Original Article
COVID-19 Impact on Infection Control Practices among Radiographers in Malaysia
*M
OHDZ
AIN, N ., C
HEM
UT, N . A . I . & J
ESUDOSS, K . D . ABSTRACT
Diagnostic examination plays an important role in the diagnosis of COVID-19 patients. Acting as a front-line of the clinical setting, radiographers have a high risk of getting infected with a new virus strain. Therefore, proactive measures in controlling the infection of COVID-19 are essential to reduce the risk of transmissions among radiographers. This study aimed to assess radiographers' behavioural intentions towards infection control practices. A cross-sectional study through an online survey was conducted amongst radiographers in East Malaysia from October 2020 to May 2021. A total of 300 radiographers participated in the study, whereby 45.7% were in the age group of 31–40 years, and 65.7% had 1–5 years of working experience. There was a significant difference in the infection control practice between the pre- COVID-19 pandemic and during the COVID-19 pandemic (p<0.001). However, only gender and the working sector have a significant association with infection control practices (p<0.05).
Meanwhile, there was no significant association between infection control practices with age, level of education, and years of working experience. Adherence to infection control measures is critical to improving the quality of hospital care in controlling the infection rate. Therefore, it is crucial to strengthen knowledge and awareness of infection control practices amongst healthcare workers.
Keywords: pre-COVID-19, during COVID-19, infection control, practices, radiographers
Medical Imaging Program, School of Health Sciences, KPJ Healthcare University College, Persiaran Seriemas Utama, Kota Seriemas, 71800 Nilai, Negri Sembilan, Malaysia
*Corresponding Author: Mohd Zain, N.
Email: [email protected] Tel: +606-7942692
Fax: +606-7942662
Received: 15 April 2022 Revised: 1 July 2022
Accepted for publication: 11 August 2022
Publisher: Malaysian Association of Medical Physics (MAMP) http://www.mamp.org.my/
https://www.facebook.com/MedicalPhysicsMalaysia
Copyright © 2022 Malaysian Association of Medical Physics.
All rights reserved.
INTRODUCTION
The world has been in a pandemic mode for more than a year since its first outbreak in December 2019. The COVID- 19 pandemic is the most significant communicable disease outbreak to have hit Malaysia since the 1918 Spanish Flu outbreak, which killed 34,644 people, the Nipah virus, which killed 105 Malaysians, and the SARS outbreak (Hashim 2021).So far, the ongoing COVID-19 pandemic has claimed about 41,129 lives as of 20 January 2022 (Zain
& Mut 2021). Healthcare workers (HCWs) play an integral part in the fight against the COVID-19 pandemic. As soldiers, they act as the medical front-line in combating the COVID-19 outbreak and have accepted the challenge despite knowing the risks they are about to face (Ministry of Health Malaysia 2022).
Medical imaging plays a vital role in evaluating suspected or confirmed COVID-19 patients. As radiographers work at the front line, they should be aware of risks and ways to mitigate the infection and ensure patient safety and care (Stogiannos 2020). Chest radiography and computed tomography (CT) examinations emerged as basic diagnostic tests in managing COVID-19 infections because their increased sensitivity in detecting lung changes during the SARS outbreak indicated that they played a vital role in early diagnosis (Ooi 2021). With the rapid spread of the pandemic, the patient demand for diagnostic examination is increasing rapidly (Niu 2020).
Another study claimed that thoracic imaging with chest radiography and CT are critical tools for pulmonary disease diagnosis and management. Nevertheless, their role in managing the COVID-19 pandemic has not been considered within the multivariable context of the severity of
respiratory disease, pre-test probability, risk factors for disease progression, and critical resource constraints (Rubin 2020). A previous study stated that although physicians could recognise advanced cases of tuberculosis, it was clear that effective treatment would require earlier detection, which imaging might provide (Mollura 2010). Therefore, in ensuring the continuation of diagnostic and interventional examination, proactive measures should be taken to minimize the risk of nosocomial transmission amongst staff and other patients (Ashari 2020).
