Impact of Video Modules-Based Training on Knowledge, Attitude, and Practices of Cleaning and Disinfection Among Housekeeping Staff at a Tertiary Care Center During the COVID-19 Pandemic

Aim To assess the knowledge, attitude, and practice toward cleaning and disinfection among housekeeping (HK) staff amid the coronavirus disease 2019 (COVID-19) pandemic. Methods A quasi-experimental was undertaken among HK staff at a tertiary care hospital. A 30-item structured questionnaire was used in the study, which consisted of questions pertaining to knowledge (11), attitude (8), and practice (11) toward cleaning and disinfection. Result One-hundred-two participants were included by convenient sampling, with mean age = 30-37 years. There was an improvement in pre-test and post-test knowledge (6.21 to 9.7) and practice score (9.97 to post-test 10.52). However, the attitude score did not show a significant change in the post-test score (p=0.964), showing that they were having a positive attitude toward the practices before training too. Conclusion Improvement in the post-test score shows that periodic targeted training sessions on cleaning and disinfection among housekeeping staff help improve their knowledge, attitude, and practices toward infection prevention and control (IPC) during the COVID-19 pandemic, thus minimizing the spread of the virus in a hospital environment, reducing their apprehension, and preparing them to work in such pandemic situations.


Introduction
Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is the causative agent of the transmissible coronavirus disease 2019 (COVID- 19), which was first detected in Wuhan, China, in 2019 and was declared a pandemic by the World Health Organization (WHO) on March 11, 2020 [1]. SARS-CoV-2 is transmitted mainly through close contact and respiratory droplets, whereas airborne transmission may be possible during aerosol-generating medical procedures [2][3]. Environmental surfaces act as potential reservoirs for the transmission of COVID-19 [2][3][4]. Many studies showed that viable virus particles are potentially infectious, can be detected on surfaces, but the extent to which people can be infected by exposure to contaminated surfaces remains to be determined [5].
Studies have also demonstrated that the SARS CoV-2 virus can remain viable on surfaces for three to five days and is susceptible to standard disinfection methods, including household bleach, at normally used concentrations. Solutions containing at least 70% alcohol can inactivate SARS-CoV-2 in less than five minutes [6][7].
Various studies suggest that environmental contamination by SARS-CoV-2 in the hospital around COVID-19 patients is extensive [6][7] and the hospital environment could potentially be a source of virus spread, among health care workers (HCWs), patients, and visitors [8][9].
In order to prevent the transmission of healthcare-associated infections (HAIs), including SARS-CoV-2, hospital infection prevention and control (IPC) procedures should be strictly followed.
Housekeeping (HK) workers, though often undervalued and overlooked, are the backbone of routine cleaning and disinfection in any healthcare facility, thus having a major role in the prevention of HAIs. Studies suggest that interventions directed at environmental service workers result in significant improvement in cleaning and disinfection [10][11]. In the midst of COVID-19, housekeeping staff act as frontline workers with the challenging responsibilities of vigorous cleaning of high-touch surfaces in healthcare facilities despite having apprehension of working in COVID-19 areas. For optimal effectiveness of environmental cleaning and disinfection measures, HK workers need to be aware of environmental disinfection and be willing to learn and improve their practices. This is in accordance with the "Knowledge-Attitude-Practice (KAP) theory," which states that changes in human practices are a step-wise process that involves the acquisition of knowledge, the subsequent generation of positive attitudes, and, finally, the adoption of practice [12]. Understanding the knowledge, attitudes, and practice of HK staff regarding cleaning and disinfection practices is important to tailor the training of HK workers according to their specific needs and allay their apprehension while working in COVID-19 areas.
In the present study, we conducted video module-based training sessions of the HK workers department working in different areas of the hospital. Their knowledge, attitudes, and practice regarding environmental cleaning and disinfection were assessed by taking a pre-test and post-test during each session. This was important in the context of this KAP study, as housekeeping staff are the backbone of the hospital infection control system. It was equally important to know whether they were able to perform their respective duties efficiently during the COVID-19 pandemic without any undue apprehension. To the best of our knowledge, there are very limited studies on this particular subgroup in a tertiary care center in India.

