Limiting spread of COVID-19 in Ghana: Compliance audit of selected transportation stations in the Greater Accra region of Ghana

Globally, little evidence exists on transmission patterns of COVID-19. Recommendations to prevent infection include appropriate and frequent handwashing plus physical and social distancing. We conducted an exploratory observational study to assess compliance with these recommendations in selected transportation stations in Ghana. A one-hour audit of 45 public transport stations in the Greater Accra region was carried out between 27th and 29th March 2020. Using an adapted World Health Organization (WHO) hand hygiene assessment scale, the availability and use of handwashing facilities, social distancing, and ongoing public education on COVID-19 prevention measures were assessed, weighted and scored to determine the level of compliance of stations. Compliance with recommendations was categorized as “inadequate” “basic”, “intermediate” and “advanced”, based on the overall score. Majority (80%) of stations in Accra have at least one Veronica Bucket with flowing water and soap, but the number of washing places at each station is not adequate. Only a small minority (18%) of stations were communicating the need to wash hands frequently and appropriately, and to practice social/physical distancing while at the station. In most stations (95%), hand washing practice was either not observed, or only infrequently. Almost all stations (93%) did not have alcohol-based hand sanitizers available for public use, while social distancing was rarely practiced (only 2%). In over 90% of the stations, face masks were either not worn or only worn by a few passengers. Compliance with COVID-19 prevention measures was inadequate in 13 stations, basic in 16 stations, intermediate in 7 stations, and advanced in 9 stations. Compliance with COVID-19 prevention measures in public transportation stations in the Greater Accra region remains a challenge. Awareness creation should aim to elevate COVID-19 risk perception of transportation operators and clients. Transport operators and stations need support and guidance to enforce hand washing and social distancing.

stations [15]. Observations were carried in a total of 45 commercial transport stations. These 1 3 2 stations were purposively selected based on their size and volume of daily passenger traffic. The data collection tool was developed by adapting questions from the WHO Hand Hygiene 1 3 7 Self-Assessment Framework [16]. The revised tool had a total of 26 question items, distributed  The third section assessed the availability of water for handwashing based on three observational 1 4 4 question items. The minimum section score was 0 and the maximum possible score was 30. The  The tool was pretested at one commercial transport station in Accra (Atomic Roundabout 1 5 2 Station), and revised using the findings and feedback from the pre-test. Data were collected 1 5 3 between 27th and 29th March 2020, just before an anticipated public mobility restriction 1 5 4 closely to determine if there were efforts not to touch surfaces that can lead to spreading of the 1 7 8 virus e.g. car doors, seats, station chairs. Also, wearing nose masks or other similar Personal 1 7 9 Protective Equipment (PPE) was observed.  Internal consistency checks were first conducted to ensure the validity and completeness of the 1 8 6 data before analysis. Descriptive statistics were used to summarize the availability of hygiene aspects of recommended COVID-19 prevention measures at the lorry stations, we calculated the 1 9 0 overall total score and total section score for each of the six different components/sections of our 1 9 1 assessment. The overall potential total score (240) was converted into quantiles of four (4), with 1 9 2 1 (one) representing the lowest or first quantile and 4 (four) representing the highest or the fourth 1 9 3 quantile. Compliance was deemed 'Inadequate' 'Basic', 'Intermediate" or 'Advanced' if the overall total 1 9 5 score fell within the 1 st , 2 nd , 3 rd, or 4 th quantile respectively. Proportions were then used to 1 9 6 describe compliance of stations. Results 1 9 8 . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) The copyright holder for this preprint this version posted June 5, 2020. .

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Characteristics of lorry stations assessed 1 9 9 A total of 45 transportation stations were assessed. Table 1 shows the characteristics of these    use audio systems to manage their operations, audio announcements about handwashing/personal 2 1 0 hygiene were made in only one (2.5%) station (Tudu Inter-city) during the observation period. . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review)   facilities (90%, n=34) were Veronica Buckets with receptacles for collecting wastewater. . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.

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The copyright holder for this preprint this version posted June 5, 2020. . https://doi.org/10. 1101/2020 Running water and soap (solid/liquid) were available in many of the stations with installed 2 2 5 handwashing facilities (93% and 90%, respectively).  As shown in Table 4, in the 38 stations where handwashing facilities were available, there was 2 3 0 no observation of the facilities being used in 5% of the stations (n=2). In the stations where they 2 3 1 were used at least once, almost all the facilities were used rarely 87% (n=34). Only in 5% (n=2) sanitizer when boarding/un-boarding vehicles was observed at only three stations (7%). . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.

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The copyright holder for this preprint this version posted June 5, 2020.  actively exercising physical distancing from each other at the station. In the majority of stations 2 4 6 (63%, n=27), only a few passengers were observed wearing personal protective equipment. We 2 4 7 observed the use of handkerchiefs, headgears, and personal clothing being used as face masks.  . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.

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The copyright holder for this preprint this version posted June 5, 2020. Overall compliance of lorry stations to COVID-19 preventive  . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.

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The copyright holder for this preprint this version posted June 5, 2020. In terms of the total thematic compliance score for all the 45 stations, Table 6 shows that for social distancing. Also, 11% (5) were classified as belonging to the fourth quantile for social 2 8 0 distancing.