Nevertheless, overcrowding, lack of isolation facilities, contaminated environment, and insufficient knowledge and awareness of infection control practices amongst HCWs contributes to disease transmission (Wu 2019). Besides, a poor understanding of the disease amongst medical imaging professionals may result in the rapid spread of infection (Kotian 2020). Thus, it is essential to further clarify and normalize the knowledge about infection control and prevention, key areas and equipment which need to disinfect, and the protection levels of medical workers, which this levels shall be dependent the on type of patients, degree of risk exposed, types of infection control measures and protective gears that should be wear (Niu 2020).
Improving infection control practices amongst HCWs is critical as it could help lead to evidence-based optimal infection control behaviours to prevent future large-scale outbreaks. A study reported a positive change in infection control amongst HCWs due to this crisis (Ashari 2020). In addition, about 83% of HCWs in Vietnam practice all COVID-19 prevention measures (Tien et al. 2021).
However, a study on radiographers' behavioural intentions towards infection control practices concerning the COVID- 19 outbreak was not done. Besides, to our knowledge, the only study in Malaysia was on the impacts of COVID-19 on radiography and radiotherapy practice (Ibrahim et al. 2021).
Imaging modalities will remain as the initial diagnosis of the COVID-19 pandemic. Radiographers will be at the front line of a clinical setting, which could be infected with the new coronavirus strain (Kooraki 2020). Therefore, it is crucial to assess the behavioural intentions towards infection control practices. From this study, the strategies to improve the preparedness of the health system and HCWs during a pandemic can be strengthen because there might be another pandemic in the future.
EXPERIMENTAL METHODS
SURVEY DESIGN AND DISTRIBUTION A cross-sectional survey was carried out from October 2020 to May 2021. Samples were recruited from all government and private hospitals in East Malaysia. The participants were only radiographers registered with the Malaysian Society of Radiographers (MSR) and had a working experience of at least 12 months. Respondents were excluded if they did not match the inclusion criteria and had working experience of less than one year. To date, the number of radiographers registered with the Malaysian Society of Radiographers (MSR) was 1300. Thus, based on
Krejcie and Morgan table, the estimation of sample size for this study is 297 respondents. A convenience sampling was used and this study managed to get 300 complete surveys which met the inclusion criteria.
The survey consisted of 17 items to assess the radiographers' behavioural intentions in practising COVID- 19 infection control measures. Section A comprised demographic data, while Section B was on behavioural intentions in practising infection control measures. The scoring was based on a 5-point Likert scale: Never (1), Seldom (2), Sometimes (3), Frequently (4), and Always (5).
The survey underwent content validity and face validation.
The online survey was then piloted with a reliability of α=0.937. A link to the online survey was shared amongst radiographers in Malaysia via social media platforms.
The ethical clearance was sought from the Ethical Review Board with registration number KPJUC/RMC/SOHS/EC/2020/303. A brief explanation about this study was included in the online survey and informed consent was obtained from each participant before participation. Confidentiality of the study participants’
information was maintained throughout the study by making the participants’ information anonymous.
STATISTICAL ANALYSIS
The survey data were analyzed using Statistical Package for Social Sciences (SPSS) Version 26.0. Descriptive analysis was done to analyze demographic data. A significant change in behaviour intentions on infection control practices between pre and during the COVID 19 pandemic was analyzed using Paired t-test. One-way ANOVA test was used to evaluate the association between radiographers' behavioural intentions towards infection control practices and demographic variables, including gender, age, education level, working sector, and years of working experience.
RESULTS
A total of 300 radiographers participated in the study. Table 1 shows the socio-demographic data of participants.