Methodology
A quasi-experimental study with a single-group pre-test and post-test design was conducted among HK staff with the aim to assess the knowledge, attitude, and practice regarding cleaning and disinfection during the current COVID-19 pandemic in a tertiary care institute for a period of one week, from 21 April to 28 April 2020. The training consisted of three events: pre-test, video-assisted training, and post-test.
The study was conducted among HK staff after approval from the institutional ethics committee vide letter no. AIIMS/IEC/20/162, dated 11/04/2020, and after obtaining written informed consent of the participants. The confidentiality of information and anonymity of the participants was maintained. Study participants were included by convenience sampling and a total of 102 HK staff posted in different COVID-19 areas and willing to participate were recruited as study participants. Those who were absent at the time of data collection and intervention were excluded from the study.

Study tool
A semi-structured questionnaire with four sections was used to collect the data; the first section was the demographic information of participants followed by knowledge, attitude, and practice questions regarding the cleaning and disinfection of the hospital. The questionnaire was prepared by experts in the field of microbiology and nursing of the hospital infection control committee, based on the cleaning and disinfection policy of the institute. Although the content of training and questionnaire was revised thoroughly by the Hospital Infection Control team members, content validation could not be done due to a shortage of time. The institutes' cleaning and disinfection policy draft was formulated based on guidelines of the World Health Organization (WHO), Center for Disease Control (CDC), Ministry of Health and Family Welfare Government of India (MoHFW, GOI), and ICMR, scientific literature, and available logistics of the institute [13][14][15][16][17].
A pre-test questionnaire was conducted for 20 minutes before the training session. The training session included videos regarding cleaning and disinfection practices to be followed at the hospital along with interactive sessions in the local language (Hindi). Later, the videos were made available on all desktops of the institute's hospital wards as well as on the YouTube channel with its link on the institute's website [18][19][20]. The post-test session was concluded with the distribution of the post-test questionnaire, which was collected after 30 minutes (Appendices 1-2).
The participants were trained in small groups of 25-30 at a time to avoid mass gatherings. All were supposed to follow the COVID protocol, with a compulsory wearing of masks at all times. A total of four such training sessions were taken. A few of the HK staff were not literate enough to read and attempt the questionnaires. For such participants, a few HCWs were requested to help them fill their tests by interviewing them.
The KAP questionnaires consisted of 11 questions of multiple-choice type pertaining to knowledge, eight questions catering to attitude on a Likert scale of 1-4, and 11 questions concerning practices toward cleaning and disinfection in the hospital amid the COVID-19 pandemic with 'Yes' and 'No' responses. An arbitrary tool was devised to assess the knowledge, attitude, and practices of HK staff regarding cleaning and disinfection. Knowledge was assessed by giving a score of one to each correct answer and 0 to the wrong answer. The knowledge score ranged from a maximum of 11 scores to a minimum of 0. Scores < 7 were taken as "poor" and ≥7 as "adequate" knowledge of cleaning and disinfection among housekeeping staff. Similarly, the attitude was assessed by giving a score of 1 to 5 for the responses of strongly disagree to strongly agree. Scores <5 were taken as "negative" and ≥5 as "positive." Likewise, for practice, a score of 1 was given to the response of Yes, depicting adequate/good practice, and 0 to the response of No, depicting poor practice. Scores < 7 were taken as "poor" and ≥7 as "adequate" practices of cleaning and disinfection among housekeeping staff.

Data analysis
Data were collected and entered in Microsoft Excel (Microsoft Corporation, Redmond, WA), and missing entries were excluded. Statistical analysis was done to assess the pre-test and post-test scores using SPSS (IBM SPSS Statistics for Windows, Version 21.0; IBM Corp., Armonk, NY). Descriptive analysis was done for frequencies and percentages. Data were checked for normality using the Shapiro Wilk test, which concluded that the data were not normally distributed. Therefore, the Wilcoxon-signed rank test was used to evaluate the mean of the pre and post-test scores of housekeeping staff. P<0.05 was considered statistically significant.

Results
A total of 102 housekeeping staff participated in this one-group pre and post-test quasi-experimental study. The mean age of participants was 30.48 ± 6.58 years. Among the participants, 53 (52%) were males, 48 (47%) had primary education, 83 (81.4%) had previous training, and 67 (65.7%) had experience of one to five years. The detailed demographic characteristics of the participants are shown in Table 1.

Assessment of knowledge
A total of 11 questions were used to measure the knowledge of cleaning and disinfection among housekeeping ( Table 1). The pre-test mean knowledge score of participants was 6.21 (SD= 2.09), which increased to 9.71 (1.5) in the post-test after the intervention. The increase in knowledge mean score was statistically significant with a p-value = 0.001 (Tables 2-3). The pre-test and post-test scores are demonstrated in Table 4. Prior to the training session, the level of knowledge was good in only 69.6% of participants, which improved impressively to 98% post-training ( Figure 1).    Note: Knowledge was assessed by assigning 1 to the correct answer and 0 to the wrong answer. The scale measured knowledge from maximum 11 to minimum 0. Scores < 7 were taken as poor and ≥ 7 as adequate knowledge of cleaning and disinfection among housekeeping staff.

