Assessment of Knowledge, Attitude and Practice Regarding COVID-19 Pandemic among Health Care Professionals: A Cross-sectional Study
Health care professionals are at greater risk of acquiring and subsequently transmitting Severe Acute Respiratory Syndrome Coronavirus-2 (SARS-CoV-2) infection to their patients, families and colleagues. It is of utmost importance for them to have a knowledge about this Coronavirus Disease (COVID-19) and hence be in a position to practice infection prevention and control.
To assess the Knowledge, Attitude and Practice (KAP) among health care professionals regarding the COVID-19 pandemic.
Materials and Methods
This is a descriptive, cross-divtional study and was conducted in the month of April, 2020, among doctors and nurses. Total 164 health care professionals from the medical college hospital were included in the study. A 53-item survey questionnaire was developed to assess KAP among the health care professionals. Data analysis was done by using Epi info 22.214.171.124 version. Chi-square test was used to analyse variables as appropriate. A p-value of <0.05 was taken to be statistically significant.
A total of 164 responses were collected and analysed. Doctors comprised 43.9% of the total study subjects while remaining 56.1% were nurses. Male to female ratio of the study subjects was 2:1. Fifty-eight percent informed that they had received training about infection control. In the present study, common source of information about COVID-19 was the internet, social media and television followed by newspaper, government sources and radio. Most of the Health Care Workers (HCWs) were aware of the mode of transmission of infection and common preventive measures. Incubation period was known to 95% of respondents. Only 48.9% of nurses thought that the mild form of disease was most common. Almost all believed that washing hands and wearing mask were important preventive measures. Around 60% of HCWs assumed that they knew the steps for wearing and removing Personal Protective Equipment (PPE), but very few could remember the exact sequence. Most of them felt that the disease was dangerous, however only 31% were scared to do hospital work. Both nurses and doctors practiced high levels of hand hygiene, cough hygiene and wearing face masks at the workplace.
This study highlights the level of existing KAP of COVID-19 among health care professionals. There is an urgent need to focus on training for correct use of PPE which can safeguard HCWs from contracting COVID-19.
COVID-19 manifests as an acute respiratory infection and is caused by the SARS-CoV-2. Infection by the virus resulted in a cluster of atypical pneumonia cases of unknown aetiology in Wuhan City, Hubei Province, China, since December 2019 . COVID-19 presents as respiratory illness. The symptoms can vary from mild flu like illness to severe pneumonia. In few cases, it can progress to Acute Respiratory Distress Syndrome (ARDS) which can be fatal . Since then, the outbreak has escalated rapidly, with the World Health Organisation (WHO) first declaring a public health emergency of international concern on 30 January 2020 and then formally declaring it a pandemic on 11 March 2020. By the end of April, the number of COVID-19, cases across the globe have crossed 3 million and more than 200,000 deaths have been reported . In India, more than 30,000 cases have been diagnosed till now .
So far, no antivirals or vaccines are available against COVID-19. In such a scenario, public health measures which focus on infection control and prevention is of utmost importance. For any preventive measures to be effective, a comprehensive approach must be taken to ensure accurate health education of the public and the healthcare professionals. In recent weeks, many interventions, such as promotion of hand hygiene, respiratory etiquette, social distancing, and avoiding social gatherings have been emphasised by public health authorities .
Information regarding the disease and its prevention, has been spread to the masses via print media (newspaper), social media, radio, TV news channels, telephonic messages, and banners in public spaces. There have been regular updates by the WHO, local public health authorities and the medical fraternity to give best available information to control the spread of the disease. At the same time, there has been circulation of unreliable information on social media, which are accessed by health care professionals too.
HCW are at great risk of acquiring and subsequently transmitting this lethal virus to their patients, families and colleagues. The hospitals should ensure that they are capable of practicing safely and provide patient care with all infection control measures. The psychosocial impact of the disease will affect attitudes of the workers towards the disease and the patients. Devastating epidemics can jeopardise the medical care provided by them in years to come. Hence, there is a need to study and assess KAP regarding the COVID-19 pandemic among health care professionals.
