# Unveiling the unknown: first comprehensive assessment of the knowledge, attitudes and practices of hospital cleaning services staff regarding COVID-19 in Lebanon during the pandemic

Dalal Youssef, Linda Abou-Abass, Hamad Hassan

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Dalal Youssef, Linda Abou-Abass, Hamad Hassan. Unveiling the unknown: first comprehensive assessment of the knowledge, attitudes and practices of hospital cleaning services staff regarding COVID-19 in Lebanon during the pandemic. Archives of Public Health, 2023, 81 (1), pp.134. 10.1186/s13690-023-01149-5. hal-04281791

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# Unveiling the unknown: first comprehensive assessment of the knowledge, attitudes and practices of hospital cleaning services staff regarding COVID-19 in Lebanon during the pandemic

Dalal Youssef<sup>1,2,3*</sup> ●, Linda Abou-Abass<sup>4</sup> and Hamad Hassan<sup>5</sup>

**Abstract**

**Background** Hospital cleaners are the unsung heroes in the fight against the COVID-19 pandemic. This study aimed to assess the knowledge, attitudes, and practices (KAP) of hospital cleaners towards COVID-19 and determine factors associated with good practices.

**Methods** A cross-sectional study was conducted in Lebanon between the 1st and 14th November 2020. Using a snowball sampling technique, data were collected through an online survey that was sent to governmental and private hospitals. The questionnaire consisted of socio-demographic characteristics and KAP of hospital cleaners towards COVID-19. Descriptive statistics and logistic regression analysis were performed.

**Results** A total of 453 cleaners completed the survey, of whom 54.3% were females. Most participants had a good level of COVID-19 knowledge (98%) and good preventive practices (89.7%). Regarding attitude, 90.7% had a positive attitude toward health facilities, 78.8% toward cleaning and disinfection, and 73.5% toward health authorities. Sociodemographic characteristics, including younger age, higher levels of education, working in private hospitals, and having more than 3 years of experience, were positively associated with good preventive practices. Our results also showed that participants who had good knowledge about COVID-19, COVID-19 prevention and treatment, cleaning and disinfection processes, and COVID-19 risk factors had a higher likelihood of positive preventive practices. Finally, a positive attitude toward health facilities, health authorities, and cleaning and disinfection was positively associated with good practices.

**Conclusion** The surveyed cleaners have a high level of knowledge and expressed positive attitudes toward health facilities and health authorities, as well as good preventive practices. Understanding the determinants of cleaning performance is critical in tailoring interventions to improve hospital cleaning.

**Keywords** Knowledge, Attitudes, Practices, Environmental cleaning staff, Lebanon, COVID-19

<footnote>*Correspondence:
Dalal Youssef
dalalyoussef.esu@gmail.com; dyoussef@moph.gov.lb
Full list of author information is available at the end of the article</footnote>
Text Box 1. Contributions to the literature

* This study comprehensively assesses the KAP of hospital cleaners in Lebanon regarding COVID-19. It highlights the challenges and opportunities specific to their cultural and healthcare context, contributing to the global understanding of cleaners' experiences during the pandemic

* The study addresses the knowledge gaps of cleaners regarding COVID-19 in healthcare settings

* The study explores the attitudes of cleaners towards health facilities. This is crucial for enhancing the work environment and cleaning practices in healthcare settings

* The study's findings have implications for improving the training provided to cleaners, as well as for enhancing cleaning practices and development of effective strategies to mitigate the spread of COVID-19 in healthcare environments

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

Study tool and design

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 incorpo-
rated 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 disinfec-
tion 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 Con-
trol and Prevention (CDC) [14, 16].

To ensure the content validity of the questionnaire, a
panel of experts was assembled, consisting of an epide-
miologist, a microbiologist, a hygienist, and a biostat-
istician. 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 administra-
tion to local participants. The translation process fol-
lowed 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 feed-
back on the understanding of the questionnaire items,
the significance of the questions, survey flow, read-
ability, layout, style, and absence of confusing wording
was carefully evaluated. Based on this face validation
process, a revised and finalized version of the question-
naire 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, nation-
ality, marital status, level of education, year of experience
in cleaning, and the type of hospital where the environ-
mental staff works.