Assessment of attitude
For the assessment of attitude, the participants (n=102) were asked eight questions. Before training, the mean score of attitudes in the pre-test was 7± 1.58 with no significant change post-intervention (Tables  2-3). About 95% of participants were having a positive attitude regarding the use of phenyl and sodium hypochlorite solution for cleaning and disinfection for infection containment and performing all practices as per institute guidelines and protocols. Prior to training, 31.4% had a negative attitude toward cleaning products used for disinfection and believed that the disinfectants might be harmful to them. This negative attitude improved slightly after training ( Table 5). After conducting training, the mean score of attitudes in post-test was 6.99 ± 1.88, which was not statistically significant (P = 0.964, Tables 2-3).

Assessment of practices
Practices regarding cleaning and disinfection among housekeeping staff were assessed by 11 questions. The mean score of practices was 9.97 in pre-test and 10.52 in post-test. The mean difference was statistically significant with a p-value of 0.003 ( Table 2, Table 6). More than 95% of participants affirmed adequate practice regarding all questions post-training, except regarding wearing of necessary PPE during cleaning (9.8% poor practice), cleaning using the triple-bucket system (9.8% poor practice), and cleaning of hightouch surfaces every four hourly (7.8% poor practice) ( Table 3).  Note: Attitude was assessed by giving 1 to the responses strongly agree and agree, depicting a positive attitude, and 0 to a response of strongly disagree and disagree, depicting a negative attitude. Scores < 5 were taken as negative, ≥ 5 as a positive attitude toward cleaning and disinfection among housekeeping staff.
On applying the Wilcoxon signed-rank test, it was observed that the difference in pre and post-test scores was statistically significant.

