key: cord-0814596-z35kk78q
authors: Polychronis, Giannis; Roupa, Zoe
title: Health Workers' knowledge and perception regarding the risk of spread of COVID‐19 during the pandemic: A systematic review
date: 2020-11-25
journal: J Public Aff
DOI: 10.1002/pa.2558
sha: 8bf1797912f9b059b0ab4980a8c9a5c520ea98ed
doc_id: 814596
cord_uid: z35kk78q

Certain Health Workers (HWs) may have inadequate knowledge and perceptions regarding COVID‐19. As a result, they may not be completely aware of the danger/risk involved, which could impact their ability to control the spread of the virus. This systematic review aims to enhance HWs' knowledge and their perception of the spread risk of COVID‐19 during the pandemic. A search was conducted in four databases (Medline, CINAHL, Scopus, and ScienceDirect) to locate peer‐reviewed studies published in English between January 2020 and April 2020. Eventually, nine articles satisfied the inclusion criteria and were, therefore, included in the present study. Six of the aforementioned studies specifically investigated HWs' perception of risk. Apart from a study that indicated medium perception (min = 56.5%), all other studies found high levels of risk perception (n = 5, max 92.1%). As for HWs' knowledge, apart from two studies that indicated medium percentage levels (min = 56.5%), the rest of the studies report high percentages (n = 7, max = 93.2%). Two of the studies, which assessed the sources of information that HWs use, agree that social media is the most widely used source of information. The findings of this study suggest that HWs had a satisfactory perception of risk during the spread of COVID‐19. Although fields with medium knowledge levels were identified, HWs' overall knowledge may also be described as satisfactory. It is also noted that certain demographic characteristics (occupation, age, and years of experience) appear to affect HWs' knowledge and perceptions. The application of educational strategies aiming to provide continuous support to HWs is unanimously recommended by all studies.

The coronavirus disease, COVID-19, and internationally the sars-COV2 virus, constitutes an issue of international concern regarding public health since it is a potentially fatal disease. In late December 2019, a cluster of patients was admitted to hospitals with an initial diagnosis of pneumonia of unknown cause. Based on an epidemiological link, uniform exposure of these patients was detected at an animal market in the city of Wuhan, China. Due to this fact, it is speculated that the origins of the virus are likely to be zoonotic (Rothan & Byrareddy, 2020) . For the current pandemic to be controlled, extended prevention measures have been taken, with particular emphasis on a susceptible and vulnerable population, including health care providers and the elderly. For example, patients are isolated to limit the transmission of the virus from one person to another (McBride et al., 2020; Rothan & Byrareddy, 2020) .

According to WHO (2020) , the COVID-19 disease outbreak has become a pandemic, which has, so far (September 2020), infected more than 30 million people and has caused more than 900,000 deaths worldwide. The abovementioned statistics include many HWs, a fact which adds another important concern to the chain of infection, which must be dealt with immediately (Zhou et al., 2020) . Likely, certain HWs are not sufficiently aware of prevention policies, and their erroneous practices and attitudes directly increase the risk of the spread of the virus (McEachan et al., 2016) . Based on the recent literature, it appears that many researchers are trying to expand HWs' knowledge and perceptions regarding the COVID-19 (Giao et al., 2020; Shi et al., 2020; Zhou et al., 2020; Bhagavathula et al., 2020; Nemati, Ebrahimi, & Nemati, 2020) . According to WHO (2006) , the term Health Workers is used to refer to any person engaged in actions whose primary intent is to enhance health.

Given that HWs' knowledge is of high importance for the prevention of the spread of the disease, and taking into consideration the significance of prevention measures during professional exposure, strategic models for the improvement and enrichment of the existing data must be developed. It has been observed that there are several deficiencies in the systematic and documented information of the existing international literature concerning the knowledge and perception of HWs during the spread of COVID-19. This study constitutes, as far as we are aware, the first systematic review of this particular field.

