key: cord-0723619-6cch630v
authors: Maurya, Vinod Kumar; Upadhyay, Vandana; Dubey, Pawan; Shukla, Surabhi; Chaturvedi, Aarti
title: Assessment of front-line healthcare workers’ Knowledge, Attitude and Practice after several months of COVID-19 pandemic
date: 2021-07-22
journal: J Healthc Qual Res
DOI: 10.1016/j.jhqr.2021.07.004
sha: d12210f48855bc60182ff42665ea71bdc69ffb38
doc_id: 723619
cord_uid: 6cch630v

Background: Frontline healthcare workers (F-HCWs) are at the forefront of medical care providers against the novel coronavirus 2019 (COVID-19) pandemic which has life-threatening potentials. Inadequate knowledge and incorrect attitudes among HCWs can directly influence practices and lead to delayed diagnosis, poor infection control practices, and spread of disease. Objectives: The aim of this study was to assess the knowledge, attitude and practice (KAP) regarding the COVID-19 pandemic among the frontline healthcare workers (F-HCWs) working at a tertiary care hospital situated in Eastern Uttar Pradesh and to identify the factors significantly associated with KAP. Methods: A cross-sectional study was conducted among 260 health care providers across eastern Uttar Pradesh including Basti city during December 2020. Data was collected using a self-primed pretested questionnaire from the FHCWs working at a tertiary care hospital of eastern Uttar Pradesh. In this survey, a convenience sampling method was adopted. 12 items on knowledge, 10 items on attitude, and 5 items on practices related to COVID-19. The other variables consisted of 4 items on socio-demographic attributes, P-value and 95% confidence intervals (CIs) were performed to assess the attitude and practices in relation to knowledge. Results: Of the total 260 study population, 228 were interviewed online, 32 were self-administered. Knowledge and attitude of the nursing staff were highest but practice score was best for residents. Among different age groups knowledge, attitude and practices scores were highest for 35-45, 45-60 and 25-35 age groups respectively. Respondents having 5-10 years of experience had the best knowledge and the attitude score was highest for HCWs having 10-20 years’ experience but the practice score was higher for HCWs having more than 20 years’ work experience. Overall knowledge score of respondents having strong correlation with attitude (p< 0.05) and to the practice (p<0.05). Conclusion: In this survey many F-HCWs reported adequate overall knowledge with a positive attitude and adopted appropriate practices. The F-HCWs with a higher level of education and more years of experience in health care facilities had better KAP towards COVID-19.

Coronavirus disease 2019, known as COVID-19 is an extremely expanding pandemic caused by a severe acute respiratory syndrome coronavirus (SARS-CoV-2), an enveloped single-stranded RNA virus, previously known as 2019-nCov [1] [2] [3] . SARS-COV-2 is transmitted from person to person by close contact (within about 6 feet) via the respiratory secretions (droplets) in coughs or sneezes or by touching virus-contaminated surfaces or objects. Due to the rapid spread of this highly transmissible virus, the disease rapidly spread all over the world affecting more than 176 million peoples and more than 3.8 million deaths. As of 15 June 2021 more than 2.3 billion vaccines have been administered [4] . COVID-19 is characterized by flu-like symptoms and may also pose fatal respiratory problems. Old age and the pre-existence of chronic illnesses have been identified as potential risk factors for severe disease and mortality [5] . The virus incubation period is 2-14 days with the majority of patients (80%) having mild symptoms that do not require medical intervention [6] . Unitl now there is no specific antiviral curative treatment that vaccine. COVAXIN (India) is also being administered but is not under EUL [7] .

The HCWs are at the frontline of COVID-19 pandemic defense and are exposed not only to infection with COVID-19 due to their frequent exposure to infected individuals, but they also suffer psychological distress, long working hours, fatigue, occupational stigma and many times may encounter physical violence [8, 9] . Knowledge of any infectious agent, its mode and route of transmission plays crucial role in planning and executing infection control. The inadequate knowledge and incorrect attitudes among HCWs can directly influence their practices and lead to delayed diagnosis, poor infection control practices, and spread of the disease [10, 11] .

Understanding HCWs' knowledge, attitudes, and possible perception of risk of infection help to predict and correlate the outcomes of COVID-19. The purpose of the study was to evaluate the knowledge, attitude, and perception (KAP) of the risk of infection with COVID-19 among HCWs in eastern Uttar Pradesh India. 

A total of 260 participants gave consent to participate in this online web-based survey. This study was conducted to assess the status of health care workers' KAP related to COVID-19 during the COVID-19 pandemic. We conducted a cross-sectional study based on the health care population at our institution.