Amongst respondents, 50.7% were males, and 49.3% were females. The age of most participants ranged from 31 to 40 years old, representing 45.7% of the sample. Overall, most responses were from private hospitals (51.3%). In addition, only 3.0% of participants had working experience of more than 10 years, and the majority (65.7%) had about 1 to 5 years of working experience as a radiographer. Most participants were working in Kuala Lumpur (n=54, 18.0%) and Selangor (17.7%) (Fig. 1).
The changes in behaviour towards infection control practices between the pre- COVID-19 pandemic and during the COVID-19 pandemic are shown in Table 2. Results revealed the mean value of each infection control practice was hiking up during the pandemic (Table 2). The change in infection control practices between the pre- COVID-19 pandemic and during the COVID-19 pandemic was statistically significant (p < 0.001). The infection control practices showed a significant relation across the socio-
demographic characteristics, such as gender and working sector (p<0.05). Meanwhile, there were no significant association between infection control practices with age (p=0.64), level of education (p=0.077), and years of working experience (p=0.46), as depicted in Table 1.
The results indicated that the males were more likely to practice infection control measures as they had a higher
mean score, 3.90 (±0.30), than females. Moreover, regarding the working sector, the mean score for infection control practices amongst participants working in government hospitals were more likely to practice infection control measures as they had a higher mean score, 3.92 (±0.28), than participants working in private hospitals.
TABLE 1 Socio-demographic data of respondents
Socio-demographic Frequency (n) Percentage (%) Mean (SD) p-value Gender
Male 152 50.7 3.90 (±0.30) <0.05
Female 148 49.3 3.82 (±0.41)
Age
21-30 102 34.0 3.84 (±0.39) 0.64
31-40 137 45.7 3.85 (±0.35)
41-50 54 18.0 3.89 (±0.32)
51-60 7 2.3 4.00 (±0.00)
Education Level
Diploma 147 49.0 3.90 (±0.32) 0.077
Degree 125 41.7 3.80 (±0.40)
Masters 24 8.0 3.92 (±0.28)
PhD 4 1.3 3.75 (±0.50)
Working sector
Private hospitals 154 51.3 3.81 (±0.41) <0.05
Government hospitals 146 48.7 3.92 (±0.28)
Years of Working Experience
1–5 years 197 65.7 3.85 (±0.36) 0.46
6–10 years 94 31.3 3.89 (±0.34)
More than 10 years 9 3.0 3.78 (±0.44)
FIGURE 1 Distribution of respondents according to state
TABLE 2 The changes in behaviour towards infection control practice between pre-and during 18 (6.0)
15 (5.0) 21 (7.0)
54 (18.0) 23 (7.7)
16 (5.3) 18 (6.0) 18 (6.0) 19 (6.3)
25 (8.3)
53 (17.7) 20 (6.7)
Johor Kedah Kelantan Kuala Lumpur Melaka Negeri Sembilan Pahang Perak Perlis Pulau Pinang Selangor Terengganu
No. of participants, N (%)
the COVID-19 pandemic
Infection control practices
Mean (SD) p-value
Pre During
5 moments of hand hygiene 1.88 (±0.93) 3.86 (±0.36)
<0.001
7 steps of hand hygiene 1.98 (±0.90) 3.84 (±0.41)
Wearing eye shield for suspected/positive patients 2.52 (±0.72) 3.89 (±0.35) Wearing surgical mask gloves when dealing with
suspected/positive patients
2.71 (±0.63) 3.89 (±0.32)
Wearing double gloves when dealing with suspected/positive patients
2.71 (±0.70) 3.89 (±0.32)
Wearing scrub suit and apron for suspected/
positive patients
2.75 (±0.66) 3.89 (±0.38)
Wearing boots or shoe covers when caring for suspected/positive patients
2.70 (±0.73) 3.81 (±0.61)
DISCUSSION
The COVID-19 pandemic has been a global public health concern and the most recent topic of conversation across all aspects of life, notably in hospital settings, since its outbreak in December 2020. Most radiographers made physical contact with COVID-19 patients while positioning them for radiological examinations. As a result, the imaging team needed to follow suitable standards of conduct to avoid exposure and getting the coronavirus (Kotian 2020; Cao 2020; Cieszanowski 2020). This study was the first in Malaysia to comprehensively survey radiographers on their perceived impact of the COVID-19 pandemic on their practice. In response to COVID-19, healthcare systems worldwide have increased their infection prevention and control efforts to slow the spread of infection.
