Background
The rapid global spread of coronavirus disease 2019 (COVID-19), along with the associated mortality and morbidity, is a cause for alarm [
1]. While person-to-person transmission through close contact is the primary mode of COVID-19 transmission, contaminated surfaces can also serve as a source of infection [
2,
3]. Generally, surfaces become contaminated when virus-containing droplets land on them or when someone with contaminated hands touches these surfaces. Recent studies indicate that COVID-19 can survive on various surfaces for different durations, ranging from eight hours to several days. For example, it can persist for up to 3 days on plastic, 2–3 days on stainless steel, and 24 h on cardboard [
4]. Therefore, it is crucial to decontaminate healthcare environments to reduce indirect transmission of COVID-19 and ensure that healthcare workers (HCWs) and patients have clean and safe settings for work and medical care [
5].
Cleaning, disinfection, and proper waste disposal are integral components of the decontamination process. Cleaning refers to the elimination of contaminants, while disinfection involves reducing the presence of persistent microorganisms to a level where they are no longer harmful [
6]. Within the realm of enhanced hygiene, hospital environmental service workers (ESWs) are the driving force, playing a crucial role in breaking the chain of infection [
7]. Among these essential workers, cleaning staff, in particular, have emerged as unsung heroes in the battle against the COVID-19 pandemic.
The pandemic has had devastating consequences for various occupations, with housekeepers and cleaning staff being severely affected. They are responsible for meticulously cleaning and disinfecting surfaces that could harbor potentially harmful microorganisms. However, hospital cleaning comes with inherent risks and numerous challenges. Cleaners assigned to coronavirus isolation rooms and intensive care units face a constant array of infection hazards as they strive to maintain the proper functioning of hospital spaces. Moreover, they bear the responsibility of preventing the spread of infections within hospital settings. Unfortunately, their behind-the-scenes role, coupled with their status as low-skilled workers, has kept them hidden from the public eye. While healthcare professionals have rightfully received praise worldwide for their life-saving efforts during the pandemic, cleaning staff are often overlooked and underappreciated.
Given the occupational risks faced by cleaning personnel, including exposure to COVID-19, it is crucial to enhance their knowledge and regularly monitor their practices to minimize the risk of infection. Understanding and highlighting their practices can provide valuable insights for improving environmental services measures [
8].
In Lebanon, there is a lack of data on the number of COVID-19 infections specifically among cleaning staff in hospitals. However, according to data from the epidemiological surveillance unit, no deaths have been reported in this category. While previous studies conducted in Lebanon have assessed the knowledge and practices of various healthcare professionals, such as physicians [
9], dentists [
10], pharmacists [
11], and nurses [
12], no studies have focused on the practices of hospital services staff during the COVID-19 era.
Considering the ongoing COVID-19 pandemic, conducting this study to evaluate the level of knowledge, attitudes, and practices among cleaning services staff working in Lebanese hospitals is of significant importance. Additionally, identifying factors associated with good practices will provide valuable insights for improving overall practices in this context.
Methodology
Due to the Lebanese government's recommendation to minimize in-person interactions during the pandemic, conducting a field-based survey in hospitals was not feasible. Therefore, potential participants were electronically invited to take part in this cross-sectional study. An online survey was conducted during a period of increasing COVID-19 cases in Lebanon, specifically between 1st and 14th November 2020.
Questionnaire development
A comprehensive literature review was conducted to gather available resources on knowledge, attitudes, and practices (KAP) towards COVID-19. Existing questionnaires on COVID-19 prevention were also examined to identify relevant items and scales, which were incorporated into different sections of the questionnaire. The knowledge section of the questionnaire was developed based on the etiology, transmission, risk, prevention of COVID-19, and recommended cleaning and disinfection procedures [
13,
14].
For the attitude section, the theoretical framework of the Health Belief Model (HBM) [
15] was utilized and adapted to the context of environmental services. The practice section was based on international guidelines for cleaning and disinfection in healthcare facilities, including recommendations from the World Health Organization (WHO) and the Centers for Disease Control and Prevention (CDC) [
14,
16].