Considering the special situation, it was not possible to conduct a full community-based study with a representative sample. Thus the study focused only on HCWs and a sampling technique of convenience was adopted to obtain the desired information for the study.

Data collection: Data was collected using a structured questionnaire. The questionnaire was put together or drawn up in English and Hindi language. It was pre-tested among a cross-section of participants to ensure the clarity of questions and to eliminate any ambiguity.

The questionnaire included socio-demographic characteristics like age group, marital status, profession, and years of experience in healthcare services. The name and gender were excluded to maintain anonymity. The other variables were knowledge, attitudes and practices related to COVID-19 and its prevention and control. The questions mainly focused on HCWs' knowledge of hospital infection control practices. Some questions were designed to assess the knowledge of the mode and route of transmission of SARS-CoV-2. Questions related to misconceptions about food habit and COVID-19 were adopted from WHO's document [12], questions related to child isolation from mother were included based on general query of population and few questions were formulated to assess the stigma towards COVID-19 patients.

At the beginning of the year 2020, there were misconceptions of the existence of SARS-CoV-2, therefore one question of knowledge was included to know whether the HCWs believe this real threat. The attitude questionnaire was designed to assess behavior towards COVID-19 positive patient, hand washing and social distancing in preventing the disease. The practice parameters covered the quotient of worry if one happens to contact the covid-19 positive patient, frequency of handwashing, use of disinfectants and maintaining social distancing. The knowledge was assessed by 12 factual statements, practice by 10 and 5 questions were related to practice.

Based on 80-100% correct answer for each question, it was considered as appropriate knowledge, and below 80.0% was considered as inappropriate knowledge. Similarly, attitudes and practices were also categorized. 

The categorical variables were described as numbers (%) and 95% confidence intervals (CIs).

The continuous variables were presented using means. All statistical analyses were performed using SPSS.26 version; P<0.05 (two-tailed) was considered statistically significant.

A total of 260 participants were interviewed in this cross-sectional study. Of the study population, 46.9% belonged to the young age (17-25 years) group, followed by the 25-35 age group (26.5%), 35-45 age group (17.3%) and participants of age more than 45 years were 9.2%. Among all participants, 56.5% were married. The majority of participants were medical students (40%) followed by medical faculty (21.2%), technicians (16.5%), nursing staff (10.4%), residents (7.7%) and others (4.2%). (Table 1) 

In the analysis of the different variables, age group 35-45 have the highest knowledge mean score was 10.38, by profession nursing staff have highest knowledge mean score was 11.19 followed by faculty which was 10.42 and by the year of experience in the healthcare profession, HCWs with 5-10 years of experience have the highest knowledge mean score of 10.70. (Table 1) Most knowledge questions had a high accuracy rate (>85%). For example, 250 (96%) respondents agreed that coughing, sneezing, or spitting by COVID-19 patient spread SARS-CoV-2 infection, and most respondents agreed that using alcohol-based hand sanitizers are effective against SARS-CoV-2 (220; 84%) and using face mask (257; 99%) can prevent COVID-19 infection. However, among all 260 respondents, only 10 (4%) disagreed that coughing, sneezing, or spitting by COVID-19 patient spread SARS-CoV-2 infection, only 9 (4%) disagreed that a person who looks healthy can have a SARS-CoV-2 infection and only 37 (14%) disagreed that asymptomatic COVID-19 patients spread SARS-CoV-2. (Table 2) 

In the different variables, age group 45-60 have more positive attitude mean score was 7.75, by profession nursing staff have more positive attitude mean score of 8.70 followed by faculty which was 8.25 and by the year of experience in the healthcare profession, 10-20 years of experience have a more positive attitude, and the mean score was 8.35. (Table 1) J o u r n a l P r e -p r o o f Among all 260 respondents, 232 (89%) agreed that if a healthcare worker is infected with SARS-CoV-2, he/she should not visit patients, and 247 (95%) agreed that if you were previously infected and cured of SARS-CoV-2, they still need to wear the mask, however, only 13 (5%) disagreed that if one was previously infected and cured with SARS-CoV-2, still need to wear the mask. (Table 2) 

The different variables analysis age group 25-35 have a practice mean score of 4.19, however, professional residents have a more appropriate practice mean score of 4.55 and by the year of experience in the healthcare profession, >20 years of experience have a better practice mean score which was 4.40. ( 