Clinical information

Section covered the current health status of the partici-
pant 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. Par-
ticipants 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" indicat-
ing 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 pos-
itive 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) meas-
ures 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 prac-
tice 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 question-
naire 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 soft-
ware (http://www.raosoft.com/samplesize.html). With an
estimated population of 4,000 actively practicing house-
keepers 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 distrib-
uted via email to directors of government-run and private
hospitals across various regions in the country. Subse-
quently, designated focal persons within Lebanese hos-
pitals 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 work-
ing 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 instruc-
tions for completing the questionnaire. Cleaners who
were seriously ill or on annual leave during the data col-
lection period were excluded from participation.

Ethical approval

Each participant provided electronic informed con-
sent 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 par-
ticipants. 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 reliabil-
ity of the knowledge, attitudes, and practice scales was
assessed using Cronbach's alpha. Descriptive statistics

were used to report categorical variables, including fre-
quency and percentages. Single-item knowledge ques-
tions 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 sta-
tistically significant. Variables with a *p*-value < 0.2 in the
bivariate analysis were included in a multivariable logis-
tic 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.

Results

Baseline characteristics of the study participants

Table 1 presents the baseline characteristics of the sur-
vey participants. A total of 453 cleaners completed the
survey, with females comprising 54.3% of the sample.
Approximately one-third of the participants were in
the age range of 21–30 years. The majority of respond-
ents were Lebanese (82.34%), married (65.56%), and
had a level of education up to a school degree or lower
(68.65%). Most participants reported good health status
(89.95%), while 27.59% had comorbidities. About two-
thirds of the cleaners worked in private hospitals, and
nearly half of them had three or more years of experience
in cleaning health facilities. In terms of income, approxi-
mately 80.79% reported earning less than 1 Million Leba-
nese pounds.

