key: cord-1003417-w9i9vzlg
authors: Ansari, D. Z.; Chaurasiya, D. B. D.; Adhikari, D. S.; Prakash, D. U. C.; Adhikari, B.; Khatoon, D. S.
title: Knowledge, attitude and practice among Ophthalmic Health Care Personnel (HCP) towards COVID-19 pandemic in Nepal: A web-based cross-sectional study
date: 2020-08-14
journal: nan
DOI: 10.1101/2020.08.13.20174052
sha: 67b7b3ce7f2361a715591ed2401bb913a96110f0
doc_id: 1003417
cord_uid: w9i9vzlg

Background: Being an added high-risk group, ophthalmic HCP are actively providing emergency eye care services, also enthusiastically participating in prevention and control of the COVID-19 pandemic. Hence, this study aimed to assess the level of knowledge, attitude, and practice (KAP) among ophthalmic HCP towards COVID-19 pandemic. Methods: A web-based cross-sectional study was conducted during the period of lockdown among ophthalmic HCP including consultant ophthalmologist, resident, optometrist, ophthalmic assistant, nursing staff, and other paramedics of eye care centers in Nepal. The KAP questionnaire was designed and distributed online. Data were analyzed using the Chi-square test, Pearson correlation, and binary logistic regression. All tests were performed at 95% Confidence Interval (CI) and p-value <0.05 was considered statistically significant. Results: Of 694 participants, the majority were male (59.1%) from the age group 31-40 years (41.5%) and tertiary eye center (68.9%). Among ophthalmic HCP, there were 29.8% consultants ophthalmologist, 22.6% residents, 23.3% optometrist, 15% ophthalmic assistant, and 9.2% other ophthalmic paramedics, 11.7% working as front-liners in COVID-19 centers. Findings showed, 98.1% had good knowledge, 59.4% had a positive attitude and only 13.3% had good practice regarding COVID-19. Binary logistic regression analysis demonstrated the age of HCP to be a significant determinant of good knowledge (Crude Odds Ratio (COR)=0.72, 95%CI=0.62-0.82), positive attitude (COR=0.92, 95%CI=0.90-0.94) and good practice (COR=1.16, 95%CI=1.10-1.21). Lower odds of poor practice was seen among junior resident (COR=0.26, 95% CI=0.14-0.47) and higher odds of poor practice was seen among HCP with job experience of 5-10 years (COR=2.38, 95% CI=1.23-4.60) towards COVID-19 pandemic. Conclusion: The majority of ophthalmic HCP have good knowledge, insufficient positive attitude, and inadequate evidence-based practice towards the COVID-19 pandemic in Nepal. Hence, this study conclusively recommends to modify existing guidelines and formulate new policies to improve KAP among ophthalmic HCP to effectively control the spread of COVID-19.

border has also currently been tagged as "red zones" as more and more cases are being diagnosed every day [9] . It was evident from the beginning when the first COVID-19 case was diagnosed in Nepal that much of the suffering will be due to imported cases. Many also indicated that it will be impossible to escape from COVID-19 and a great preparation will be required if we were to limit the suffering [10] . Till mid-June 2020, Nepal has more than 6000 confirmed cases and 19 mortalities [8] .

Due to various restrictions and "lockdown", COVID-19 has affected all services including eye care facility. In Nepal, ophthalmic health care personnel are still actively providing emergency and not allowing much-needed services to falter. At the same time, they have also been enthusiastically participating in the prevention and control of the COVID-19.

In Nepal, especially medical colleges and teaching hospitals that are also providing emergent eye care services, have also been converted into special COVID-19 hospitals/centers. As a result, the ophthalmic health care personnel (HCP) have become directly or indirectly involved in the service to COVID-19 patients.

Owing to the pre-requisites and requirements in an ophthalmic examination, it is almost impossible to maintain a "physical distance" or "time restrictions" as recommended by the WHO or the CDC. The distance between the patient and the ophthalmic HCP is as close as 20 centimeter (cm) in most of the circumstances and the time required for a comprehensive ocular assessment also easily surpasses the guidelines. Contact with the patient is inevitable [11] .

Although the risk of transmission is low, acute viral conjunctivitis can be a feature of COVID-19 and tear film (ocular secretions) have the potential for viral transmission [12] .

Ophthalmic health care personnel are among high risk compared to other health workers. Due to the frequent exposure to suspected or infected patients, HCP are at serious occupational health risk of COVID-19 [13] . Thus, HCP must have updated knowledge on the source, transmission, symptoms, and preventive measures which will help to impose a positive attitude and good practice to assure safety and protection of not only themselves but also of their patients [14] .