In line with this, the current study found a significant difference in infection control measures before and during the COVID-19 pandemic. This finding was extensively consistent with the results of other studies that similarly reported a high level of practice towards the prevention and control behaviour of the infection (Deressa 2021; Lai 2020).
This finding was also consistent with another study which was conducted in the city of Addis Ababa, Ethiopia. The level of practice on COVID-19 prevention was reported to increase amongst the respondents, particularly regarding the use of a face mask, hand washing for at least 20 seconds, covering mouth and nose when coughing or sneezing, and avoiding touching eyes, nose, and mouth with unwashed hands as far as possible (Deressa 2021). The compliance rate rose after the intervention measures were applied.
In the one-way ANOVA analysis, socio-demographics which were significantly associated with the practice of infection control measures were the gender and working
sector. This study confirmed some gaps in the practice of infection control measures between males and females. In a similar study by Desta (2018), male healthcare employees were twice as likely to be knowledgeable about infection prevention. However, this finding did not correlate with other studies, indicating that females were more likely to comply with infection control measures than males (Huang 2021; Powell-Jackson 2020).The current COVID-19 cases in many countries may influence the result, which consistently reported that the mortality rate amongst males was higher than females (Sui 2020). Therefore, this might influence the awareness amongst the male participants.
In this study, participants in government hospitals practice infection control measures more than in private hospitals. Since the first outbreak of COVID-19, public hospitals been chosen to manage COVID-19 cases as these hospitals met the stringent criteria of infrastructure, staff and systems (Ministry of Health Malaysia 2021; Hashim et al.
2021) which might influence the difference in infection control practices between radiographers working in public and private hospitals. However, it is found that age, education level and working experience do not influence the infection control practices among the respondents. This result is inconsistent with the previous infection control practices studies (Desta et al. 2018). The difference in this finding is due to the sudden outbreak of COVID-19 that might influence the awareness and responsibility sense of the respondents to avoid the transmission to their loved ones.
To ensure adherence on infection control practice, continuous training should be implemented. Repetitive education sessions improved healthcare personnel's understanding with a drop in the prevalence and infections (Mody 2015; Koo 2016). Furthermore, knowledge level
improved significantly from baseline to two months, and the compliance with hand hygiene increased from 43.6% to 63% after the educational intervention amongst the healthcare workers in Vietnam (Phan 2018). Knowledge is power; thus, it is critical to use the formal education program to improve infection control compliance among healthcare workers. Therefore, hospital management needs to arrange training sessions for healthcare workers to improve their knowledge and compliance level of infection control.
CONCLUSION
With the global pandemic spreading by the day, it is more critical to ensure that preparations are well made to safeguard healthcare workers from infection and the safety of patients and limit hospital cross-infection. The radiographers in this study showed that their infection control practice during COVID-19 has been improved. To ensure this good practice is maintained and improved, well- equipped hospital settings and repetitive training are the keys for healthcare workers always to be alert, and the adherence to infection control practice continues to improve.
ACKNOWLEDGEMENT
The authors would like to express their heartfelt gratitude to all who have contributed to this study formally and informally. We thank all the respondents for their cooperation and support.
REFERENCES
Ashari, M. A., Zainal, I. A. & Zaki, F. M. 2020. Strategies for radiology departments in handling the COVID-19 pandemic. Diagn. Interv. Radiol. 26(4): 296-300.