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For the overall compliance score, 29%(13), 36%(16), 16% (7), and 20%(9) of the stations were 2 8 2 classified as belonging to first, second, third, and fourth quantiles respectively (Table 6).   . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.

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The copyright holder for this preprint this version posted June 5, 2020. . transportation is an indispensable service that must continue during a COVID-19 outbreak 2 9 1 situation. A key outcome of the study is that majority (80%) of public transportation stations 2 9 2 have at least one Veronica Bucket with flowing water and soap. While this effort to ensure observed actively using these facilities, or were using them infrequently. Our data demonstrate 2 9 5 that it is not sufficient to provide handwashing facilities. It is therefore important to generate adverse consequences of uncontrolled COVID-19 spread, it may be appropriate to go beyond 2 9 8 appealing to station users and managers to use the facilities and to use other means, necessary, to 2 9 9 . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.

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The copyright holder for this preprint this version posted June 5, 2020. . https://doi.org/10.1101/2020.06.03.20120196 doi: medRxiv preprint enforce basic hand hygiene practices. This may involve using methods similar to the safety 3 0 0 practices utilized in the airline industry to prevent terrorism which have become routine public alcohol-based hand sanitizer or washing with soap and water kills viruses that may be on your  Indeed, the benefits of good practices at stations that are implementing COVID-19 prevention  pandemic started rather late, coupled with a general low-risk perception of COVID-19 3 1 7 community spread. Second, it could be linked to the simple but also cultural fact that people may 3 1 8 not be used to washing their hands routinely in public, especially at lorry at the stations. It will 3 1 9 take time for people to acquire the habit of washing hands frequently. This suggests a need for 3 2 0 continuous public education using appropriate local mediums and language to ensure that 3 2 1 COVID-19 prevention information, advice, and recommendations are easily accessible and 3 2 2 . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.

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The copyright holder for this preprint this version posted June 5, 2020. warranted given that only a small minority of stations (18%) in this study were communicating 3 2 4 the need to wash hands frequently and appropriately, and to practice social/physical distancing, to the fact that the stations and transport operators may not aware of the role they can play in the 3 2 7 national efforts to prevent the spread of COVID-19. Further, there are also not experts with 3 2 8 capacity for responding to such a health risk in a systematic fashion. They will therefore need to 3 2 9 be supported by the city administration in this regarding.

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This study also showed that social distancing was rarely practiced; in fact, it was observed in 3 3 1 only one station. One explanation for this could be that there is insufficient risk perception of an unmet need that requires training and sustained enforcement beyond the transport operators.

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We also observed that the majority of passengers were not using any PPE. The use of face masks 3 4 4 in crowded lorry stations, where the practice of social distancing is almost non-existent is a 3 4 5 . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.

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The copyright holder for this preprint this version posted June 5, 2020. . https://doi.org/10.1101/2020.06.03.20120196 doi: medRxiv preprint public health concern [19]. At the time of the study, the government had not mandated use of  The findings of our study should be interpreted with certain limitations in mind. The study the data collection process. Despite these limitations, we believe our findings apply to other 3 5 6 public transport stations across the country, making our research relevant for policy directions. The audit of transport stations revealed that compliance with COVID-19 prevention measures in passengers. State and private sector support and guidance should be provided to transport 3 6 7 . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.

(which was not certified by peer review)
The copyright holder for this preprint this version posted June 5, 2020. . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.

(which was not certified by peer review)
The copyright holder for this preprint this version posted June 5, 2020. .   . CC-BY-NC-ND 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) The copyright holder for this preprint this version posted June 5, 2020. . https://doi.org/10.1101/2020.06.03.20120196 doi: medRxiv preprint 1 8 . G  i  l  b  e  r  t  M  ,  P  u  l  l  a  n  o  G  ,  P  i  n  o  t  t  i  F  ,  V  a  l  d  a  n  o  E  ,  P  o  l  e  t  t  o  C  ,  B  o  ë  l  l  e  P  Y  ,  e  t  a  l  .  P  r  e  p  a  r  e  d  n  e  s  s  a  n  d  4  3  4  v  u  l  n  e  r  a  b  i  l  i  t  y  o  f  A  f  r  i  c  a  n  c  o  u  n  t  r  i  e  s  a  g  a  i  n  s  t  i  m  p  o  r  t  a  t  i  o  n  s  o  f  C  O  V  I  D  -1  9  :  a  m  o  d  e  l  l  i  n  g  s  t  u  d  y  .  L  a  n  c  e  t  .  4  3  5  2  0  2  0  ;  3  9  5  :  8  7  1  -8  7  7  .  d  o  i  :  1  0  .  1  0  1  6  /  S  0  1  4  0  -6  7  3  6  (  2  0  )  3  0  4  1  1  -6  4  3  6   1  9  .  W  o  r  l  d  H  e  a  l  t  h  O  r  g  a  n  i  z  a  t  i  o  n  .  A  d  v  i  c  e  o  n  t  h  e  u  s  e  o  f  m  a  s  k  s  i  n  t  h  e  c  o  n  t  e  x  t  o  f  C  O  V  I  D  -1