Various studies have shown that lack of knowledge and misunderstandings among HCP leads to delayed diagnosis, acceleration of the spread, the establishment of a dangerous "chain of transmission" [15] . This will not only lead to infection in HCP but will make them a potential "super spreader". Such missed events have already been documented around the globe [13] .

A good knowledge, positive attitude, and evidence-based practice against COVID-19 are very important to fight against this pandemic. Hence, during the period of lockdown when social distancing was a must, this web-based study was designed to assess the level of knowledge, attitude, and practice among ophthalmic health personnel towards COVID-19.

We believe the results will enable us to assess the level of knowledge, attitude, and practice (KAP) among ophthalmic health personnel, which is very essential at the moment. With the help of the results of the study, we can ourselves know where we stand-on in this crisis based on KAP. This can help further design essential plans required for training and interventions, subsequently providing optimum eye care services at the time of pandemic without compromising the protection and safety of the ophthalmic health care personnel and patients.

A web-based cross-sectional study was conducted from May 20 th to June 9 th , 2020 during the period of lockdown in Nepal. There was an increasing number of COVID-19 positive cases, as it was not feasible to conduct a population-based study. So, following the norms of the social distancing web-based online data collection method was selected.

In the present study, ophthalmic health care personnel (HCP) i.e. ophthalmologist consultant, residents, optometrists, ophthalmic assistant and others (nursing staff, optician, orthoptics) who were directly involved or not involved in COVID-19 pandemic prevention and control, in different eye care health service centers of Nepal during this period of COVID-19 era were the study population.

The sample size was calculated using the Yamane formula. The total sample size was estimated to be 694 with a 5% margin of error at a 95% confidence interval. The study population unit was selected using a convenience method of sampling. The survey was started from 20 th May and response acceptance was closed on 9 th June 2020 after the required sample number achieved. A total of 694 participants were included in the final analysis of this study.

A semi-structured questionnaire was self-designed with the help of a literature review of various studies on COVID-19. The questionnaire was created using the Google-form platform and was distributed via online tools like Emails, Viber, WhatsApp, Facebook/Messenger, Twitter, and Instagram to all participants across the country. Instant online consent was taken from each participant before participating in the survey after a brief introduction to this survey. Pieces of information provided by participants were kept completely confidential and all the data collected in this research were anonymous. All participants' responses were recorded in Google-forms.

The questionnaire used in the present study consist of 31 items for assessing Knowledge (10 items), attitude (10 items), and practice (11 items) among ophthalmic health care personnel.

The KAP questionnaire was developed based on the study by Ahmed M. Asaad study towards the Middle East Respiratory Syndrome Coronavirus (MERs CoV) [16] , the question and answer about COVID-19 in the webpage of WHO [17] , COVID-19 ophthalmology practice guidelines by American Academy of Ophthalmology (AAO) and Nepal Ophthalmic society(NOS) [18, 19] .

Questionnaire pretesting was done by the principal investigator in the presence of a public health expert and an eye specialist, among 10 ophthalmic health care personnel from B.P.

Koirala Institute of Health Sciences (BPKIHS), (same sorts of sample that is included in this study) using personal interview method through ZOOM, video-conferencing application. As per results and recommendation questionnaires were further modified to increase its intelligence and validity. Pre-tested data were not included in the final analysis of this study. Section two consisted of 10 items of questionnaires assessing knowledge of ophthalmic HCP towards COVID-19 pandemic with multiple choices answering options i.e. "Yes", "No" and "I don't know". The correct response ("Yes") was assigned 1 point while incorrect response ("No" and "I don't know") were assigned zero points. Total maximum scores assigned were 10 with cut off level of greater than or equal to 7 for good knowledge, and less than 7 for poor knowledge.

Section three consisted of 10 items of questionnaires to assess the attitude of ophthalmic HCP towards COVID-19 pandemic with multiple-choice options to answer. Responses were recorded on 5 points likert scale as follows-strongly disagree (1 point), disagree (2 points), undecided/neutral (3 points), agree (4 points), and strongly agree (5 points). Total score ranged from 10 to 50 with an overall higher mean score indicates a positive attitude toward COVID-19.

Section four consisted of 11 items of questionnaires to assess the practice of ophthalmic HCP towards COVID-19 pandemic with multiple-choice options to answer ("Yes", "Sometimes" and "No"). The correct response ("Yes") was assigned 1 point while incorrect response ("Sometimes" and "No") were assigned zero points. Total maximum scores were 11, cut off level of greater than equal to 7 for good practice, and less than 7 for poor practice.