Research of the existing literature was conducted to locate studies that examined the knowledge and perceptions of HWs during the spread of COVID-19. The specific research questions that were examined are: (a) What is the HWs' knowledge level during the spread of COVID-19? (b) What is the HWs' level of perception of the risk related to the COVID-19 pandemic?

A protocol was created before the study was conducted and, also, the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) (Moher, Liberati, Tetzlaff, & Altman, 2009 ) guidelines have been followed. Due to the essential heterogeneity of the population and the data collection methods of targeted research studies, the results collected were not combined for meta-analyses.

The criteria for the inclusion of the studies were the following:

(a) Primary studies that followed any methodological design;

(b) studies presenting knowledge and perceptions during the spread of COVID-19, (c) HWs are used as a sample (as they are defined by WHO).

The criteria for the exclusion of studies were: (a) Secondary studies (editorials, commentaries, and reviews); (b) or studies that focused on psychological fields (anxiety, depression, etc.); (c) or a sample that does not fall into the category of HWs (the public, patients, students and people not employed in the health sector).

The research was conducted using four electronic databases (Medline, CINAHL, Scopus, and ScienceDirect) with a language limitation (studies published in English), a time limitation (January 2020 until April 2020), and using only peer-reviewed periodicals. Further research was done using other sources (Google Scholar, bibliography/reference lists of other studies) so that no articles would be excluded that could be included because they were relevant and reliable.

The subject terms used, and the way (Boolean operators, limitations) the search was conducted, resulted in only locating articles referring to the relevant population, intervention, and results related to this study. An example of the strategic search on CINAHL through EBSCO can be seen in Table 1 . The search was repeated on May 15, 2020.

The results of the search were stored with the use of reference management software.

The PRISMA flow diagram ( Figure 1 ) provides information regarding the process of selecting studies. Through the aforementioned search strategy, the articles (n = 5,102) were checked for duplication using reference management software. Subsequently, two independent researchers (G.P. and Z.R.) examined the articles in three stages. During the first stage, only the headings of the articles were checked (n = 4,552). The summaries of the articles were checked in the second stage (n = 374). If there was any disagreement or if the information included in the heading or the summary was not clear, then it was deemed necessary to further evaluate the article (third stage). Finally, during the third stage, the same researchers evaluated the full text of the articles remaining (n = 17) regarding population and outcomes, which were related to this systematic review's scope of interest. In case of disagreement regarding eligibility, the disagreement was resolved through discussion.

Two independent authors (G.P. and Z.R.) exported the data, on a pilot basis, to a predesigned document, under the following categories: 

The synthesis of the findings appears in text and tables. The narrative approach was employed as far as the results are concerned, because the studies, apart from their design, were heterogeneous in terms of the population as well as their data collection methods, since an improvised scale was used in all of them (the questionnaire was designated by the authors).

The search has yielded nine articles to be analyzed ( Figure 1 ). The studies appear to have been conducted mainly in the Asian continent.

Specifically, apart from a study Bhagavathula et al. (2020) , which collected information on a global scale, the participants of the remaining studies were located in Vietnam (Giao et al., 2020) , China (Shi et al., 2020; Zhou et al., 2020) , Iran (Maleki et al., 2020; Nemati et al., 2020; Taghrir et al., 2020) , India (Modi et al., 2020) and Pakistan (Saqlain et al., 2020) .

All the studies made use of the cross-sectional approach to formulate their research hypothesis, although no such limitation had been imposed on the methodological design during the selection process. This is due to the purpose of the studies since they attempted to provide a quick "snapshot" of the knowledge and perceptions of HWs during the emergency situation of the COVID-19 pandemic.