KAP study provides us with the information regarding how people think, know, feel and behave with regards to certain things . The objective of the present study was to investigate the KAP of health care professionals with reference to the COVID-19 pandemic.
Materials and Methods
This was a cross-sectional descriptive study, done in the first week of April 2020 by the Department of Respiratory Medicine, Jaipur National University Institute for Medical Sciences and Research Centre, Jaipur, India.
Inclusion criteria: Study participants were doctors (senior residents, junior residents, assistant professors, associate professors and professors) and staff nurses from all the departments of the medical college hospital, who gave consent to be a part of the study.
Exclusion criteria: Doctors and nurses who did not give consent and those who did not respond even after two visits were excluded from the study.
The sample size was calculated using a confidence level of 95%, margin of error 5%, response distribution of 50% and population size of 280. The sample size derived was 163. Questionnaire was distributed among 180 HCWs. The study received response from 164 participants making a response rate of 91.11% and strict protocol was followed to maintain the confidentiality of their response. The study was approved by the Institutional Ethics and Scientific Committee. (JNUIMSRC/IEC/2020/180, Jaipur).
Paper questionnaire were personally distributed to the participants who were approached on the basis of convenience and feasibility while on duty. They were encouraged to fill in the questionnaire honestly. The sheets were collected back in the same working shift, once it was completed. The questionnaire was standardised and well-constructed to assess the required objectives. The questions were framed as per guidance of the KAP survey methodology . Previous articles on swine flu and Middle East respiratory syndrome (MERS) were reviewed [6,7]. Also, data from frequently asked questions about COVID-19 from WHO, and review article on COVID-19 were included to design the questions [2,8,9]. The proforma was prepared initially in English and then translated into Hindi, which is a local language. The questionnaire was pre-tested and tested. Questionnaire consisted of close ended questions. The questionnaire was divided into four parts. First part included demographic details of the participants, such as age, sex, qualification or job description, among other parameters. The second part included questions to assess the knowledge regarding the aetiology, epidemiology, pathogenesis, and clinical features of the disease. The third part dealt with infection control measures and prevention, which have to be followed in clinical practice or at the workplace. The fourth part contained questions for evaluation of attitudes of the individual towards the disease and its effects. Each question was scored as per the correctness of the response.
All data was entered in MS Excel spreadsheet. Analysis was done by using Epi info 126.96.36.199 version. Categorical variable was expressed as frequency and percentage. Statistical analysis like Chi-square test was used to analyse variables as appropriate. A p-value of <0.05 was taken to be statistically significant.
A total of 164 responses from the study subjects were collected and analysed. [Table/Fig-1] shows the demographic details of the respondents. Doctors comprised 43.9% of the total subjects while remaining 56.1% were nurses. A 78.3% of the nurses were in the age group of 20-29 years. Male to female ratio in the study subjects was 2:1. Approximately, 58% informed that they had received training about infection control. Most of the subjects had received information from multiple sources. [Table/Fig-2] describe the knowledge of the study subjects. Most of the HCWs were aware of the mode of spread of infection and common preventive measures. 90% of doctors felt that touching an infected person does not spread infection. Most of the participants recognised ARDS, death and pneumonia as possible complications of COVID-19 (90%). Almost all believed that washing hands and wearing a mask are important preventive measures. Incubation period was known to 95% of respondents. Only 48.9% of nurses thought that mild form of disease is most common [Table/Fig-2]. The present study assess the attitude of HCWs towards the disease and its preventive measures [Table/Fig-3,4, 5]. Most of them felt that the disease is dangerous but only 31% were scared to do hospital work. More nurses believed that government institutions would be able to control the pandemic. [Table/Fig-5] mentions the existing practice among HCWs. Nurses were better in doing hand hygiene before wearing a face mask. Around 60% of HCWs assumed that they knew the steps for wearing and removing PPE, but only 8.9 % and 5.8% could remember the exact sequence of donning and doffing, respectively [Table/Fig-4].