To ensure the content validity of the questionnaire, a panel of experts was assembled, consisting of an epidemiologist, a microbiologist, a hygienist, and a biostatistician. The experts evaluated the clarity, relevance, accuracy, and interpretability of the questions in each domain (knowledge, attitude, and practice), selecting the best items to be included.
The questionnaire was initially developed in English and then translated into colloquial Arabic, the official national language of Lebanon, to facilitate administration to local participants. The translation process followed standard guidelines for backward and forward translation, with two forward translations by a sworn translator and an epidemiologist, followed by backward translation by a language communication expert and another epidemiologist to ensure accuracy [
17].
Face validity of the questionnaire was assessed by testing it on 10 cleaners and housekeepers. Their feedback on the understanding of the questionnaire items, the significance of the questions, survey flow, readability, layout, style, and absence of confusing wording was carefully evaluated. Based on this face validation process, a revised and finalized version of the questionnaire was produced, incorporating minor modifications and clarifications. This version will be used for the data collection process.
The questionnaire is designed as an anonymous, self-administered tool comprising five sections: (1) socio-demographic characteristics, (2) clinical information, (3) knowledge of cleaning and disinfecting, (4) attitude towards COVID-19, and (5) prevention practices towards COVID-19 among hospital cleaning services staff.
Socio-demographic characteristics
Section included information about age, gender, nationality, marital status, level of education, year of experience in cleaning, and the type of hospital where the environmental staff works.
Section covered the current health status of the participant and the presence of any comorbidity.
Knowledge section
This section comprised five dimensions with a total of 26 items. These questions were designed to assess the cleaners' understanding of various aspects related to COVID-19, including its nature, symptoms, mode of transmission, prevention and treatment measures, risk factors, and cleaning and disinfection procedures. Participants responded to the questions using a true/false format, with the option of "do not know" also available. Each correct response was assigned a value of "1," while incorrect or "don't know" responses were given a value of "0." The Knowledge score was calculated by summing the scores for each item, resulting in a possible range of 0 to 26 points. The overall knowledge of the cleaners was categorized as good if the score fell between 60 and 100% (16–26 points) and poor if the score was below 60% (< 16 points), based on the modified Bloom's cut-off point [
16].
Attitude section
To assess the attitudes of the cleaners, three dimensions were used. The first dimension focused on their attitudes towards health facilities, the second dimension examined their attitudes towards health authorities, and the final dimension targeted their attitudes towards cleaning and disinfection. Participants rated their agreement with the statements using a 3-point Likert scale, with "1" indicating disagreement and "3" indicating agreement. A score of 1 was assigned to responses indicating agreement, while responses indicating disagreement or neutrality received a score of 0. Similar to the knowledge section, the attitude score in each domain was categorized as positive if the score was between 60 and 100% and negative if the score was below 60%.
Practice section
This section comprised 21 items. Participants rated their practice behaviors using a 3-point Likert scale: "never," "occasionally," and "all the time." The scale aimed to capture specific information regarding the frequency of adopting infection prevention and control (IPC) measures by the cleaners. A score of 1 was given to responses indicating "all the time," while responses indicating "never" or "occasionally" received a score of 0. The practice score was also categorized using the original Bloom's cut-off point, with scores falling between 60 and 100% considered good and scores below 60% considered poor. Before the actual data collection period, the questionnaire was pre-tested on 5% of the sample. This allowed for the evaluation of the survey flow, functionality, and language.
Calculation of sample size
The sample size was determined using the online RAOSOFT sample size calculator for web survey software (
http://www.raosoft.com/samplesize.html). With an estimated population of 4,000 actively practicing housekeepers at the health facility level, a confidence level of 95%, and an absolute error of 5%, the minimum required sample size was calculated to be 351 participants.
