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Corona health‐care warriors in India: knowledge, attitude, and practices during COVID‐19 outbreak

BACKGROUND: COVID‐19 has become a global health emergency after its first case in Wuhan city, China. An increasing number of cases and deaths are challenging the health‐care system globally. This study aims to assess knowledge, attitude, and practice toward COVID‐19 disease among health personnel in rapid outbreak in India. MATERIALS AND METHODS: A cross‐sectional survey was conducted using Google Forms through Google platform on‐line. A total of 713 health personal allied health‐care staff, working in different public and private health‐care facilities, was conducted in the mid of April 2020. A structured knowledge, attitude, and practice questionnaire used to assess health personnel’s knowledge, attitude, and practice toward COVID‐19. All instruments were validated and pretested before use. Chi‐square test, followed by binary logistic and multivariate regression, was applied to determine factors associated with knowledge scores. RESULTS: Seven hundred and thirteen health personnel participated, and 703 (98.6%) participants responded were analyzed for final results. 95.9% of the health personnel were aware about route of transmission and clinical symptoms (95.3%) of COVID‐19. 63.7% believed that virus outbreak would be controlled globally and followed standard precautions (81.8%), including wearing the mask. Further, majority (98.3%) of the participants avoided social contact by not going to crowded places and not calling people to their homes (82.2%) during the advisory of the government. In binary logistic regression analyses, the adequate knowledge score found significantly associated with MBBS/bachelor’s degree (odds ratio [OR]: 2.309, confidence interval [CI]: 1.232–4.324, P < 0.009) and master’s degree (OR: 2.944, CI: 1.485–5.835, P < 0.002), working with government health‐care facility (OR: 3.662, CI: 1.624–8.285, P < 0.002), and holding a post of a physician (OR: 7.735, CI: 2.210–27.091, P < 0.001) during outbreak. CONCLUSIONS: The level of education is associated with adequate knowledge scores among the health personnel. Type of health‐care facility and post held in a health‐care facility are significant predictors of adequacy of knowledge.


Introduction
A cluster of pneumonia cases were detected in Wuhan in the Hubei province of China at the end of 2019. The new strain of coronavirus was named "severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2)" and disease as "COVID-19." [1] COVID-19 is a respiratory pneumonia which became pandemic spreading rapidly to involve various areas of the world. [2,3] COVID-19 is highly contagious and characterized by symptoms of mild fever, myalgia, dry cough, fatigue, headache, and sometimes gastrointestinal symptoms such as vomiting, abdominal pain, and diarrhea. [3,4] SARS-CoV-2 was transmitted through direct contact and in the form of droplets mainly. [5] However, a lot of scientific work is underway to figure out the source of infection, reservoir, transmission rate, severity, and impact on health-care system. [2,6,7] Considering the high transmission rate and huge mortality, the World Health Organization (WHO) declared COVID-19 as "Public Health Emergency of International Concern" on January 30, 2020. [8] The Ministry of Health and Family Welfare in India reported 26,496 as total confirmed cases (including 111 foreign nationals), 5804 discharged/cured/migrated cases, and 824 deaths with COVID-19 infection till April 26, 2020, 08:00 GMT + 5:30 (https://www.mohfw.gov. in). Globally, the countries need to use robust system for surveillance and audit of COVID-19 testing to detect suspected cases by specified case definition and detailed investigation protocol as recommended by the WHO. [9] In India, certain states namely Maharashtra, Gujarat, and National Capital, Delhi has been severely affected by the attack of the COVID-19 outbreak. The Indian government has taken some unprecedented measures to break the chain of transmission of the COVID-19 in the country including complete lockdown in the country, initially for 21 days, which was extended to another 19 days till May 3, 2020. The lockdown constituted suspension of schools/colleges, public transportation, public places, i.e., restaurant, hotel, bar, religious gathering, and close surveillance of high-density community areas using drone cameras, and mandatory 14-day quarantine for an individual who comes in contact with COVID-19-confirmed case. However, problem to break the chain of transmission of COVID-19 and mortality becomes more complex in reaction to lack of prophylactic vaccine, scientific treatment line, and lack of sound knowledge and experience among health personnel to manage such infectious diseases in the past. [10] Facing the grim situation, health personnel are holding the frontline to provide round-the-clock services to COVID-19-affected patients. Lack of timely implementation of strict and scientifically oriented infection control measures may propel the disease transmission to the community level. [11] Subclinical and asymptomatic carriers of COVID-19 at the workplace and community are a potential source of infection and remain a big threat to the health personnel. This can make the vulnerable more susceptible to get infection to other patients and hazardous source of infection for other health team members. [11,12] Winning a war against this deadly virus depends on scientific knowledge, appropriate practice, and optimistic attitude of health personnel toward COVID-2019. [13] Therefore, the health personnel should have scientific knowledge of different aspects of infectious disease and have an attitude to handle grim situation using appropriate practices to prevent the transmission to others. Thus, the study focusses on assessment of knowledge, attitude, and practices toward COVID-19 among health personnel in India.