Cleaners self-reported knowledge

The knowledge scale demonstrated good reliability, as
indicated by a Cronbach's alpha value of 0.782. Nearly
98% of the cleaners surveyed obtained a good overall
knowledge score, indicating a strong understanding of
the subject matter (≥ 60%). Figure 1 provides a visual rep-
resentation of the cleaners' knowledge scores across dif-
ferent domains. The majority of respondents exhibited
high levels of awareness and knowledge, with over 90%
achieving good scores in all targeted knowledge domains,
including the nature and symptoms of COVID-19, its
mode of transmission, prevention and treatment, fac-
tors increasing the risk of infection, and decontamina-
tion procedures. While the majority of cleaners (90%)
answered the majority of knowledge items correctly,
some questions were less familiar and yielded the low-
est correctness rates. For example, questions related to
the transmission of COVID-19 through urine and feces
of an infected person had a correct response rate of only
46.4%. Awareness regarding the availability of specific
treatment for COVID-19 (66.9%) and the need to reduce
<table><caption>**Table 1** Baseline information of the hospital cleaners services staff, Lebanon 2020 (N=453)</caption><thead><tr><th></th><th>n</th><th>%</th></tr></thead><tbody><tr><td><strong>Gender</strong></td><td></td><td></td></tr><tr><td>Male</td><td>207</td><td>45.70%</td></tr><tr><td>Female</td><td>246</td><td>54.30%</td></tr><tr><td><strong>Age</strong></td><td></td><td></td></tr><tr><td>21–30 years</td><td>152</td><td>33.55%</td></tr><tr><td>31–40 years</td><td>146</td><td>32.23%</td></tr><tr><td>41–50 years</td><td>125</td><td>27.59%</td></tr><tr><td>More than 50 years</td><td>30</td><td>6.62%</td></tr><tr><td><strong>Nationality</strong></td><td></td><td></td></tr><tr><td>Lebanese</td><td>373</td><td>82.34%</td></tr><tr><td>Other</td><td>80</td><td>17.75%</td></tr><tr><td><strong>Marital status</strong></td><td></td><td></td></tr><tr><td>Married</td><td>297</td><td>65.56%</td></tr><tr><td>Others<sup>a</sup></td><td>156</td><td>34.44%</td></tr><tr><td><strong>Educational level</strong></td><td></td><td></td></tr><tr><td>Middle School degree or less</td><td>311</td><td>68.65%</td></tr><tr><td>Secondary or BT degree or more</td><td>142</td><td>31.35%</td></tr><tr><td><strong>Health status</strong></td><td></td><td></td></tr><tr><td>Fair</td><td>21</td><td>4.64%</td></tr><tr><td>Average</td><td>25</td><td>5.52%</td></tr><tr><td>Good</td><td>407</td><td>89.85%</td></tr><tr><td><strong>Presence of comorbidities</strong></td><td></td><td></td></tr><tr><td>No</td><td>328</td><td>72.41%</td></tr><tr><td>Yes</td><td>125</td><td>27.59%</td></tr><tr><td><strong>Type of hospital</strong></td><td></td><td></td></tr><tr><td>Private</td><td>347</td><td>76.60%</td></tr><tr><td>Public</td><td>106</td><td>23.40%</td></tr><tr><td><strong>Income</strong></td><td></td><td></td></tr><tr><td>Less than 1 Million L.L</td><td>366</td><td>80.79%</td></tr><tr><td>1–2 Millions L.L</td><td>84</td><td>18.54%</td></tr><tr><td>More than 2 Millions L.L</td><td>3</td><td>0.66%</td></tr><tr><td><strong>Years of experience in hospital cleaning</strong></td><td></td><td></td></tr><tr><td>Less than 3 years</td><td>217</td><td>47.90%</td></tr><tr><td>3 years or more</td><td>236</td><td>52.10%</td></tr><tr><td><strong>Total</strong></td><td><strong>453</strong></td><td><strong>100%</strong></td></tr></tbody></table>

Others<sup>a</sup> includes single, divorced and widowed

N Frequency, % Percentage

the frequency of cleaning in the room of a COVID-19 patient (67.1%) was relatively lower. Similarly, items pertaining to the importance of rinsing surfaces after applying disinfectant (51.7%), and factors amplifying the risk of COVID-19 infection, such as virus concentration (69.3%) and the time elapsed since an infected person left the area (72.8%), were less well-known compared to other knowledge items (refer to Additional file 1: Appendix 1 for further details).

# Cleaners' attitudes

## Assessment of cleaners attitudes towards health facility

The attitude scale exhibited a good level of reliability, with a Cronbach's alpha value of 0.819. The majority of cleaners (87.7%) expressed agreement that patient safety is prioritized in the hospital where they work, and they believe that the hospital values their safety (90.7%). Furthermore, they reported that the hospital provides them with the necessary equipment and supplies for cleaning and disinfection (90.7%). Similarly, they perceived that infection prevention and control (IPC) measures are well implemented at the hospital level (87.2%), and the health facility has effectively fulfilled its role in raising awareness about the risk of COVID-19 transmission and its prevention (90.4%). Approximately half of the cleaners (47%) indicated that their hospital is continuously seeking innovative approaches to enhance hygiene practices. However, a notable proportion of cleaners (33.8%) felt that their hospital does not appreciate their extra efforts, and 29.8% believed that even if they perform their best, it will go unrecognized by the hospital. Similarly, around 28% of cleaners expressed that the hospital pays little attention to their concerns and disregards their complaints and requests (see Additional file 1: Appendix 2 for additional details).

## Cleaners' attitudes towards health authorities

Among the 453 participants, a substantial majority of cleaners, specifically 321 individuals (76.9%), expressed their belief that Lebanese health authorities have actively fulfilled their responsibilities in combating COVID-19, particularly within healthcare settings, by supplying personal protective equipment (PPE) and delivering training programs. Additionally, the majority of respondents (66.2%) expressed their confidence in the government's ability to successfully overcome the challenges posed by the COVID-19 pandemic (Additional file 1: Appendix 2).