General characteristics of study subjects.
|Characterstics studied||Row labels||Doctors (N=72)||Nurses (N=92)||Total (N=164)||p-value|
|Age group (years)||20-29||21 (29.2%)||72 (78.3%)||93 (56.7%)||<0.001*|
|30-39||28 (38.9%)||16 (17.4%)||44 (26.8%)|
|40-49||5 (6.9%)||1 (0.1%)||6 (3.7%)|
|50-59||5 (6.9%)||3 (3.3%)||8 (4.9%)|
|60-69||13 (18.1%)||0||13 (7.9%)|
|Gender||Female||22 (30.6%)||32 (34.8%)||54 (32.9%)||0.686|
|Male||50 (69.4%)||60 (65.2%)||110 (67.1%)|
|Duration of service||<2 years (Junior Resident)||18 (25%)||32 (34.8%)||50 (30.5%)||0.007*|
|2-4 years (Senior resident)||20 (27.8%)||29 (31.5%)||49 (29.9%)|
|5-10 years||15 (20.8%)||25 (27.2%)||40 (24.4%)|
|>10 years||19 (26.4%)||6 (6.5%)||25 (15.2%)|
|Training||Yes||32 (44.4%)||64 (69.6%)||96 (58.5%)||0.651|
|No||40 (55.6%)||28 (30.4%)||68 (41.5%)|
|Source of information||Social media||51 (70.8%)||63 (68.5%)||114 (69.5%)||0.771|
|Television||50 (69.4%)||50 (54.3%)||100 (61%)||0.071|
|Internet||58 (80.6%)||72 (78.3%)||130 (79.3%)||0.868|
|Govt. Sources||52 (72.2%)||44 (47.8%)||96 (58.5%)||0.003*|
|Newspaper||40 (55.6%)||58 (63%)||98 (59.8%)||0.418|
|Friend and family||24 (33.3%)||30 (32.6%)||54 (32.9%)||0.945|
|Radio||9 (12.5%)||19 (20.7%)||28 (17.1%)||0.243|
*p<0.05 is considered to be statistically significant
Knowledge of study subjects.
|Knowledge assessment||Doctors (N=72)||Nurses (N=92)||p-value|
|Mode of spread||Through respiratory droplets produced when a person sneezes or coughs||70 (97.2%)||88 (95.7%)||0.910|
|Touching eyes, face and nose after contact with surfaces contaminated with virus particles||68 (94.4%)||89 (96.7%)||0.740|
|Touching an infected person||59 (81.9%)||87 (94.6%)||0.021*|
|Symptoms||Cough, difficulty in breathing, chest pain and sore throat||72 (100%)||89 (96.7%)||0.337|
|Fever, body ache||71 (98.6%)||85 (92.4%)||0.142|
|Vomiting, loose stool||41 (56.9%)||44 (47.8%)||0.316|
|Eye congestion, running nose||54 (75%)||60 (65.2%)||0.228|
|Possible complications||Respiratory failure (ARDS) and death||70 (97.2%)||89 (96.7%)||0.780|
|Pneumonia||66 (91.7%)||70 (76.1%)||0.015*|
|Neurological symptoms||15 (20.8%)||22 (23.9%)||0.779|
|Shock (drop in BP) and renal failure||38 (52.8%)||34 (37%)||0.062|
|Preventive measures||Washing hands||72 (100%)||91 (98.9%)||0.902|
|Wearing a face mask||71 (98.6%)||92 (100%)||0.911|
|Avoid touching eyes, nose, and mouth||72 (100%)||91 (98.9%)||0.902|
|Others||Incubation period 1-14 days||69 (95.8%)||86 (93.5%)||0.755|
|COVID-19 can be caught from a person who has no symptoms||65 (90.3%)||69 (75%)||0.021*|
|Health care workers involved in care of COVID-19 patients, can catch infection from their patients||70 (97.2%)||88 (95.7%)||0.910|
|Diagnosis of COVID-19 can be confirmed by laboratory testing of a respiratory sample (cough/naso-oro-pharyngeal swab||68 (94.4%)||82 (89.1%)||0.354|
|Which body system does it affect the most (Respiratory system)||70 (97.2%)||89 (96.7%)||0.780|
|Which form of disease is most common (Mild disease)||50 (69.4%)||45 (48.9%)||0.013*|
|Which age group of people are more at risk of severe illness (>65 years)||72 (100%)||81 (88%)||0.006*|
|Is there any vaccine available for protection against coronavirus infection (No)||61 (84.7%)||73 (79.3%)||0.497|
*p<0.05 is considered to be statistically significant; ARDS: Acute Respiratory Distress Syndrome; BP: Blood pressure
Practices of study subjects.