Ethical approval was obtained from the Nepal Health Research Council (reference no. 2466).

The study questionnaire contained a consent portion that stated purpose, nature of the survey, study objectives, volunteer participation, declaration of confidentiality, and anonymity.

Responses recorded in Google-form were exported to and cleaned in Microsoft Excel 2019 and later imported to Statistical Package for Social Sciences (version-20.0) for statistical 1 0 analysis. The data were summarized in terms of frequency, percentage, mean and standard deviations (SD) and presented in the form of bar diagram and tables. The confidence interval around the proportion was determined using the Clopper-Pearson method. Chi-square tests were applied to determine the association of knowledge (good vs poor), attitude (positive vs negative), and practice (good vs poor) with socio-demographic characteristics. Pearson correlation was applied to determine the correlation between knowledge, attitude, and practice scores. To find possible determinants of good knowledge and practice, a binary logistic regression analysis was applied. Throughout the study, all tests were two-tailed and carried out at 95% CI and p-value less than 0.05 was considered statistically significant. Table 1 presents the socio-demographic characteristics of the participants. Binary logistic regression analysis (Table 3) 

Pearson correlation tests revealed a statistically significant moderate positive correlation between knowledge-attitude (r=0.609, p<0.001) and weak positive correlation between knowledge-practice (r=0.300, p<0.001), and attitude-practice (r=0.124, p=0.001). Attitude-practice 0.124** 0.001

To the best of our knowledge, this is the first study that has been conducted aimed to determine the level of knowledge, attitude, and practice among ophthalmic health care personnel in Nepal towards the COVID-19 pandemic. Even we assumed, this might be the first KAP study that has been done among ophthalmic health care personnel even across the world about COVID-19 pandemic.

In the present study, 98.1% have good knowledge towards COVID-19 pandemic in Nepal, our findings were consistent to the studies conducted by Hussain et al. [20] , Richa et al. [21] in Chitwan (Nepal), Saqlain et al. [22] in Pakistan, Zhou et al. [23] in China and Giao et al. [24] in Vietnam which reported good knowledge among 82.2%, 93.2%, 89%, and 88.4%

participants respectively towards COVID-19. In contrast to our findings, a study conducted among nurses reported that 56.5% of respondents had sufficient knowledge regarding the transmission, symptoms, and treatment of COVID-19 [14] . This awareness has got more significance in the current scenario when no vaccine has been available till now and various researches are ongoing. So all ophthalmic and non-ophthalmic HCP must be aware of all the updates and should take precautions regarding treatment and prevention of COVID-19

infection [23] .

In this study, 1.9% had poor knowledge regarding COVID-19, this mostly accounted because

of the incorrect answer of questions regarding the risk of irreversible maculopathy at the higher doses of chloroquine and hydroxychloroquine for short periods (30.8% incorrect responses) and use of FDA issued remdesivir -an emergency authorization for the treatment of suspected or laboratory-confirmed COVID-19 (28.8% incorrect responses). The role of chloroquine and hydroxychloroquine in COVID-19 is still under investigations, many trials are going on all over the world as per WHO [25] . Since these drugs can cause ocular toxicity but its use for small duration has not been extensively studied, hence it is controversial. Also, remdesivir [26] being a new promising and emerging drug, found effective against COVID-19. Hence, public health practitioners must be updated on the most promising potential therapeutic drugs that are under investigation. These might be reasons behind the incorrect response to these questions. knowledge [21, 22] in agreement to present study but Giao et al. failed to find a significant association between knowledge and age [24] . Similar to this study, Richa et al. reported a significant association between age and positive attitude [21] , and in contrast Saqlain et al.

and Albarrak et al. failed to find a significant association [22, 28] .

There was no statistically significant difference of knowledge, attitude, and practice among males and females which was similar to the findings of Saqlain et al. and Giao et al. [22, 24] , and was different from Richa et al. and Albarrak et al. [21, 28] In this study, there was no Albarrak et al., and Giao et al. [21] [22] 24, 28] . Job experience was significantly associated with attitude score in a study by Richa et al. [21] [21, 22] .

This finding inferred that ophthalmic HCP with a positive attitude are more interested in seeking knowledge and then put knowledge into practice. This correlation could also be explained by the "Reasoned action theory" which stated, "a person's intention to a specific behavior is a function of their attitude towards that behavior" [29] .

Binary logistic regression analysis demonstrated the age of HCP to be a significant Ophthalmogists and its allied health care professionals at more risk.

Apart from transmission by respiratory droplets, hand to eye contact, contaminated euipments, can also transmit through tears and ocular secretions. 

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