## Cleaners' attitudes towards cleaning and disinfection

The survey results revealed that a substantial majority of cleaners, exceeding 85%, recognized the effectiveness of essential preventive measures in combating COVID-19, including regular hand washing, proper utilization of personal protective equipment (PPE), and thorough cleaning and disinfection of surfaces. These measures were perceived as crucial for eliminating the virus and preventing infection. Figure 2 provides a graphical representation of the attitude scores of the cleaners. The findings indicate that the majority of cleaners exhibited a positive attitude towards health facilities, health authorities, and
## Housekeepers' and cleaners' Knowledge domains

<figure><img src="image_3.png" /><figcaption>**Fig. 1** Knowledge domains of hospital cleaning services staff, Lebanon 2020</figcaption></figure>

## Attitudes of housekeepers towards cleaning and disinfection; health facilities and health authorities

<figure><img src="image_4.png" /><figcaption>**Fig. 2** Attitudes of hospital cleaning services staff towards health facilities, health authorities, and cleaning procedures in Lebanon: 2020</figcaption></figure>

the implementation of infection prevention and control (IPC) precautions (Additional file 1: Appendix 2).

## 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).

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
<table><caption>**Table 2** Self-reported practices of hospital cleaning services staff during COVID19 pandemic in Lebanon, November 2020</caption><thead><tr><th>Practices</th><th>Never<br>n(%)</th><th>Occasionally<br>n(%)</th><th>All the times<br>n(%)</th></tr></thead><tbody><tr><td>Washing hands with soap and water, and also using disinfectants regularly</td><td>6(1.3%)</td><td>35(1.3%)</td><td>412(90.9%)</td></tr><tr><td>Maintaining social distance with everyone in the hospital (1.5 m)</td><td>3(0.7%)</td><td>107(23.6%)</td><td>343(75.7%)</td></tr><tr><td>Wearing a face mask all the time at the hospital</td><td>12(2.6%)</td><td>27(6%)</td><td>414(91.4%)</td></tr><tr><td>Avoiding the presence in crowded places</td><td>9(2%)</td><td>56(12.4%)</td><td>388(85.7%)</td></tr><tr><td>Avoiding touching surfaces than touching eyes or faces</td><td>9(2%)</td><td>25(5.5%)</td><td>419(92.5%)</td></tr><tr><td>Adhere to the prevention measures requested by MOPH</td><td>6(1.3%)</td><td>29(6.4%)</td><td>418(92.3%)</td></tr><tr><td>Respecting cough and sneeze etiquette</td><td>3(0.7%)</td><td>24(5.3%)</td><td>426(94%)</td></tr><tr><td>Checking the availability of the needed cleaning supplies with my supervisor before starting</td><td>3(0.7%)</td><td>53(11.7%)</td><td>397(87.6%)</td></tr><tr><td>Cleaning and disinfecting common areas at hospitals (such as rest rooms, halls, reception, corridors and lifts)</td><td>3(0.7%)</td><td>46(10.2%)</td><td>404(89.2%)</td></tr><tr><td>Cleaning and disinfecting surfaces and objects that are frequently touched, such as handles, elevator buttons, handrails, doorknobs and dispensers</td><td>3(0.7%)</td><td>34(7.5%)</td><td>416(91.8%)</td></tr><tr><td>Keeping the room where disinfectant solution is prepared used aerated and Labelling the prepared solution of disinfectant</td><td>12(2.6%)</td><td>61(14.1%)</td><td>377(83.2%)</td></tr><tr><td>Following the manufacturer's instructions to ensure that disinfectants are prepared and handled safely</td><td>9(2%)</td><td>31(6.8%)</td><td>413(91.2%)</td></tr><tr><td>Wearing appropriate PPE when visiting COVID-19 patient room</td><td>3(0.7%)</td><td>21(4.6%)</td><td>429(94.7%)</td></tr><tr><td>Donning and doffing PPEs appropriately</td><td>5(1.1%)</td><td>33(7.3%)</td><td>415(91.6%)</td></tr><tr><td>Following regular training on IPC including PPEs donning and doffing</td><td>11(2.4%)</td><td>44(9.7%)</td><td>398(87.9%)</td></tr><tr><td>I wash my hands before and after wearing PPEs</td><td>3(0.7%)</td><td>26(5.7%)</td><td>424(93.6%)</td></tr><tr><td>Handling laundry carefully to mitigate the risk of potential transmission</td><td>3(0.7%)</td><td>23(5%)</td><td>427(94.3%)</td></tr><tr><td>Putting textiles, linens, and clothes in special, marked laundry bags</td><td>21(4.6%)</td><td>28(6.2%)</td><td>404(89.2%)</td></tr><tr><td>Washing laundry in warm cycles (60-90°C) with the usual detergents</td><td>21(4.6%)</td><td>53(11.7%)</td><td>379(83.7%)</td></tr><tr><td>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</td><td>6(1.3%)</td><td>24(5.3%)</td><td>423(93.4%)</td></tr><tr><td>Following COVID-19 news</td><td>30(6.6%)</td><td>135(29.8%)</td><td>288(63.6%)</td></tr></tbody></table>