Data collection
An online questionnaire using Google Docs was distributed via email to directors of government-run and private hospitals across various regions in the country. Subsequently, designated focal persons within Lebanese hospitals were contacted by phone and informed about the survey and its purpose. After obtaining their agreement to participate, the survey link was shared with them via "WhatsApp". The respective hospitals then disseminated the survey link to their cleaners and housekeepers working in the health facilities through social media platforms, predominantly WhatsApp. The survey link clearly stated that all cleaners working in Lebanese hospitals who were capable of reading and writing in Arabic were eligible to participate. The link also provided a brief introduction to the background of the study, its objectives, and instructions for completing the questionnaire. Cleaners who were seriously ill or on annual leave during the data collection period were excluded from participation.
Ethical approval
Each participant provided electronic informed consent before participating in the survey. Participation in the study was entirely voluntary, and all information collected was kept anonymous and treated with strict confidentiality. The study design ensured the adequate protection of participants, and the information presented did not pose any plausible harm or stigma to the participants. It is important to note that the study does not involve clinical data about patients and does not qualify as a clinical trial. Consequently, the study was exempted from requiring ethical approval by the Lebanese Ministry of Public Health.
Data analysis
The collected data was exported from the Google Form to Microsoft Excel 2016 for cleaning and coding purposes. Data analysis was conducted using SPSS (Statistical Package for Social Sciences), version 22.0. The reliability of the knowledge, attitudes, and practice scales was assessed using Cronbach's alpha. Descriptive statistics were used to report categorical variables, including frequency and percentages. Single-item knowledge questions were presented as percentages of correct responses. Bivariate analysis was performed using chi-squared tests to examine the relationship between nominal variables. A significance level of p-value < 0.05 was considered statistically significant. Variables with a p-value < 0.2 in the bivariate analysis were included in a multivariable logistic regression model to identify factors associated with the dependent variable (good practice). The adequacy of the final logistic regression model was assessed using the Hosmer and Lemeshow test. The adjusted odds ratio and the corresponding 95% confidence intervals were reported.
Cleaners' practices
Table
2 presents the items related to cleaners' practices. Upon calculating Cronbach's alpha, the practice scale demonstrated good reliability (α = 0.713). The findings indicate that the majority of cleaners consistently adhered to infection prevention and control (IPC) standard precautions. This included practicing hand hygiene (90.7%), maintaining social distancing (75.7%), avoiding crowded places (85.7%), wearing face masks at the hospital (91.4%), refraining from touching surfaces and then their eyes or faces (92.5%), and observing proper cough and sneeze etiquette (94%). Additionally, 92.4% of the cleaners reported compliance with the prevention measures recommended by the Ministry of Public Health (MOPH).
Table 2
Self-reported practices of hospital cleaning services staff during COVID19 pandemic in Lebanon, November 2020
Washing hands with soap and water, and also using disinfectants regularly | 6(1.3%) | 35(1.3%) | 412(90.9%) |
Maintaining social distance with everyone in the hospital (1.5 m) | 3(0.7%) | 107(23.6%) | 343(75.7%) |
Wearing a face mask all the time at the hospital | 12(2.6%) | 27(6%) | 414(91.4%) |
Avoiding the presence in crowded places | 9(2%) | 56(12.4%) | 388(85.7%) |
Avoiding touching surfaces than touching eyes or faces | 9(2%) | 25(5.5%) | 419(92.5%) |
Adhere to the prevention measures requested by MOPH | 6(1.3%) | 29(6.4%) | 418(92.3%) |
Respecting cough and sneeze etiquette | 3(0.7%) | 24(5.3%) | 426(94%) |
