims are poorly written. They are extremely broad and do not give the reader a sense of where the analyses and results will be heading. It would be acceptable to have broad aims but to follow these up with specific objectives.

Authors’ response: We thank the reviewer for this suggestion. We acknowledge the aims of our study were indeed broad and mostly descriptive of nature. We also agree that our specific objective to look at subgroups, such as potential differences in perceptions of male and female HCWs, were not clearly described to readers in the Introduction section. We have therefore updated the Introduction of the manuscript accordingly.

Changes to the manuscript: see p. 5, lines 97-101 of the track changes version of the manuscript.

5. The use of a survey methodology also needs to be justified – both of the current aims strike me as being better suited to a qualitative study. Again, the gap in the literature that this study (using a survey approach) addresses needs to be clear.

Authors’ response: Thank you for this remark. The choice of survey methodology was driven, in part, by a pragmatic need to rapidly collect data that could be used to inform operational response. The dimensions included in the survey linked with key factors that are known to influence adherence to infection control guidelines and which can then guide specific actions to improve staff adherence to guidelines.We agree that a qualitative study related to these issues would have provided rich insights into many of the issues raised. Indeed, many of the other groups that implemented this survey in other parts of the world as part of the WHO R&D Blueprint ‘COVID-19 Social Science in Outbreaks’ (the study protocol and survey tool are freely available), included a free text open comments box in their surveys and elicited interesting findings. However, in our case, by using a survey design we were able to acquire a large sample size and international reach, which would have been far smaller if we would have used a qualitative study. It is also important to note that during our study period, at the beginning of the COVID-19 pandemic in Europe, there was already a high burden on healthcare professionals. Survey methods are much lower commitment for participants already under strain.

Changes to the manuscript: we have added the rationale for a survey study design to the Methods section, see p. 15, lines 333-335 of the track changes version of the manuscript.

Methods

6. The section on the survey tool is confusing. It says the tool was developed ‘to capture theoretically informed influences on HCWs’ motivation, opportunity and ability to follow general IPC precautions’. There needs to be info on the number of items, how many captured each of these three things (motivation, opportunity and ability), and some example questions. There also needs to be basic info about the psychometrics of the survey once it had been developed for use in round 2 of the research (i.e., following the first round of the research). It is not sufficient to say the authors didn’t have this information to begin with.

Authors’ response: This study was rapidly conceived and developed at the start of the COVID-19 pandemic to respond to a need to better understand how prepared health workers were to adhere to infection prevention and control guidelines. At the point of protocol development, a well-developed and pre-validated tool to capture behavioral determinants of guideline adherence was not in existence. We therefore rapidly developed a tool based on expert opinion and guided by the Theoretical Domains Framework. Data from the first round of data collection in this study were used to explore the psychometric properties of the tool, not only for the second round of sampling but also for groups implementing the same survey in different parts of the world.

Changes to the manuscript: no changes were made to the manuscript, the information above is already depicted in the original paper, please see p. 6-7, lines 124-135.

7. The section on the survey tool is also confusing because at the end of the paragraph the authors throw in that the purpose of the first round of the survey was to develop and refine the tool which is used in round 2. This should have been clear from the abstract and the introduction. If such a tool (which is the foundation of the research) didn’t exist prior to the survey being conducted, then one of the aims of the study was surely to develop such a measure? Aside from this only one other questionnaire is used, so it is important that this is clarified.

Authors’ response: We apologize for any confusion. The purpose of the first round of the survey was not specifically “to develop” the tool for a second round of sampling within our study (ie. the second round with different sampling method was performed because of low response rate). However, when deciding on a second round of sampling we did use data from the first round of data collection to explore the psychometric properties of the tool and to refine the items for data collection, also for groups implementing the same survey in different parts of the world. See also the explanation above. We hope this clarifies.

8. The statistical analyses section refers to objectives – but these objectives are not outlined anywhere earlier in the paper. These objectives need to be provided at the end of the introduction. The methods is not the place to introduce new objectives.

Authors’ response: Thank you for this comment. The respective statistical analyses section refers to the objectives stated at the end of the Introduction section of the paper, which were previously there referred to as ‘aims’. We acknowledge this was not clear to readers.

Changes to the manuscript: we have updated the text and clarified the objectives – please see p. 5, lines 97-101 of the track changes version of the manuscript).

9. ‘bivariate analyses for gender, job role, European region and providing COVID-19 care by

independent sample T-test or one-way ANOVA’: when were independent sample T-tests used and when were ANOVAS used? This needs to be clarified

Authors’ response: an independent sample T-test is carried out to investigate two groups, whereas ANOVA is used to compare multiple (>2) groups (ANOVA is equivalent to running multiple T-tests). We have clarified this in our manuscript.

Changes to the manuscript: please see p. 7, lines 162-163 of the track changes version of the manuscript).

10. The statistical analyses section also describes conducting tests relating to examining gender etc differences in wellbeing and factors relating to ‘HCWs’ perceived sense of control over getting infected with COVID-19’. Due to unclear aims and objectives earlier in the paper, these analyses seem to ‘come out of nowhere’. Really the issue here is not what is in the statistical analyses section but the foregoing information in the paper. There is a lack of build-up and explanation in the intro to prepare readers for these analyses and they are not clear in the aims/objectives of the study.