Seven of the studies focused on more than two specialties of the healthcare sector. One of the studies (Nemati et al., 2020) focused solely on nurses and contained the smallest sample (n = 85) compared to the others. The study by Taghrir et al. (2020) was only about fifth to seventh-year medical students (n = 240), who, while practicing medicine, came into direct contact with suspected COVID-19 cases of infected individuals. Apart from the study by Bhagavathula et al. (2020) , which clearly seems to adequately include all age groups, all the other studies included mainly ages >40. With the exception of two studies (Bhagavathula et al., 2020; Modi et al., 2020) , the rest focused on the participants' years of experience as well. The percentages of the genders were almost equal in four of the studies (Shi et al., 2020; Zhou et al., 2020; Bhagavathula et al., 2020; Saqlain et al., 2020) . The time devoted to gathering data ranged between T A B L E 1 Search strategy example Search Ebsco search strategy Results Query

SU attitudes OR SU knowledge OR SU practice 6,672 #2 TI ("attitude*" OR "perce*" OR "opinion*" OR "thought*" OR "feeling*" OR "experienc*" OR "view*" OR "reflection*" OR "belief*" OR "perspective*" OR "awareness" OR "anxiety*" OR "knowledge*" OR "practic*" OR "education*" OR "understand*" OR "awareness" OR "consideret*" OR "mentality" OR "mindset*" OR "behavio*" OR "placement*" OR "position*" OR "concept*" OR "gasp" OR "insight*") OR AB ("attitude*" OR "perce*" OR "opinion*" OR "thought*" OR "feeling*" OR "experienc*" OR "view*" OR "reflection*" OR "belief*" OR "perspective*" OR "awareness" OR "anxiety*" OR "knowledge*" OR "practic*" OR "education*" OR "understand*" OR "awareness" OR "consideret*" OR "mentality" OR "mindset*" OR "behavio*" OR "placement*" OR "position*" OR "concept*" OR "gasp" OR "insight*") TI ("coronavirus" OR "corona-virus" OR "corona virus" OR "covid19" OR "covid-19" OR "2019-ncov" OR "2019ncov" OR "2019-ncov" OR "2019ncov" OR "sars-cov-2" OR "sarscov2" OR "sarscov-2" OR "sars-cov2" OR "SARS-CoV" OR "pandemi*" OR "epidemi*" OR "outbreak*" OR "diseas*" OR "glycoprotein" OR "glycosylation") OR AB ("coronavirus" OR "corona-virus" OR "corona virus" OR "covid19" OR "covid-19" OR "2019-ncov" OR "2019ncov" OR "2019-ncov" OR "2019ncov" OR "sars-cov-2" OR "sarscov2" OR "sarscov-2" OR "sars-cov2" OR "SARS-CoV" OR "pandemi*" OR "epidemi*" OR "outbreak*" OR "diseas*" OR "glycoprotein" OR "glycosylation") #8 TI ("physician*" OR "doctor*" OR "clinician*" OR "nurs*" OR "paramedic*" OR "medical worker*" OR "healthcare provider*" OR "healthcare professional*") OR AB ("physician*" OR "doctor*" OR "clinician*" OR "nurs*" OR "paramedic*" OR "medical worker*" OR "healthcare provider*" OR "healthcare professional*") January 2020 and April 2020, which according to WHO (2020) was a period during which there was an outbreak of the virus.

The researchers of these studies prefer to gather their data online since only two used printed means to collect data (Giao et al., 2020; Maleki et al., 2020) and, as is evident from the studies, this is due to the reduction of exposure to the virus. Finally, two of the studies (Giao et al., 2020; Maleki et al., 2020) used random sampling, another study (Zhou et al., 2020) Nu (100) SAQ/according to WHO information's The average score with respect to the participants concern about disease caused by COVID-19 was 6.02 ± 2.6 (1-10) while worry regarding the possibility that a member of their family might become sick was 6.87 ± 2.8 (1-10). More than half of the participants (56.5%) had a good level of knowledge with respect to transmission, symptoms, indications, prognosis, treatment and mortality rate of COVID-19. 