Checking the availability of the needed cleaning supplies with my supervisor before starting | 3(0.7%) | 53(11.7%) | 397(87.6%) |
Cleaning and disinfecting common areas at hospitals (such as rest rooms, halls, reception, corridors and lifts) | 3(0.7%) | 46(10.2%) | 404(89.2%) |
Cleaning and disinfecting surfaces and objects that are frequently touched, such as handles, elevator buttons, handrails, doorknobs and dispensers | 3(0.7%) | 34(7.5%) | 416(91.8%) |
Keeping the room where disinfectant solution is prepared used aerated and Labelling the prepared solution of disinfectant | 12(2.6%) | 61(14.1%) | 377(83.2%) |
Following the manufacturer’s instructions to ensure that disinfectants are prepared and handled safely | 9(2%) | 31(6.8%) | 413(91.2%) |
Wearing appropriate PPE when visiting COVID-19 patient room | 3(0.7%) | 21(4.6%) | 429(94.7%) |
Donning and doffing PPEs appropriately | 5(1.1%) | 33(7.3%) | 415(91.6%) |
Following regular training on IPC including PPEs donning and doffing | 11(2.4%) | 44(9.7%) | 398(87.9%) |
I wash my hands before and after wearing PPEs | 3(0.7%) | 26(5.7%) | 424(93.6%) |
Handling laundry carefully to mitigate the risk of potential transmission | 3(0.7%) | 23(5%) | 427(94.3%) |
Putting textiles, linens, and clothes in special, marked laundry bags | 21(4.6%) | 28(6.2%) | 404(89.2%) |
Washing laundry in warm cycles (60-90ºC) with the usual detergents | 21(4.6%) | 53(11.7%) | 379(83.7%) |
Placing disposable items (hand towels, gloves, medical masks, tissues) in a container with a lid and following hospital action plan and national regulations for waste management | 6(1.3%) | 24(5.3%) | 423(93.4%) |
Following COVID-29 news | 30(6.6%) | 135(29.8%) | 288(63.6%) |
Regarding cleaning and disinfection practices, 87.6% of the surveyed cleaners confirmed that they always checked with their supervisor for the availability of necessary cleaning supplies before commencing work. Over 80% of them ensured proper ventilation in rooms and consistently followed the manufacturer's instructions to ensure safe handling and preparation of disinfectants. Furthermore, approximately 90% of the cleaning staff reported regular cleaning and disinfection of common areas in hospitals, as well as high-touch surfaces such as handles, elevator buttons, handrails, and doorknobs. Moreover, a significant majority (94.3%) demonstrated careful and appropriate handling of laundry to minimize the risk of potential transmission. Specifically, 89.2% used designated, labeled laundry bags for textiles, linens, and clothes, while 83.7% washed laundry in warm cycles (60-90ºC) using standard detergents.
Concerning the use of personal protective equipment (PPE), 94.7% of cleaners reported consistent usage of appropriate PPE when entering the room of COVID-19 patients for cleaning purposes. Additionally, 91.6% of them confirmed proper donning and doffing of PPE. Furthermore, more than 90% of the cleaners consistently followed recommended hand hygiene practices before and after wearing PPE or engaging in cleaning activities. The majority of respondents (87.9%) also attended regular training sessions on IPC during the COVID-19 pandemic. In terms of waste management, 93.4% of cleaners reported efficient handling of waste by placing disposable items (hand towels, gloves, medical masks, and tissues) in containers with lids, and they followed both the hospital's waste management plan and national regulations. However, only 63.6% of them consistently stayed updated with COVID-19 news.
Factors associated with cleaners' good practices
Table
3 presents the results of the multivariable logistic regression analysis examining the factors associated with cleaners' adoption of good practices. The findings indicate that gender, marital status, and the presence of comorbidities were not significantly associated with good practices. However, age was found to be a significant factor. Cleaners aged over 40 years were less likely to adopt good practices compared to their younger counterparts, with an adjusted odds ratio (aOR) of 0.712 (95% CI: 0.202 to 0.851). On the other hand, cleaners with a secondary degree education or higher were 1.869 times more likely to engage in good practices compared to those with the lowest educational level (aOR = 1.869, 95% CI: 1.271 to 3.045).