Cao, Y., Liu, X., Xiong, L. & Cai, K. 2020. Imaging and clinical features of patients with 2019 novel coronavirus SARS-CoV-2: a systematic review and meta-analysis. J. Med. Virol. 92(9): 1-11.
Cieszanowski, A., Czekajska, E., Giżycka, B., Gruszczyńska, K., Podgórska, J. & Oronowicz- Jaśkowiak, A. 2020. Management of patients with COVID-19 in radiology departments, and indications regarding imaging studies - recommendations of the Polish Medical Society of Radiology. Pol. J.
Radiol. 85: e209–e214.
Deressa, W., Worku, A., Abebe, W., Getachew, S. &
Amogne, W. 2021. Social distancing and preventive practices of government employees in response to COVID-19 in Ethiopia. Plos One 16(9): e0257112.
Desta, M., Ayenew, T., Sitotaw, N., Tegegne, N., Dires, M.
& Getie, M. 2018. Knowledge, practice and associated factors of infection prevention among healthcare workers in Debre Markos referral hospital, Northwest Ethiopia. BMC Health Serv. Res. 18(465): 1-10.
Hashim, J. H., Adman, M. A., Hashim, Z., Radi, M. F. M. &
Kwan, S. C. 2021. COVID-19 Epidemic in Malaysia:
Epidemic progression, challenges, and response. Front.
Public Health 9(560592): 1-19.
Huang, Q., Luo, L., Wang, Y., Jin, Y. & Zeng, X. 2021.
Gender differences in psychological and behavioral responses of infected and uninfected health-care workers during the early COVID-19 outbreak. Front.
Public Health 9(638975): 1-8.
Ibrahim, M. I., Akib, R. & Jaffar, M. F. 2021. Impact of the COVID-19 pandemic on radiography & radiotherapy practice in Malaysia. Mal. Appl. Biol. 50(2): 55-60.
Koo, E., McNamara, S., Lansing, B., Olmsted, R. N., Rye, R. A., Fitzgerald, T. & Mody, L. 2016. Making infection prevention education interactive can enhance knowledge and improve outcomes: Results from the Targeted Infection Prevention (TIP) Study. Am. J.
Infect. Control 44(11): 1241-1246.
Kooraki, S., Hosseiny, M., Myers, L. & Gholamrezanezhad A. 2020. Coronavirus (COVID-19) outbreak: what the department of radiology should know. J. Am. Coll.
Radiol. 17(4): 447–451.
Kotian, R. P., Faujdar, D., Kotian, S. P. & D'souza, B. 2020.
Knowledge and understanding among medical imaging professionals in India during the rapid rise of the COVID-19 pandemic. Health Technol. 25: 1-6.
Lai, X., Wang, X., Yang, Q., Xu, X., Tang, Y., Liu, C., Tan, L., Lai, R., Wang, H., Zhang, X., Zhao, Q. & Chen, H.
2020. Will healthcare workers improve infection prevention and control behaviours as COVID-19 risk emerges and increases in China? Antimicrob. Resist.
Infect. Control 9: 83(2020).
Ministry of Health Malaysia. 2021. Senarai Pusat Saringan COVID-19 (Hospital) dan Hospital Yang Mengendalikan Kes COVID-19 [Internet]. Available from: https://covid-19.moh.gov.my/garis- panduan/garis-panduan-kkm/Annex_3_-
_Senarai_Pusat_Saringan_Dan_Hospital_Yang_Menge ndalikan_Kes_COVID-19.pdf [30 June 2022]
Ministry of Health Malaysia. 2022. COVID-19 Cases in Malaysia [Internet]. COVIDNOW. Available from:
https://covidnow.moh.gov.my/cases/ [15 May 2021].