Authors’ response: We agree with the reviewer that these analyses should have been more clearly introduced in the Introduction section of the paper.

Changes to the manuscript: please see p. 4, lines 68-70 and p. 5, 97-101 of the track changes version of the manuscript.

11. Halfway through a paragraph in the statistical analyses section, a factor analysis is mentioned with minimal information. If the purpose of the factor analysis is to develop the main tool which is used in the paper (which it is) I would expect much, much more information about this – the type of analysis done, the scree plot, the factor loadings etc. As it is, we don’t know from the manuscript even how many items the authors started with and the approach they used to reducing the number of items they had. This is very concerning. I would expect to see all the original items in a table with their factor loadings and then the approach used for reducing these. I’d also expect to see some kind of justification for the sample size.

Authors’ response: We apologize for any confusion. In contrary to the reviewer’s comment, the factor analysis was not performed “to develop” the main tool, but rather to evaluate the psychometric properties of the tool after the first round of data collection was performed. The data collection tool was developed rapidly based on literature review and expert opinion (as explained above and in p. 6-7, lines 124-135 of the Methods section). As mentioned in the paper, no formal sample size was performed before the start of this study (see p. 9, lines 185-186).

Changes to the manuscript: We have added the following to the paragraph to provide further explanation for the use of principal component factor analysis, which was used to develop variables measuring beliefs about PPE effectiveness, PPE availability, skills, and institutional trust in the multivariable models (see p. 8-9, lines 172-184).

From the Likert-scale questions, we conducted principal component factor analysis to examine correlation matrices and construct indices from the first principal component for the following constructs: beliefs about effectiveness of PPE, availability of PPE at the respondent’s institution, skills, and institutional trust test. The first principal component for each of these constructs was then included as an explanatory variable in the multivariable analysis. This allowed us to test, for example, for the independent effect of institutional trust, on the dependent variable, HCWs’ perceived sense of control over getting infected with COVID-19, while control for other regression model covariates. For each of the constructed indices, Cronbach’s alpha scores for the Likert-scale components exceeded 0.75.

12. Information about how much data was missing and how this was managed needs to be provided in the statistical analyses section

Authors’ response: we thank the reviewer for this important comment. As mentioned in the Methods section, surveys with completion of only the first part of the survey containing demographic and basic information about IPC training (corresponding to survey completion <58%) were excluded from data analyses. Due to mid- or end-survey dropout, the denominator per statement is different. Therefore, the total number of respondents per statement is provided in Fig 1, and if otherwise, in the manuscript body. For example in case of perceptions about emotional wellbeing, the sentence “There were 2180 (95%) HCWs who completed all questions about emotional wellbeing” is provided. In case of other denominators (for example when analyzing subgroups), this is also mentioned specifically in the manuscript text. We agree with the reviewer that this information should also be available in the Methods section.

Changes to the manuscript: please see p. 9, lines 188-190 of the track changes version of the manuscript).

Submitted filename: 20211017 Response to reviewers.docx

Click here for additional data file.

17 Dec 2021

The experience of European hospital-based health care workers on following infection prevention and control procedures and their wellbeing during the first wave of the COVID-19 pandemic

PLOS ONE

Dear Dr. van Hout,

Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process.

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10 Jan 2022

Reviewer #2: This manuscript assesses the perception of hospital HCWs on the adequacy of local IPC measures and concludes that institutions should adopt a multifaceted approach in IPC preparedness and training in order to best support hospital HCWs at work during an infectious diseases pandemic. The authors discuss factors that contribute to staff wellbeing and the perceived efficacy of PPE and the results are clearly presented.

Author’s response: We would sincerely like to thank the reviewer for their valuable time and we sincerely appreciate the careful reading of our manuscript. In the following we will address all comments point by point.

Minor comments: While a PCA is mentioned in the methods section, there are no details on the results of the PCA and a more detailed description of this analysis should be added as a supplementary file.

Author’s response: we thank the reviewer for this comment. The principal component factor analysis was performed to construct indices from the first principal component for the following measures: beliefs about effectiveness of PPE, availability of PPE at the respondent’s institution, and skills for preparedness for dealing with COVID-19. The index constructed from the first principal component for each of these measures was then included as an explanatory variable in the multivariable analysis. We agree with the reviewer that details on data-analysis and results of the PCA were missing in the manuscript.

Changes to the manuscript: details on the PCA were clarified in the main paper (please see p. 8, lines 168-174), and a detailed description of the PCA was added as a new supplementary file – please see “S2 File”.

The background section of the abstract would be strengthened if the rational behind the study was discussed in more detail.

Changes to the manuscript: To clarify the rationale of the study in the abstract, we have updated the text – please see p. 2, lines 29-31 of the revised manuscript.

Submitted filename: 20220110 Response to reviewers.docx

Click here for additional data file.

17 Jan 2022

The experience of European hospital-based health care workers on following infection prevention and control procedures and their wellbeing during the first wave of the COVID-19 pandemic

PONE-D-20-40846R2

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27 Jan 2022

PONE-D-20-40846R2

The experience of European hospital-based health care workers on following infection prevention and control procedures and their wellbeing during the first wave of the COVID-19 pandemic

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