Table 3
Multivariable logistic regression analysis of factors associated with good practices among hospital cleaning services staff: Lebanon, 2020
Gender | | | 0.18 | | | |
Male | 19(9.2%) | 188(90.8%) | | | | |
Female | 28(11.4%) | 218(88.6%) | | | | |
Age | | | < 0.001 | | | |
21–30 years | 1(0.7%) | 151(99.3%) | | 1.000 | | |
31–40 years | 8(5.5%) | 138(94.5%) | | 0.851 | 0.605 | 1.576 |
More than 40 years | 38(24.5%) | 117(75.5%) | | 0.712 | 0.202 | 0.851 |
Marital status | | | 0.208 | | | |
Single | 5(4.5%) | 106(95.5%) | | | | |
Others (single, separated or widowed) | 15(9.7%) | 141(90.3%) | | | | |
Educational level | | | 0.023 | | | |
Middle School degree or less | 39(12.5%) | 272(87.5%) | | 1.000 | | |
Secondary or BT degree or more | 8(5.7%) | 134(94.3%) | | 1.869 | 1.271 | 3.045 |
Presence of comorbidities | | | 0.251 | | | |
No | 37(11.3%) | 291(88.7%) | | | | |
Yes | 10(8%) | 115(92%) | | | | |
Type of hospital | | | < 0.001 | | | |
Public | 27(25.5%) | 79(74.5%) | | 1.000 | | |
Private | 20(5.8%) | 327(94.2%) | | 2.083 | 1.340 | 3.436 |
Years of experience in hospital cleaning | < 0.001 | | | |
Less than 3 years | 40(18.43%) | 177(81.57%) | | 1 | | |
3 years and more | 7(3%) | 229(97%) | | 2.942 | 2.214 | 3.747 |
Knowledge regarding COVID-19 symptoms | 0.006 | | | |
Poor | 10(43.5%) | 13(56.5%) | | 1.000 | | |
Good | 37(8.6%) | 393(91.4%) | | 2.076 | 1.895 | 3.463 |
Knowledge of COVID-19 mode of transmission | | 0.833 | | | |
Poor | 6(14%) | 37(86%) | | | | |
Good | 41(10%) | 369(90%) | | | | |
Knowledge of COVID-19 prevention and treatment | 0.019 | | | |
Poor | 6(37.5%) | 10(62.5%) | | 1 | | |
Good | 41(9.4%) | 396(90.6%) | | 2.717 | 1.594 | 4.051 |
Knowledge of cleaning and disinfection | 0.031 | | | |
Poor | 6(27.3%) | 16(72.7%) | | | | |
Good | 41(9.5%) | 390(90.5%) | | 2.934 | 1.699 | 4.126 |
Knowledge about the risk factors of getting COVID-19 | 0.004 | | | |
Poor | 10(26.3%) | 28(73.7%) | | 1 | | |
Good | 37(8.9%) | 378(91.1%) | | 1.937 | 1.569 | 3.150 |
Attitudes of Housekeepers towards health facility | < 0.001 | | | |
Negative | 16(35.6%) | 29(64.4%) | | 1 | | |
Positive | 31(7.6%) | 377(92.4%) | | 2.481 | 1.591 | 4.388 |
Attitudes of Housekeepers towards cleaning and disinfection | < 0.001 | | | |
Negative | 23(26.1%) | 65(73.9%) | | 1 | | |
Positive | 24(6.6%) | 341(93.4%) | | 3.939 | 1.819 | 5.126 |
Attitudes of Housekeepers towards health authorities | 0.021 | | | |
Negative | 27(32.1%) | 57(67.9%) | | 1 | | |
Positive | 20(5.4%) | 349(94.6%) | | 2.303 | 1.106 | 3.863 |
Furthermore, working in private hospitals (aOR = 2.083, 95% CI: 1.340 to 3.436) and having more than 3 years of experience in hospital cleaning (aOR = 2.942, 95% CI: 2.214 to 3.747) were positively associated with the adoption of good practices. In terms of knowledge, cleaners with good knowledge levels in various domains related to COVID-19, including its nature, prevention and treatment, cleaning and disinfection, and factors affecting the risk of COVID-19, were more likely to exhibit good practices (aOR range: 1.397 to 2.934, all p < 0.05).