Mody, L., Krein, S. L., Saint, S. K., Min, L. C., Montoya, A., Lansing, B., McNamara, S. E., Symons, K., Fisch, J., Koo, E., Rye, R. A., Galecki, A., Kabeto, M. U., Fitzgerald, J. T., Olmsted, R. M., Kaufmann, C. A. &
Bradley, S. F. 2015. A targeted infection prevention in nursing home residents with indwelling devices: A randomised clinical trial. JAMA Intern. Med. 175(5):
714-723.
Mollura, D. J., Morens, D. M., Taubenberger, J. K. & Bray, M. 2010. The role of radiology in influenza: Novel H1N1 and lessons learned from the 1918 pandemic. J.
Am. Coll. Radiol. 7(9): 690-697.
Niu, Y., Xian, J., Lei, Z., Liu, X. & Sun, Q. 2020.
Management of infection control and radiological protection in diagnostic radiology examination of COVID-19 cases. Radiat. Med. Prot. 1(2): 75-80.
Ooi, J. W. L., Er, A. T. W., Chong, C. M., Tsai, K. T. &
Chong, M. C. 2021. Knowledge, attitudes and perceptions of radiology healthcare workers during the
COVID-19 pandemic. Proc. Singapore Healthc. 1-10.
Phan, H. T., Tran, H. T. T., Tran, H. T. M., Dinh, A. P. P., Ngo, H. T., Theorell-Haglow, J & Gordon, C. J. 2018.
An educational intervention to improve hand hygiene compliance in Vietnam. BMC Infect. Dis. 18(116): 1-6.
Powell-Jackson, T., King, J. J. C., Makungu, C., Spieke, R.
N., Woodd, S., Risha, P. & Goodman, C. 2020.
Infection prevention and control compliance in Tanzanian outpatient facilities: a cross-sectional study with implications for the control of COVID-19. Lancet Glob. Health 8(6): e780-e789.
Rubin, G. D., Ryerson, C. J., Haramati, L. B., Sverzellati, N., Kanne, J. P., Raoof, S., Schluger, N. W., Volpi, A., Yim, J.-J., Martin, I. B. K., Anderson, D. J., Kong, C., Altes, T., Bush, A., Desai, S. R., Goldin, J., Goo, J. M., Humbert, M., Inoue, Y., Kauczor, H.-U., Luo, F., Mazzone, P. J., Prokop, M., Remy-Jardin, M., Richeldi, L., Schaefer-Prokop, C. M., Tomiyama, N., Wells, A.
U. & Leung, A. N. 2020. The role of chest imaging in patient management during the covid-19 pandemic: a multinational consensus statement from the Fleischner Society. Chest 158(1): 106-116.
Stogiannos, N., Fotopoulos, D., Woznitza, N. &
Malamateniou, C. 2020. COVID-19 in the radiology department: What radiographers need to know.
Radiography 26(3): 254-263.
Sui, W. K., Hairi, N. N. & Ming, M. F. 2020. Men and COVID-19 [Internet]. Malay mail; Available from:
https://www.malaymail.com/news/what-you- think/2020/11/09/men-and-COVID-19-wan-kim-sui- noran-naqiah-hairi-and-moy-foong-ming/1920782 [6 May 2021].
Tien, T. Q., Tuyet-Hanh, T. T., Linh, T. N. Q., Phuc, H. H.
& Nhu, H. V. 2021. Knowledge, attitudes, and practices regarding covid-19 prevention among Vietnamese healthcare workers in 2020. Health Serv. Insights 14: 1- 7.
Wu, Z. & McGoogan, J. M. 2020. Characteristics of and Important Lessons from the Coronavirus Disease 2019 (COVID-19) Outbreak in China: Summary of a Report of 72 314 Cases from the Chinese Center for Disease Control and Prevention. JAMA 323(13): 1239-1242.
Zain, N. M. & Mut, N. A. I. C. 2021. Healthcare worker perceptions on the outbreak of covid-19: A cross- sectional study in Malaysia. Adv. Res. Soc. Behav. Sci.
22(1): 30-40.