Discussion
To the best of our knowledge, this is the first study especially targeting the HK staff working in healthcare facilities during the current COVID-19 pandemic. The surge of COVID-19 cases has emphasized the importance of environmental cleaning in hospitals and thus the role of HK workers as pillars for primordial prevention. Formal training in infection control is conducted by some hospitals as a component of preservice compulsory training, however, regular reinforcement training to provide skill-based training for empowering the HK workers is usually not considered.
In our study, 47% had either primary level education or less while about 38.2% of HK workers had at least secondary level education. Ni K et al. showed, that in their study, 60.5% of sanitation workers were uneducated or with primary education [21]. We did not find a correlation between workers' age, gender, years of experience, preservice training, or education level, and their knowledge in our study suggests that the observed pre/post changes were due to the training intervention and not due to differences in participant characteristics. A previous study by Boyce et al. demonstrated that continuous education and feedback improved disinfection by our housekeeping staff [22].
Previous studies also suggest that assessment and feedback of cleaning performance is a critical part of environmental infection prevention [23][24]. Our study findings are of reinforcement training focusing on cleaning procedures and 81.4% of the workers had received training previously during their service similar to the study findings of Ni et al. [21]. Although most of the participants (81.4%) affirmed that they participate in one or more training related to infection prevention and control practices, some (18.6%) started their activities without any prior training. These results indicate that the hospital HK workers may serve as a potential risk for transmission of COVID-19 as well as other healthcare-associated infections.
The main aim of conducting reinforcement training in this study was to educate HK workers and improve their knowledge and practices. Previous studies have also found that educational interventions alone may not lead to sustained improvements in hospital cleaning and disinfection and that sustained optimal improvement may be achieved only when education is ongoing and additional strategies are implemented [11,[25][26]. The results of our study suggest that training intervention met the need of the hour and significant improvement in baseline knowledge was noted. Significant improvement in the knowledge of HK workers with respect to aspects of the use of personal protective equipment, the frequency for cleaning of high-touch surfaces in COVID areas, and the correct technique of mopping was also noted. For several questions, more than 90% of participants answered correctly. In our study, 83.3% of the HK workers were aware of necessary PPE prior to training. Similar post-intervention observations have been reported by Martin et al. [27]. There is often a lack of awareness amongst cleaning staff, regarding occupational safety and health, including the use of PPE such as mask and rubber or latex gloves, and reluctance to use them as they felt that using PPE affected the efficiency of their cleaning practices [21]. However, in our study, participants were found to be willing to follow correct practices after receiving training. There was no significant change in the attitude of the staff post-intervention, which can be explained by a high baseline positive attitude in the pre-training phase.
In this study, training given to HCWs was assisted with various video modules and was found to be very effective and practical. Similar video-assisted training has been found to be useful for training HCWs in various studies [28][29]. We were also able to identify the gaps in our training program by analyzing the pre and post-training assessments. Although significant gain in knowledge was appreciated in all questions, there was still scope of improvement regarding a few aspects like the concentration of various disinfectants to be used and cleaning of low-touch surfaces and metallic surfaces.
Targeted surface disinfection with a special focus on frequently touched surfaces is indispensable in the current scenario. The role of daily disinfection of high-touch surfaces in isolation rooms as an adjunctive measure to reduce transmission has previously been suggested by Kundrapu et al. [30]. However, disinfectants may be hazardous to HCWs and patients, as well as to the environment, and require special safety precautions. The correct use of disinfectant products is crucial for the control of HAIs so information on the products commonly used in healthcare facilities should be easily available. The cleaning staff must essentially be well-versed with information regarding when, where, and how different products need to be applied. In our study, participants had poor baseline knowledge regarding disinfectants, their use, and concentration. This could be due to poor primary-level education among HKs. Although statistically significant improvement was observed post-intervention, only 65.7% of participants were aware of the disinfection of low-touch surfaces and 80.4% knew about the disinfection of metallic surfaces, highlighting the scope for improvement and need for reinforcement in this domain.
Most of the literature related to the optimum environmental cleaning in healthcare systems and knowledge and practices of cleaning workers comes from countries with relatively plentiful resources. In resourcelimited healthcare settings, additional challenges exist, such as inadequate infrastructure, logistics, or limited or uneducated staff, etc., which contribute to inadequate cleaning of environmental surfaces in healthcare settings [21,26]. Studies examining the level of knowledge and application of adequate IPC practices by HK workers during the current COVID-19 pandemic are largely absent in the literature, with comparisons not possible. In view of several knowledge gaps and high-risk cleaning and disinfection practices found amongst HK staff at our institute, we recommend that similar studies should be done to identify gaps in knowledge about safe and effective practices in other resource-constrained healthcare settings. The paucity of resources at our institute, a central government center, during the ongoing COVID pandemic may be reflective of the situation across smaller districts or municipality hospitals in India. Tailored prevention messages should highlight identified gaps and provide targeted information using digital or social media regarding safe cleaning and disinfection.
The strength of our study is the intervention in form of the in-house video in the local language (Hindi) designed specifically for frontline HK workers, addressing common barriers to the implementation of best practices, which was well-received by the participants. The limitation of our study was that being a singlecenter study with a small sample size, our findings may not be generalized. Another limitation of this study was that the extent of the perceived risk of contracting COVID-19 among the HCWs could not be assessed, which is relevant for understanding the attitude and cleaning practices of HKs. Also, we could not assess the actual practices of workers by observing them during work, rather only assessed through conducting questionnaires. We recommend that covert observation may be done to assess cleaning practices of staff members for future studies. It is also important to take the feedback of the HK workers regarding their needs and training provided along with an assessment of available logistics.

Conclusions
This article presents an understanding of cleaning and disinfection practices in HK staff members. In this underexplored group of healthcare workers, the results of our study suggest that they had a high level of knowledge regarding cleaning and disinfection, with a good attitude toward working in COVID-19 areas, and were willing to follow good practices if provided with necessary cleaning equipment and protective gear. They also understand the importance of their role in the healthcare facility, which is indeed critical to prevent the transmission of infections in a healthcare facility.  Kindly go through each questionnaire carefully and put a tick (✓) mark against the most suitable answer. Your identity will be kept confidential.  Kindly go through each attitude questionnaire carefully and put a tick mark (✓) against the most suitable answer. Your identity will be kept confidential.

Appendices Appendix 1: Youtube Link of video modules used for training
Q. No.

Questions on Attitude
Strongly agree/ Disagree/ Agree/ Strongly agree 9. Are you cleaning the low-touch surfaces like tables and chairs every week? Animal subjects: All authors have confirmed that this study did not involve animal subjects or tissue.

Conflicts of interest:
In compliance with the ICMJE uniform disclosure form, all authors declare the following: Payment/services info: All authors have declared that no financial support was received from any organization for the submitted work. Financial relationships: All authors have declared that they have no financial relationships at present or within the previous three years with any organizations that might have an interest in the submitted work. Other relationships: All authors have declared that there are no other relationships or activities that could appear to have influenced the submitted work.