|Coughing||Cover mouth and nose with tissue or handkerchief or elbow||Doctor||72 (100%)||0||0||0.201|
|Nurses||88 (95.6%)||1 (1.1%)||3 (3.3%)|
|Throw away the used tissue into the dustbin||Doctor||69 (95.8%)||0||3 (4.2%)||0.306|
|Nurses||90 (97.8%)||1 (1.1%)||1 (1.1%)|
|Turn your face from the surrounding people||Doctor||64 (88.9%)||3 (4.2%)||5 (6.9%)||0.012*|
|Nurses||64 (69.6%)||11 (12%)||17 (18.5%)|
|Washing hands||Before touching your eye and nose||Doctor||68 (94.4%)||3 (4.2%)||1 (1.4%)||0.231|
|Nurses||91 (98.9%)||1 (1.1%)||0|
|After covering the nose while sneezing||Doctor||68 (94.4%)||2 (2.8%)||2 (2.8%)||0.637|
|Nurses||87 (94.6%)||4 (4.3%)||1 (1.1%)|
|Before wearing a face mask||Doctor||66 (91.7%)||4 (5.6%)||2 (2.8%)||0.019*|
|Apply soap while washing your hands||Doctor||70 (97.2%)||2 (2.8%)||0||0.794|
|Nurses||90 (97.8%)||2 (2.2%)||0|
|Wear face mask||When you are in hospital||Doctor||72 (100%)||0||0||0.922|
|Nurses||91 (98.9%)||0||1 (1.1%)|
|When you are in public places||Doctor||71 (98.6%)||1 (1.4%)||0||0.061|
|Nurses||83 (90.2%)||3 (3.3%)||6 (6.5%)|
|Do you change the facemask after using it once||Doctor||70 (97.2%)||2 (2.8%)||0||0.011*|
|Nurses||84 (91.3%)||0||8 (8.7%)|
*p<0.05 is considered to be statistically significant
Donning and doffing of Personal Protective Equipment (PPE) practice among study subjects.
|Questions on PPE||Doctors (N=72)||Nurses (N=92)||p-value|
|Do you know the correct steps of wearing and removing PPE||42 (58.3%)||55 (59.8%)||0.978|
|Correct sequence for wearing PPE||9 (12.5%)||5 (5.4%)||0.185|
|Correct sequence of removing PPE||6 (8.3%)||3 (3.3%)||0.285|
Attitude of study subjects.
|Questions on attitude||Doctors (N=72)||Nurses (N=92)||p-value|
|Wash your hands more frequently||71 (98.6%)||89 (96.7%)||0.794|
|Follow infection control guidelines||69 (95.8%)||91 (98.9%)||0.448|
|Eat well and take care of your own heath||70 (97.2%)||90 (97.8%)||0.794|
|Avoid going to crowded places or follow social distancing||71 (98.6%)||90 (97.8%)||0.830|
|Feel that the disease is dangerous||65 (90.3%)||90 (97.8%)||0.078|
|Scared of doing your hospital work||28 (38.9%)||23 (25%)||0.082|
|Worried about one of your family members getting infection||59 (81.9%)||75 (81.5%)||0.507|
|Transmission of COVID-19 can be prevented by standard public health measures, such as isolation, as advised by Ministry of Health & Family Welfare, Government of India and WHO, among others||67 (93.1%)||85 (92.4%)||0.889|
|Government institutions will be able to control the pandemic||47 (65.3%)||76 (82.6%)||0.018*|
|If a vaccine for COVID-19 is available, would you take it?||61 (84.7%)||86 (93.5%)||0.117|
|Interested in following the disease news||65 (90.3%)||92 (100%)||0.008*|
*p<0.05 is considered to be statistically significant
COVID-19 is a global pandemic and all the countries are fighting with this disease. Health care professionals like doctors and nurses are the most important front-line workers. It is important to know the knowledge and attitude of HCWs and also assess their practice. Hence, author’s evaluated these important aspects by standardised questionnaire in this study.