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 (60-90°C) 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.

## Sources of information

Cleaners reported that the most frequently accessed sources of information were health care professionals (66.8%), health authorities (66.2%), and social media (61.6%) (Additional file 1: Appendix 3). However, when it came to reliability, the cleaners ranked the Ministry of Public Health (MOPH) as the most trustworthy source (67.5%), followed by printed materials (55.6%) and trainings (54.7%) (Fig. 3).

## 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
Reliability of used sources of information as perceived by Cleaners

<figure><img src="image_5.png" /><figcaption>**Fig. 3** Perceived reliability of COVID-19 information sources among hospital cleaning services staff: Lebanon, 2020</figcaption></figure>

lowest educational level (aOR=1.869, 95% CI: 1.271 to 3.045).

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 preven-
tion, particularly in healthcare settings. To address this,
the CDC and WHO have established extensive guidelines
and recommendations for healthcare facilities to imple-
ment effective infection control practices [14, 16]. These
measures encompass various aspects such as maintain-
ing proper hand hygiene, ensuring the appropriate use
of personal protective equipment (PPE), following dis-
infection 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, atti-
tudes, 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 con-
ducted in hospitals in Palestine (53.9%) and Iran (57%)
[20, 21]. This discrepancy may be attributed to varia-
tions in sample size, sociodemographic factors, and the
specific items used to assess knowledge. While numer-
ous 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 poten-
tial 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].
<table><caption>**Table 3** Multivariable logistic regression analysis of factors associated with good practices among hospital cleaning services staff: Lebanon, 2020</caption><thead><tr><th rowspan="2"></th><th rowspan="2">Poor practices<br>n(%)</th><th rowspan="2">Good practices<br>n(%)</th><th rowspan="2">P-value</th><th rowspan="2">aOR</th><th colspan="2">95% C.I.for aOR</th></tr><tr><th>Lower</th><th>Upper</th></tr></thead><tbody><tr><td><strong>Gender</strong></td><td></td><td></td><td>0.18</td><td></td><td></td><td></td></tr><tr><td>Male</td><td>19(9.2%)</td><td>188(90.8%)</td><td></td><td></td><td></td><td></td></tr><tr><td>Female</td><td>28(11.4%)</td><td>218(88.6%)</td><td></td><td></td><td></td><td></td></tr><tr><td><strong>Age</strong></td><td></td><td></td><td>&lt;0.001</td><td></td><td></td><td></td></tr><tr><td>21-30 years</td><td>1(0.7%)</td><td>151(99.3%)</td><td></td><td>1.000</td><td></td><td></td></tr><tr><td>31-40 years</td><td>8(5.5%)</td><td>138(94.5%)</td><td></td><td>0.851</td><td>0.605</td><td>1.576</td></tr><tr><td>More than 40 years</td><td>38(24.5%)</td><td>117(75.5%)</td><td></td><td>0.712</td><td>0.202</td><td>0.851</td></tr><tr><td><strong>Marital status</strong></td><td></td><td></td><td>0.208</td><td></td><td></td><td></td></tr><tr><td>Single</td><td>5(4.5%)</td><td>106(95.5%)</td><td></td><td></td><td></td><td></td></tr><tr><td>Others (single, separated or widowed)</td><td>15(9.7%)</td><td>141(90.3%)</td><td></td><td></td><td></td><td></td></tr><tr><td><strong>Educational level</strong></td><td></td><td></td><td>0.023</td><td></td><td></td><td></td></tr><tr><td>Middle School degree or less</td><td>39(12.5%)</td><td>272(87.5%)</td><td></td><td>1.000</td><td></td><td></td></tr><tr><td>Secondary or BT degree or more</td><td>8(5.7%)</td><td>134(94.3%)</td><td></td><td>1.869</td><td>1.271</td><td>3.045</td></tr><tr><td><strong>Presence