SAQ/based on previous study A medium perception of risk was found. The average percentage of correct answers with regard to knowledge was 86.96%. The average percentage of preventative behaviours was 94.47%. A high level of the relevant knowledge as well as preventative behaviours was found, but a medium perception of risk. Despite a self-reported high level of preventive behaviours, a medium perception of risk among medical students may cause concern with respect to their protection behaviour. As a vulnerable group, they need to take the matter more seriously. The negative correlation between preventative behaviours and perception of risk was the most interesting finding in this study. be applied when managing individuals presenting serious symptoms.

CDC (2020) adds to the previous comment that asymptomatic carriers also play an important role in the spread of COVID-19.

Another study (Modi et al., 2020) , which also concluded that the participants' overall knowledge is high (71.2%), specifies that the highest percentage of correct answers belonged to undergraduate medical students, while the lowest ones were from non-clinical administrative personnel. The same study also reports that fewer than half of the respondents were able to correctly define the concept "close contact" as well as the correct sequence of actions required to put on a mask.

The results of several studies (Maleki et al., 2020; Modi et al., 2020; Shi et al., 2020; Zhou et al., 2020) indicated that specific demographic characteristics may affect both the knowledge as well as the attitudes of HWs. In the study by Bhagavathula et al. (2020) , there appears to be a correlation between certain demographic characteristics (age and occupation) and both inadequate knowledge and negative attitude towards the virus. The study by Zhou et al. (2020) agrees with the previous comment since it has concluded that similar variables (work experience and occupation) affect HWs', while it adds that

HWs' knowledge level also influences their attitudes and practice. It is worth noting that, according to the same study, the Medical Staff felt more tired during the pandemic, compared to paramedical staff (H = 0.438, 95% CI: 0.256, 0.748), since even HWs with 5-9 years of experience were found to be less likely to feel tired (0.639, 95% CI: 0.429, 0.950), thus proving that this group was particularly able and experienced in dealing with Public Health emergencies. The study by Giao et al. (2020) summarises the findings of the previous authors since it indicated the negative correlation between the knowledge scores and the perception scores (r = −0.21, p < .001).

Finally, three of the studies (Bhagavathula et al., 2020; Saqlain et al., 2020; Nemati et al., 2020) assessed the sources of information the HWs used regarding COVID-19. Two of them (Bhagavathula et al., 2020; Saqlain et al., 2020) agreed that social media was the most frequently used source of information, while the study by Nemati et al. (2020) has found them to be second in HWS' preferences since, in the above mentioned study, official websites appeared to rank higher (WHO,CDC, etc.).

Six out of the nine studies investigated a specific field of HWs' perception related to their opinion about the risk of the virus. Apart from a study by Taghrir et al. (2020) , which stated that the participants had a moderate perception of risk (2.04 ± 0.97, 1-4), all the other studies that investigated this issue (Giao et al., 2020; Shi et al., 2020; Zhou et al., 2020; Bhagavathula et al., 2020; Maleki et al., 2020) found high percentages of risk perception. For example, the study by Giao et al. (2020) indicated that 82.3% of HWs held the belief that they would probably become sick with the virus, while the study by Maleki et al. (2020) reached the conclusion that 92.1% of the participants expressed the fear that the virus would be transmitted to their family. In the study by Bhagavathula et al. (2020) , the researchers investigated the knowledge and perceptions of HWs using an international online questionnaire and concluded that they were optimistic regarding the defeat of the virus.

The purpose of this systematic review was to investigate HWs' knowledge and their perception of the risk of COVID-19 spread during the pandemic. The period of time devoted to collecting data related to the studies examined lasted from January 2020 to April 2020, which, according to WHO (2020) Studies show that HWs' level of knowledge appears to range from high (n = 7, max = 93.2%) to moderate quantitative levels (n = 2, min = 56.5%). HWs appear to excel in specific fields of knowledge, such as the ways that the virus is transmitted, while there seems to be room for improvement regarding preventative behaviors.

HWs' attitudes towards the risk of the virus appear to be quite satisfactory since all the studies, except one (min = 56.5%), which focused on this issue agree on high perception (n = 5, max 92.1%).