Since COVID-19 is caused by a novel virus and the disease is new, most of the information about COVID-19 comes from alternative sources rather than medical textbooks. In this study, common sources of information were internet, social media and television, followed by newspaper, government sources and radio. It is easier to access information from the internet but there is a concern regarding the authenticity of the material available. There is a risk that HCWs will be exposed to malicious or false data which can result in wrong behaviour or practice. Hence, it is important for the health authorities to disseminate reliable information via these medium. This will play an important role in controlling infection.
In this study, only 58% admitted that they had received formal training. Hence, there is huge potential at the institutional level to conduct more training sessions among HCWs. This will prepare them to perform their duties more efficiently in this difficult time.
Despite less training, this study observed that study subjects had good knowledge regarding the mode of spread, symptoms, disease complications, incubation period, high-risk populations and treatment options. This finding is in contrast to the observation made by Bhagavathula AS et al., which was done in the first week of March 2020. Only 50% of HCWs were aware of the incubation period as compared to 95% in this study . In another study by Huynh G et al., from Vietnam, only 60-70% of the HCWs were aware of the incubation period, treatment options and route of transmission . The higher awareness in the present study might be due to better information availability in the last two months. As the number of cases is increasing in India, HCWs are getting more knowledgeable. There was no significant difference between the knowledge of doctors and nurses except few aspects. For example, 19% of doctors assumed that they would not contract infection after touching an infected person, whereas this assumption was only 5% among nurses. This false presumption among some doctors could increase their risk of contracting disease from patients.
In this study, both nurses and doctors were aware of preventive measures, such as hand washing, wearing face masks and avoiding touching the eyes, nose, and mouth. This is similar to observations made by Khan MU et al., during the MERS-CoV epidemic . It was also noted that doctors are better aware that the mild form of COVID-19 is the most common presentation and that the disease is more severe in case of elderly people more than 65 years of age.
Another important finding in the present study was that majority of HCWs had positive attitude towards the disease. They all admitted that they had seen increasing compliance with preventive measures in their practice. Many are worried about spreading the disease to their family members because of their hospital exposure. These findings are similar to the observation made by Huynh G et al., . The high score on attitude in this study was possibly due to better knowledge among HCWs. It was also noted that doctors are less interested in newer information about the disease compared to nurses. This may be due to mental saturation from too much information received from various sources.
In this study, the authors also looked into the practices adopted by the study subjects while at work. Both nurses and doctors, practiced high levels of hand hygiene, cough hygiene and wearing face masks. This was reported to be 75% in a study done by Modi PD et al. In the same study, they looked into the use of PPE by HCWs and they found that three-fourth of respondents knew about correct use of PPE and use of N95 mask, indicating that the correct sequence of donning and doffing of PPE is equally important . The practice of this aspect was lacking in the present study. Very few HCWs were aware of correct sequence of wearing and removing coverall PPE as recommended by WHO. This could be due to minimal exposure to handling suspected COVID-19 patients in a private teaching hospital as usually all patients are being referred to government run medical college hospitals.
This was a single center study and does not correctly depict KAP of doctors and nurses working in various teaching, non-teaching, public and private healthcare centers of the whole country.
The study highlights the level of existing KAP among health care professionals with regard to COVID-19. Health authorities should utilise social media and internet to disseminate best available information and facts about COVID-19. There is an urgent need to focus on training for the correct use of PPE which can safeguard health care professionals from contracting COVID-19.*p<0.05 is considered to be statistically significant*p<0.05 is considered to be statistically significant; ARDS: Acute Respiratory Distress Syndrome; BP: Blood pressure*p<0.05 is considered to be statistically significant*p<0.05 is considered to be statistically significant
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