Moreover, cleaners with a positive attitude towards health facilities (aOR = 2.481, 95% CI: 1.591 to 4.388) and a positive attitude towards health authorities and the government (aOR = 2.303, 95% CI: 1.106 to 3.863) were more likely to demonstrate good practices. Lastly, participants with a positive attitude towards cleaning and disinfection were 3.939 times more likely to implement good practices during their work.
Discussion
The COVID-19 pandemic has brought attention to the significant importance of hygiene and infection prevention, particularly in healthcare settings. To address this, the CDC and WHO have established extensive guidelines and recommendations for healthcare facilities to implement effective infection control practices [
14,
16]. These measures encompass various aspects such as maintaining proper hand hygiene, ensuring the appropriate use of personal protective equipment (PPE), following disinfection and cleaning protocols, practicing respiratory hygiene, and implementing patient isolation procedures. As a result, the pandemic has highlighted the often-underestimated contributions of hospital cleaners, whose essential role in upholding cleanliness and hygiene within healthcare settings has become more evident. To our knowledge, this is the first nationwide study conducted in Lebanon that aims to investigate the knowledge, attitudes, and practices of environmental cleaning staff regarding cleaning and disinfection during the COVID-19 pandemic. By gaining insights from cleaners, we can identify areas for improvement and target interventions to address any gaps or weaknesses.
Our study revealed several key findings. Firstly, the majority of surveyed cleaners (98%) demonstrated a good overall knowledge score, indicating a high level of awareness across various knowledge domains related to COVID-19. This encompassed understanding the nature and symptoms of the virus, its modes of transmission, preventive measures, treatment options, risk factors, and decontamination procedures. These findings align with a similar study conducted among healthcare workers in Ethiopia, where 84.7% displayed good knowledge levels [
18]. A study conducted in Addis Ababa yielded similar findings [
19]. However, our results regarding knowledge scores surpassed those reported in other studies conducted in hospitals in Palestine (53.9%) and Iran (57%) [
20,
21]. This discrepancy may be attributed to variations in sample size, sociodemographic factors, and the specific items used to assess knowledge. While numerous studies have examined various aspects of this subject among healthcare workers (HCWs), none of them have specifically addressed the knowledge and application of infection control principles and cleaning practices among environmental services staff members. Consequently, there is a notable gap in the literature, making direct comparisons difficult.
Nevertheless, certain pieces of information remained less recognized by the cleaners, such as the potential transmission of COVID-19 through urine or feces and the availability of specific treatments for the virus. It is worth noting that although COVID-19 has been detected in stool samples and, rarely, in urine, current evidence does not support fecal or wastewater exposure as a primary route of transmission for the virus [
22]. Furthermore, it is important to note that the availability of specific treatments for COVID-19 is time-sensitive and subject to ongoing trials. Similarly, not all cleaners were aware of the need to reduce the frequency of cleaning in COVID-19 patient rooms. While enhancing hygiene practices during the pandemic is crucial, it is also necessary to strike a balance between effective cleaning and minimizing the risk of COVID-19 exposure. Compared to other areas of knowledge, cleaners exhibited a lower level of awareness regarding factors that amplify the risk of COVID-19 transmission. Therefore, raising awareness about these factors is essential in empowering cleaners to effectively prevent infections.
Likewise, the majority of respondents expressed a strong agreement on questions related to the importance of cleaning in reducing infections for patients and their families. Cleaners demonstrated a clear understanding of their responsibilities and assigned a high priority to patient safety within their organization.