of comorbidities</strong></td><td></td><td></td><td>0.251</td><td></td><td></td><td></td></tr><tr><td>No</td><td>37(11.3%)</td><td>291(88.7%)</td><td></td><td></td><td></td><td></td></tr><tr><td>Yes</td><td>10(8%)</td><td>115(92%)</td><td></td><td></td><td></td><td></td></tr><tr><td><strong>Type of hospital</strong></td><td></td><td></td><td>&lt;0.001</td><td></td><td></td><td></td></tr><tr><td>Public</td><td>27(25.5%)</td><td>79(74.5%)</td><td></td><td>1.000</td><td></td><td></td></tr><tr><td>Private</td><td>20(5.8%)</td><td>327(94.2%)</td><td></td><td>2.083</td><td>1.340</td><td>3.436</td></tr><tr><td><strong>Years of experience in hospital cleaning</strong></td><td></td><td></td><td>&lt;0.001</td><td></td><td></td><td></td></tr><tr><td>Less than 3 years</td><td>40(18.43%)</td><td>177(81.57%)</td><td></td><td>1</td><td></td><td></td></tr><tr><td>3 years and more</td><td>7(3%)</td><td>229(97%)</td><td></td><td>2.942</td><td>2.214</td><td>3.747</td></tr><tr><td><strong>Knowledge regarding COVID-19 symptoms</strong></td><td></td><td></td><td>0.006</td><td></td><td></td><td></td></tr><tr><td>Poor</td><td>10(43.5%)</td><td>13(56.5%)</td><td></td><td>1.000</td><td></td><td></td></tr><tr><td>Good</td><td>37(8.6%)</td><td>393(91.4%)</td><td></td><td>2.076</td><td>1.895</td><td>3.463</td></tr><tr><td><strong>Knowledge of COVID-19 mode of transmission</strong></td><td></td><td></td><td>0.833</td><td></td><td></td><td></td></tr><tr><td>Poor</td><td>6(14%)</td><td>37(86%)</td><td></td><td></td><td></td><td></td></tr><tr><td>Good</td><td>41(10%)</td><td>369(90%)</td><td></td><td></td><td></td><td></td></tr><tr><td><strong>Knowledge of COVID-19 prevention and treatment</strong></td><td></td><td></td><td>0.019</td><td></td><td></td><td></td></tr><tr><td>Poor</td><td>6(37.5%)</td><td>10(62.5%)</td><td></td><td>1</td><td></td><td></td></tr><tr><td>Good</td><td>41(9.4%)</td><td>396(90.6%)</td><td></td><td>2.717</td><td>1.594</td><td>4.051</td></tr><tr><td><strong>Knowledge of cleaning and disinfection</strong></td><td></td><td></td><td>0.031</td><td></td><td></td><td></td></tr><tr><td>Poor</td><td>6(27.3%)</td><td>16(72.7%)</td><td></td><td></td><td></td><td></td></tr><tr><td>Good</td><td>41(9.5%)</td><td>390(90.5%)</td><td></td><td>2.934</td><td>1.699</td><td>4.126</td></tr><tr><td><strong>Knowledge about the risk factors of getting COVID-19</strong></td><td></td><td></td><td>0.004</td><td></td><td></td><td></td></tr><tr><td>Poor</td><td>10(26.3%)</td><td>28(73.7%)</td><td></td><td>1</td><td></td><td></td></tr><tr><td>Good</td><td>37(8.9%)</td><td>378(91.1%)</td><td></td><td>1.937</td><td>1.569</td><td>3.150</td></tr><tr><td><strong>Attitudes of Housekeepers towards health facility</strong></td><td></td><td></td><td>&lt;0.001</td><td></td><td></td><td></td></tr><tr><td>Negative</td><td>16(35.6%)</td><td>29(64.4%)</td><td></td><td>1</td><td></td><td></td></tr><tr><td>Positive</td><td>31(7.6%)</td><td>377(92.4%)</td><td></td><td>2.481</td><td>1.591</td><td>4.388</td></tr><tr><td><strong>Attitudes of Housekeepers towards cleaning and disinfection</strong></td><td></td><td></td><td>&lt;0.001</td><td></td><td></td><td></td></tr><tr><td>Negative</td><td>23(26.1%)</td><td>65(73.9%)</td><td></td><td>1</td><td></td><td></td></tr><tr><td>Positive</td><td>24(6.6%)</td><td>341(93.4%)</td><td></td><td>3.939</td><td>1.819</td><td>5.126</td></tr><tr><td><strong>Attitudes of Housekeepers towards health authorities</strong></td><td></td><td></td><td>0.021</td><td></td><td></td><td></td></tr><tr><td>Negative</td><td>27(32.1%)</td><td>57(67.9%)</td><td></td><td>1</td><td></td><td></td></tr><tr><td>Positive</td><td>20(5.4%)</td><td>349(94.6%)</td><td></td><td>2.303</td><td>1.106</td><td>3.863</td></tr></tbody></table>

