key: cord-0857566-svqoca4a
authors: Saqlain, Muhmmad; Munir, Muhammad Muddasir; Rehman, Saif ur; Gulzar, Aqsa; Naz, Sahar; Ahmed, Zaheer; Tahir, Azhar Hussain; Mashhood, Muhammad
title: Knowledge, attitude, practice and perceived barriers among healthcare professionals regarding COVID-19: A Cross-sectional survey from Pakistan
date: 2020-05-11
journal: J Hosp Infect
DOI: 10.1016/j.jhin.2020.05.007
sha: 3ee75f10454ec7c7d97555b0b543cb6b83492ab9
doc_id: 857566
cord_uid: svqoca4a

A self-administered validated (Cronbach alpha= 0.077) questionnaire was used to assess knowledge, attitude and practice among HCPs in Pakistan regarding COVID-19. Findings showed HCPs had good knowledge (93.2%, n=386), positive attitude (8.43±1.78) and good practice (88.7%, n=367) regarding COVID-19. HCPs perceived that limited infection control material (50.7%, n=210) and poor knowledge regarding transmission (40.6%, n=168) are the major barriers in infection control practice. Regression analysis indicated pharmacist role (OR: 2.247, 95% CI: 1.11-4.55, P=0.025) was the substantial determinant of good practice. HCPs in Pakistan have good knowledge, yet, there were areas where gaps in knowledge and practice were observed.

Healthcare professionals (HCPs) of all levels and groups are involved in caring for patients with 3 this highly transmittable pathogen. COVID-19 has posed serious occupational health risk to the 4 HCP owing to their frequent exposure to infected individuals [5] . Literature suggest that lack of 5 knowledge and misunderstandings among HCPs leads to delayed diagnosis, spread of disease 6 and poor infection control practice. Several thousand healthcare workers have already been 7 infected, mainly in China [5] . Preventing intrahospital transmission of the communicable disease 8 is therefore a priority.

Amidst to current pandemic, the WHO has issued several guidelines, started online courses and 10 training sessions to raise awareness and preparedness regarding prevention and control of 11 COVID-19 among HCPs [6] . Knowledge, attitude, and practice survey provides a suitable 12 format to evaluate existing programs and to identify effective strategies for behavior change in 13 society. Currently, there is scarce information regarding the awareness level of HCPs in Pakistan, 14 Therefore, the present study aimed to identify the current status of knowledge, attitude and 15 practices regarding COVID-19 among healthcare professionals in Pakistan. In addition, study 16 highlighted the information sources utilized and barriers in infection control perceived by HCPs.

A multi-centric cross-sectional survey-based study was conducted during the month of March 20 2020, during the days of strict lockdown to implement social distancing to avoid spread of 21 pandemic. As it was not feasible to conduct a population-based survey in this critical condition, the investigators selected an online data collection method. Sample size calculated by Raosoft 1 was 377 assuming a response rate of 50%, confidence interval (CI) 95%, Z as 1.96, and margin 2 of error as 5%. Considering, an additional 10% (n=37) for any error in questionnaire filling, a 3 final sample size of 414 will be required. Survey was started on 25, March 2020, and response 4 acceptance was closed (05-April 2020) when required sample size was achieved.

The study population eligible for participation in this survey was HCPs including doctors, 6 pharmacists, and nurses from all healthcare facilities in Punjab. A questionnaire was designed on 7 google forms and link generated was shared on WhatsApp groups of HCPs. Link was also shared 8 personally to HCPs who were in contact list of investigators. Respondents from other provinces 9 were also eligible to participate if they are willing to fill the questionnaire. Each question was respondent on 5-point Likert scale as follows strongly agree, agree, 12 undecided, disagree, and strongly disagree. Responses were presented as frequencies and 13 percentages. 

The study was performed in accordance to declaration of Helsinki. Due to lockdown, universities 16 were closed, hence study protocol was approved from Hospital board (756/THQ/HR). Study 17 questionnaire contained consent portion that stated purpose, nature of survey, study objectives, 18 volunteer participation, declaration of confidentiality and anonymity. 

Descriptive and inferential statistics were applied by using SPSS V.21. Chi-square tests,

Independent sample t-test and one-way ANOVA analysis were applied to find difference in knowledge, attitude and practice of HCPs by demographic characteristics. Pearson-rank 1 correlation tests were applied to find any correlation between knowledge, attitude and practice 2 sections. To find possible determinants of good knowledge and practice, a binary logistic 3 regression analysis will be applied and expressed as odds ratio (OR) and 95% confidence interval 4 (CI). A p value of less than 0.05 will be considered as significant in all tests. (Table I) . 8 For HCPs, good knowledge, positive attitude, and good practices of following precautionary 9 measures such as wearing gloves, protective clothing, goggles and face mask is imperative in 10 effective dealing with infected patients with minimum risks. Also, ongoing pandemic nature of 11 disease made it necessary for HCPs to multiply their alarms corresponding to critical situation 12 and to put efforts in following and implementing related hygienic conditions as well as Interestingly, when questions asked regarding at-risk groups, testing, and influenza vaccine 12 protection against COVID-19, 21.01%, 23.91% and 23.19% respondents respectively were 13 unable to identify correct responses (Fig. 2, Supplementary file 1 The study has number of implicit limitations. Firstly, it is a cross-sectional study conducted 8 during lockdown period, and universities were also closed, therefore institutional review board 9 was not approached. Secondly, this is an online survey, responses mainly depend upon honesty 10 and partly affected by recall ability and thus may subject to recall bias. Potential sample 11 clustering might also limit the generalizability of study.

The study highlights gaps in specific aspects of knowledge, and practice that should be focused Authors' contributions 1 The manuscript idea, concept, writing, and layout was done by MS, MM and AG. MMM and SN 2 provided critical help in writing, statistical and layout designing. SUR and ZA provided critical 3 input regarding data analysis at every step of the manuscript writing process. MS, SUR and ZA 4 proof read the manuscript and provided input in formulating the draft. The authors declare that they have not received any direct or indirect funding from any 7 organization.

The authors have no relevant affiliations or financial involvement with any organization or entity 10 with a financial interest in or financial conflict with the subject matter or materials discussed in 11 the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, * Knowledge section total score ranges from 0-14 and a cut off level of ≤10 was set for poor knowledge and ≥11 for good knowledge. *** Practice items total score ranged as 0-6, and a score of 1-4 indicates poor practice regarding COVID-19. Note: A p value of less than 0.05 considered significant. Bold values shoeing significant differences.

Clinical features of patients infected

Knowledge section total score ranges from 0-14 and a cut off level of ≤10 was set for poor knowledge and ≥11 for good knowledge. ** Attitude section total score ranges from 7 to 35, with an overall lower mean score indicates positive attitude toward COVID-19. *** Practice items total score ranged as 0-6, and a score of 1-4 indicates poor practice regarding COVID-19

The authors would like to extend heartfelt graciousness to all the 21 participants and teachers who provided support at every step of the research.