In terms of attitude, most cleaners exhibited a positive outlook towards health facilities. They believed that hospitals prioritize patient safety and the well-being of their staff. Cleaners acknowledged that hospitals provided them with the necessary equipment and supplies for cleaning and disinfection, implemented infection prevention and control measures, and offered education on the risk of contracting COVID-19. This positive attitude can be attributed to their good levels of knowledge, as supported by findings from a study conducted in Iran [
23]. However, it is important to recognize that cleaners' attitudes and perceptions about their work can influence their motivation and the effectiveness of their cleaning practices. Therefore, understanding and addressing these attitudes and beliefs are crucial for continual improvement of environmental cleaning services [
7].
Similarly, cleaners demonstrated a strong consensus on the importance of cleaning in preventing infections, their understanding of their role expectations, and their prioritization of patient safety within their organization. These findings align with studies conducted in Canada and the United States, which highlighted the recognition among environmental services workers (ESWs) of the significance of their work in ensuring patient safety. Additionally, cleaners displayed a sense of dedication and pride in their work [
24]. Notably, a majority of participants in our study emphasized the importance of receiving feedback on their performance. Unfortunately, most cleaners reported a lack of regular feedback regarding their work.
However, our findings also revealed that many cleaners do not feel appreciated by the hospital and other healthcare workers for their additional efforts. More than a quarter of them believed that the hospital showed little interest in them, neglected their well-being, and disregarded their complaints and requests. The lack of recognition and appreciation for their efforts may lead to demotivation among some cleaners, resulting in a decline in their performance. Similar findings were reported in a study conducted among environmental services workers in New York [
24]. Therefore, the perceived lack of organizational support, feedback, and investment in cleaning resources should not be underestimated. Understanding the factors that influence cleaning performance is crucial for developing strategies to enhance healthcare cleanliness and reduce the risk of infection transmission.
It is worth noting that most cleaners expressed positive attitudes towards Lebanese health authorities and believed that the government has effectively fulfilled its role in combating COVID-19, especially within healthcare settings. These positive attitudes and high confidence in controlling COVID-19 can be attributed to the Lebanese government's proactive response, including implementing strict control measures and precautions such as lockdowns, flight suspensions, and restrictions on public gatherings. Similarly, the majority of cleaners demonstrated positive attitudes towards infection prevention and control (IPC) measures, including handwashing, wearing personal protective equipment (PPE), and surface decontamination. They recognized these measures as effective in reducing the risk of COVID-19 infection.
Based on the responses of cleaners, a significant majority consistently adhered to IPC standards, including practicing hand hygiene, maintaining social distancing, avoiding crowded places, wearing face masks at the hospital, refraining from touching surfaces and then their faces, and following proper cough and sneeze etiquette. Furthermore, 92.4% of cleaners reported compliance with the prevention measures recommended by the Ministry of Public Health (MOPH). This high level of self-reported compliance aligns with the findings of a previous study conducted among other healthcare workers (HCWs) [
25]. However, other studies that used observation for data collection reported lower compliance rates. However, studies that utilized observation-based data collection methods have reported lower compliance rates [
26].
Regarding cleaning and disinfection practices, most surveyed cleaners followed recommended protocols. They ensured the availability of necessary cleaning supplies and equipment before starting their work, maintained proper ventilation in the rooms, and followed manufacturer's instructions for safe handling of disinfectants. They diligently cleaned and disinfected common areas, frequently touched objects, and handled laundry with care. When it came to personal protective equipment (PPE), over 90% of cleaners stated that they always wore appropriate PPE when cleaning COVID-19 patient rooms or units, and they followed proper donning and doffing procedures along with practicing hand hygiene. Additionally, a significant proportion of cleaners implemented efficient waste management practices in accordance with the hospital's action plan and national regulations. However, it is important to note that such statements may be influenced by social desirability bias, emphasizing the need for field studies that closely observe actual practices.
Our findings also revealed that the majority of cleaners regularly attended training sessions on IPC during the COVID-19 pandemic. This finding helps explain the high levels of knowledge and adherence observed among the surveyed cleaners. Training sessions focused on current guidelines likely enhanced their understanding of fundamental practice standards and facilitated consistent implementation. Moreover, up-to-date knowledge and skills regarding cleaning and disinfection likely increased cleaners' confidence in complying with recommended guidelines.