C.I. Confidence interval, aOR Adjusted Odds Ratio
Furthermore, it is important to note that the avail-
ability 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 fre-
quency 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 transmis-
sion. 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 posi-
tive outlook towards health facilities. They believed
that hospitals prioritize patient safety and the well-
being of their staff. Cleaners acknowledged that hospi-
tals 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 rec-
ognize that cleaners' attitudes and perceptions about
their work can influence their motivation and the effec-
tiveness of their cleaning practices. Therefore, under-
standing 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 organi-
zation. These findings align with studies conducted
in Canada and the United States, which highlighted
the recognition among environmental services work-
ers (ESWs) of the significance of their work in ensur-
ing patient safety. Additionally, cleaners displayed a
sense of dedication and pride in their work [24]. Nota-
bly, a majority of participants in our study emphasized
the importance of receiving feedback on their perfor-
mance. 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 hospi-
tal 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 clean-
ers, resulting in a decline in their performance. Simi-
lar 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 develop-
ing strategies to enhance healthcare cleanliness and
reduce the risk of infection transmission.

It is worth noting that most cleaners expressed posi-
tive attitudes towards Lebanese health authorities and
believed that the government has effectively fulfilled its
role in combating COVID-19, especially within health-
care settings. These positive attitudes and high confi-
dence 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 pre-
vention and control (IPC) measures, including hand-
washing, 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 major-
ity consistently adhered to IPC standards, including
practicing hand hygiene, maintaining social distancing,
avoiding crowded places, wearing face masks at the hos-
pital, 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. How-
ever, studies that utilized observation-based data collec-
tion 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 fol-
lowed 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.