Aoyagi, Beck, Dingwall, and Nguyen- Van-Tam (2015) add that the perception of danger has been proven to directly affect HWs' willingness to work during a pandemic.

Demographic characteristics, such as occupation, age, and HWs' years of experience, appear to directly affect their knowledge and perceptions in most studies (n = 5). Therefore, more emphasis must be placed on the abovementioned demographics during educational interventions. Moreover, all the studies, without any exception, recommend the use of additional educational interventions for HWs.

Finally, it was recognized by certain studies (n = 3) that the most widely used source of information was social media followed by official health websites. According to a systematic review by Aoyagi et al. (2015) , information must be readily available and frequently reviewed so that the organizational readiness of the information sources may contribute to the development of trust of HWs regarding their exposure to danger.

The purpose of each study is clearly stated but methodological quality generally ranged from average to poor (Table 3) . Crosssectional studies are weak in the following areas: (a) Selection bias, (b) information bias, and (c) confounding bias (Pandis, 2014) .

The increased need for international literature to obtain findings immediately (WHO, 2020), and given that their knowledge is of high significance regarding the prevention and control of the spread of the (Etikan, 2016) . Selection bias also increases in most of the studies with the exception of the one conducted by Giao et al. (2020) and Maleki et al. (2020) since data collection was realized via the Internet (Greenacre, 2016) .

Since that data collection was realised with the use of self-report questionnaires in all the studies, the likelihood of information bias is probably increased (Pandis, 2014) . Two studies (Maleki et al., 2020; Nemati et al., 2020) do not present the necessary documentation for the desired number of representative sample and, besides that, the size of the sample they eventually examined may be considered small.

The quality of these two studies has been rated as poor since very small samples undermine the internal and external validity of a study and prevent the generalisation of their results (Faber & Fonseca, 2014) . 

Although the results of this systematic review may contribute to the enrichment of the existing literature, they still need to be recognized, and the study's limitations should be taken into consideration in order for it to contribute to the progress of future research.

First of all, due to the fact that all the studies included were cross-sectional, the cause of the findings cannot be examined; only a systematic snapshot of HWs' knowledge and perception in an emergency spread of COVID-19 pandemic may be provided. In addition, the low number of studies that fulfilled the inclusion criteria of this study prevents further examination of relevant parameters of this issue.

Most of the studies used convenience sampling to collect data, which increases selection bias. Selection bias is also increased in most studies since data collection was realized via the Internet. Due to the fact that data collection was realized with the use of self-report questionnaires in all the studies, the likelihood of Information bias is probably increased. All the bias errors that have been recognized constitute important factors that should make one cautious regarding the generalization of the results.

The findings of this study indicate that HWs had a satisfactory perception of risk during the COVID-19 spread. Even though fields with medium knowledge levels were recognized, HWs' overall knowledge may also be characterized as satisfactory. It is also noted that specific demographic characteristics (occupation, age, and years of experience) seem to affect HWs' knowledge and perceptions.

The studies' population was mainly located in the Asian continent, a fact which leaves a research gap regarding the rest of the population.

To summarise, this study highlights the need for adequate knowledge of HWs in the case of an emergency pandemic like COVID-19.

The implementation of educational strategies, which aim to continually support HWs in terms of information and knowledge, available so far, about the virus, as well as protection measures and measures for the prevention of the spread of the virus on an individual as well as a collective level, is unanimously recommended by the studies because the people's-patients' life is our first concern in this area. Also, to help the sick, the people whose duty is to take care of them must be healthy.

All authors contributed to the design and implementation of the research, to the analysis of the results and to the writing of the manuscript.

Giannis Polychronis https://orcid.org/0000-0002-1437-4754

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How to cite this article: Polychronis G, Roupa Z. Health Workers' knowledge and perception regarding the risk of spread of COVID-19 during the pandemic: A systematic review