More than half of the cleaners reported consistently following COVID-19 news, with a notable finding that social media was the most commonly used source of information. However, it is important to note that while social media platforms provide easy access to information, they can also be a breeding ground for fake news and panic [
27]. Therefore, it is highly recommended for cleaners to seek information from scientific and reputable sources. Interestingly, the cleaners ranked the Ministry of Public Health (MOPH) as the most reliable source of information, followed by printed materials. This highlights the significance of government involvement in providing real-time emergency information during infectious disease outbreaks, as it contributes to promoting engagement in protective behaviors [
28].
Gender, marital status, and the presence of comorbidities were not found to be associated with the adoption of good practices. However, our findings indicated a negative association between age and good practices, with cleaners aged 31 and above being less likely to adopt good practices compared to those aged 21–30 years. It is worth noting that previous studies have yielded inconsistent results regarding the impact of age [
29‐
31].
Furthermore, our results revealed that work experience was a strong predictor of good practices. Cleaners with more than three years of experience were four times more likely to exhibit good practices in cleaning and disinfection compared to their counterparts with less than three years of experience. As the number of years of practice increases, cleaners are exposed to hazards repeatedly and gain valuable experience through working with senior staff.
In terms of educational level, cleaners with a higher level of education were more likely to adopt good practices compared to those with lower educational levels. This finding aligns with a study conducted in Ethiopia, which found that a higher educational level was associated with engaging in infection prevention and control activities [
32]. One possible explanation for this association is that cleaners with higher educational levels may have better access to local and international information sources and training platforms, enabling them to adopt good practices.
Additionally, this study revealed that cleaners working in private hospitals were ten times more likely to adopt good practices. This finding is consistent with a study conducted in Bangladesh among healthcare workers [
33]. Private hospitals may have implemented regular administrative supervision and monitoring of cleaners, along with intensive training on cleaning and disinfection, proper use of personal protective equipment (PPE), and waste management. The financial resources generated by private hospitals may contribute to ensuring better quality services compared to government hospitals.
Knowledge serves as the foundation for effective practices, and in this study, cleaners with good knowledge about COVID-19 were more likely to adopt good practices in infection prevention and control. Therefore, knowledge plays a crucial role in promoting preventive measures and enhancing good practices in the fight against the disease.
Furthermore, attitude has long been recognized as a key factor influencing people's behavior [
34,
35]. Cleaners who held positive attitudes towards health facilities or health authorities were more likely to exhibit good practices. Having a positive attitude towards cleaning and disinfection emerged as a significant predictor for good practices in the workplace. Cleaners' attitudes and beliefs regarding the importance of cleaning and disinfecting can impact their motivation to clean and, consequently, the effectiveness of their efforts [
36]. Numerous studies have demonstrated successful infection control outcomes following the implementation of enhanced cleaning and disinfection approaches [
34].
Implications of the study
This study provides valuable insights that have practical implications for improving cleaning practices, enhancing public health outcomes, and guiding future research efforts in this domain.
As for its implications in clinical practice, the study's findings can be utilized to develop targeted training programs for cleaners, aimed at improving their knowledge and adherence to recommended cleaning protocols. By enhancing their understanding and practices, the risk of infection transmission in healthcare settings can be effectively reduced.
In terms of public health, the study underscores the importance of fostering a supportive work environment for cleaners. Recognizing the impact of their attitudes towards health facilities and authorities, efforts should be made to create an environment that motivates and empowers cleaners to maintain cleanliness and prevent infections effectively.
Finally, this study contributes to the existing body of literature on the experiences of cleaners during the COVID-19 pandemic, specifically within the unique context of Lebanon. The insights gained from this study can inform further research endeavors aimed at comprehensively understanding the factors that influence cleaners' knowledge, attitudes, and practices. Such research can facilitate the identification and implementation of effective strategies to enhance cleaning practices in healthcare facilities.
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