## Limitations of study

Our study has several limitations that should be acknowledged. Firstly, due to its cross-sectional design, we cannot establish a temporal relationship between the outcome and predictor variables. Additionally, the study is susceptible to social desirability bias, which may lead to over- or underestimation of the findings. While validated questions were used in the questionnaire, some respondents had a different first language than Arabic, resulting in difficulties comprehending the Arabic version of the questionnaire for those who were not fluent in Arabic. This hindered their participation in the study. Future studies or hospitals wishing to assess the knowledge of environmental services staff members may consider using verbal surveys. The positioning of questions related to attitudes, roles of cleaning, and perceived organizational support at the end of the questionnaire, which primarily consisted of questions for other purposes, may have influenced responses to these specific questions. In certain hospitals, environmental services staff members expressed cynicism when asked about their attitudes and perceived organizational support. Despite reassurances about data confidentiality, some respondents were concerned about their responses being identifiable by the hospital, especially regarding perceived organizational support. For future studies, it is recommended to separate the assessment of knowledge and practice from attitudes and perceived organizational support.

## Conclusion

Cleaning staffs are on the front lines of fighting this global pandemic. Our results indicate that environmental services staff members have a high level of knowledge and expressed positive attitudes towards health facilities and authorities. They are also aware of the importance of their role. Nevertheless, there seems to be a perceived lack of support, feedback, and investment from the organization in terms of cleaning resources. It is important not to disregard the attitudes of the environmental services staff members, and it is essential to understand the factors that influence their performance in order to develop targeted interventions that enhance hospital cleaning and minimize the risk of infection transmission. The findings of this study will benefit future planning if another outbreak wave occurs.

## Abbreviations

MOPH Ministry of Public Health

KAP Knowledge, attitudes and practices

HCWs Health care workers

COVID-19 Coronavirus disease 2019

aOR Adjusted Odds Ratio

SPSS Statistical Package for Social Sciences

## Supplementary Information

The online version contains supplementary material available at https://doi.org/10.1186/s13690-023-01149-5.

**Additional file 1: Appendix 1.** Hospital cleaning services staff responses to knowledge items (N= 453). **Appendix 2.** Attitudes of housekeepers and cleaners towards health facility, health authorities and cleaning.

**Appendix 3.** Sources of information reported by cleaners to get information about COVID-19.

**Additional file 2.**

## Acknowledgements

The authors acknowledge all infection control personnel for their assistance with data collection. The authors also thank all cleaners and environmental services staff working in Lebanese hospitals who participated in this study.

## Authors' contributions

Conception and design: D.Y. Analysis and interpretation of the data: D.Y. Critical revision of the article for important intellectual content: D.Y., L.A.A. and H.H. All authors read and approved the final version of the article.

## Funding

This research received no external funding.

## Availability of data and materials

The datasets generated during the current study are not publicly available but are available from the corresponding author on reasonable request.

## Declarations

### Ethics approval and consent to participate

Informed consent for participating in the study was obtained digitally through Google Forms from all subjects, and all methods were carried out in accordance with the relevant guidelines and national regulations for the Non-clinical studies. Specifically, at the beginning of the questionnaire, participants were asked whether they agree to participate in the research in order to be
included in the study. Participants were also informed that their participation was voluntary and that they had the right to leave at any time without providing any explanation. No incentives were provided to the study participants.

### Consent for publication

Not applicable.

### Competing interests

The authors declare no competing interests.

### Author details

¹Clinical Trial Program, Ministry of Public Health, Beirut, Lebanon. ²Bordeaux Research Center for Population Health, Institut de sante publique, d'épidemiologie et de développement (ISPED), Bordeaux University, Bordeaux, France. ³Lebanese Higher Institute of Technical and Professional, Ministry of Education, Beirut, Lebanon. ⁴Neuroscience Research Center, Faculty of Medical Sciences, Lebanese University, Beirut, Lebanon. ⁵Ministry of Public Health, Beirut, Lebanon.

Received: 1 March 2022 Accepted: 7 July 2023

Published online: 17 July 2023

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