A multivariate linear regression analysis was carried out to determine association between sociodemographic characteristics and mean knowledge, attitude and practice scores, after controlling for other variables. In comparison to faculty, the youngest respondents mainly students (17-25 years) had least knowledge score (mean=1.034, 95% CI= 0.47 to 1.60, p <0.001), attitude (mean=1.360, 95% CI= 0.862 to 1.86, p <0.001), practice (mean=0.386, 95% CI= 0.03 to 0.74, p 0.034). In addition, nurses had significantly higher practice score compared to technicians (mean=0.568, 95% CI= 0.07 to 1.07, p 0.027). While respondents with faculty levels had statistically significant knowledge of COVID-19 practices related to COVID-19 residents respondents score was noted higher in comparison to others included in this study. (Table 3) Positive linear correlations were noted between knowledge and attitude (r = 0.508), attitude and practice (r = 0.389), and knowledge and practice (r = 0.393), with all three correlations being statistically significant. (Table 4) 

It is basically a web-based survey involving 260 F-HCWs working at different hospitals or clinical settings. F-HCWs reported adequate knowledge with a positive attitude and most of them adopted the appropriate practices. Individuals associated with adequate knowledge were doctors, nurses and a few paramedical staff. This study involving over 260 respondents was conducted to assess healthcare workers' (HCWs) KAP related to COVID-19 during the pandemic and found that levels of knowledge (mean: 9.77out of 12 points), attitudes (mean: 7.38 out of 10 points), and practices (mean: 4.05out of 5 points) of COVID-19 were relatively high. However, gaps in knowledge, misconceptions and discriminatory attitudes regarding COVID-19 patients were common, for example, 25 (10%) respondents disagreed that asymptomatic COVID-19 patients spread SARS-CoV-2 and only 50 (19%) respondents disagreed that sharing food items with COVID-19 patients spread SARS-CoV-2 transmission. Misconceptions were mostly prevalent inward attendants, workers and security personnel. Moreover, faculty level respondents had higher levels of knowledge and attitude related to COVID-19 (both p-value for trend <0.05) but practice score was higher of resident doctors (mean score: 4.55).

In contrast to previous studies of KAP related to other infectious diseases (Ebola, H7N9, etc.) [13] [14] [15] , our study showed that COVID-19 awareness was high among health care workers. Alzoubi H et al. mentioned that the commonest source of knowledge of their participants was social media [16] . Although most people try to obtain correct information about COVID-19 through various media, most workers lack professional knowledge and still believe some rumors.

It is essential to wear PPE throughout taking care of the patients, especially when performing aerosol-generating procedures such as; intubation, cardio-pulmonary resuscitation, and nebulization. At the initial stage of the disease outbreak, F-HCWs were infected as most of them were not properly using facemask, gown, and gloves. A negligible amount of N95 respirators were available for the F-HCWs. Upon the arrival of the adequate PPE kits, training of donning and doffing, strict implementations of guidelines the infection to the F-HCWs went down to almost zero. Infection transmission to the F-HCWs at the initial stage was attributable to carelessness, inadequate knowledge, insufficient PPEs, and even improper practices. So, the WHO has also given a particular focus on the correct use of PPEs, including masks, goggles, gloves, and gowns. Additionally, those F-HCWs who used PPEs had comparatively fewer infection rates.

As the health sector comes in the first place as regards the risk that entails its employees, reducing this risk is the first step in providing quality healthcare. The HCWs risk perception could strongly affect not only their mental health but also their exposition to this risk [17, 18] . It is worth mentioning that, despite their high knowledge score, the vast majority of our respondents were afraid and felt more susceptible to acquire COVID-19 infection even after wearing PPE (16%). This comes in line with Zhou et al. and Maleki et al. [19, 20] who found that 85% and 92% of HCWs, respectively, were afraid of getting infected with the disease and transmitting it to the family. Determining the risk perceived by the HCWs is considered the basic tool to change the attitude and make the workplace more healthy and safe [17, 18] .

In this study, lack of the PPE was the most commonly mentioned cause for feeling more Clinicians can monitor their staff and their attitude towards patients so that nosocomial infections can be prevented. All these measures will be helpful in strengthening the healthcare system and its delivery.

In this study the number of participants is limited. As the participation in the study was voluntary, much of HCW's knowledge could not be recorded. This study included participants of our institution and associated hospital, but it could provide a better analysis of the KAP of HCWs if more government and private hospitals and medical institutions across the country were included. Participants of our study belonged to government organization only which works as a non-profiting service provider but the HCWs working in the private sector may have different view and attitude. Furthermore, like other survey-based studies, results in our study may not be unaffected by response bias.

It can be concluded that F-HCWs reported adequate overall knowledge with a positive attitude and adopted the appropriate practice. The F-HCWs with a higher level of education and more years of experience in health care facilities had better KAP towards COVID-19. Many HCWs specially technicians and students were found lacking appropriate knowledge towards COVID- 

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