Materials and Methods
A cross-sectional survey was conducted using Google Forms through Google platform online. A total of 713 health personnel, physicians, nurses, and allied health staff (dentists, hospital attendants, and student nurses), working in public and private health-care facilities, participated in an online survey, and 703 participants completed the survey for final analysis. The survey questionnaire was adapted for local use, [14] and survey link was shared on E-mail and WhatsApp to the different health-care groups across the nation with a request to participate in the study. The study was planned as a rapid survey to generate evidence for interventions based on study findings. Hence, the survey link was left open for 1 week, and the final analysis was done after closing the link. Survey link: https://drive.google.com/fil e / d / 1 j W Q O k j X W z n B i V f 1 M a w d o O 6 y njKwUAC3y/view?usp = sharing The study was approved by the Institutional Ethics Committee (AIIMS/IEC/20/158). A consent form was also provided in the survey link and asked to provide consent before participating in online survey. However, the survey questionnaire was refrained to obtain any personal information of the participant.

Sociodemographic sheet
It consists information on age, gender, professional qualification, occupation, professional experience, sources of information about COVID-19, involvement in the direct care of COVID-19 patients, and experience of involvement in care of infectious disease, i.e., "SARS," "Middle East respiratory syndrome coronavirus (MERS-CoV)," or influenza A H1N1. The profile was pretested and validated by experts in the field of infectious disease, microbiology, medicine, and nursing.

Knowledge questionnaire
A structured knowledge questionnaire was used to collect information on various aspects of COVID-19. It consists of 11 items on origin, route of transmission, clinical symptoms, preventive strategies, and availability of vaccine in the market to cure COVID-19. Participants were asked to respond to the question on dichotomous response (yes/no) with an extra "not sure/don't know" option. Each right response was scored as one point and zero was assigned to wrong or unknown response. Getting higher knowledge score suggested better knowledge about COVID-19 and vice versa. Further, the knowledge score was categorized into adequate (>60%) and inadequate (≤60%) level based on correct response of a participant to knowledge items. The knowledge questionnaire was validated and pretested before final use.

Structured attitude and practice questionnaire
Attitude toward COVID-19 was assessed by four questions about "confidence in successful winning over COVID-19 globally," "use of standard precautions to break the chain of transmission," "sharing scientific information about COVID-19 with others," and "behaving more civilized and responsible manner during an outbreak." The practices were measured by six questions on isolation, visiting crowded places, using the mask, washing hands, avoiding social contacts, and compliance to government advisory. Practice items are scored dichotomously (yes/no) indicative presence or absence of a particular practice during an outbreak. The validity of the questionnaires was established through experts' opinions in the field of infectious diseases, microbiology, medicine, and nursing.

Statistical analysis
The demographic characteristics were compared with level of knowledge score using Chi-square test. Bivariate regression analysis was applied using knowledge score as a dependent variable. Similarly, multivariate logistic regression was applied to determine factors associated with knowledge score of health personnel. Odds ratios (ORs) with 95% confidence interval (CI) were used to quantify the strength of association between sociodemographic characteristics and knowledge score of health personnel. Data analyses were carried in IBM SPSS Statistics for Windows, Version 23.0. Armonk, NY: IBM Corp The level of significance was set at P < 0.05 (two-sided).

Results
The online survey form was responded by 713 participants, and 10 did not give consent to use their information for research purpose and were excluded from the analysis. The final sample size of the study consisted of 703 (98.6%) participants. The mean age of the study population was 30.27 years (standard deviation [SD] ±7.04), ranging from 18 to 68 years. Among the 703 participants, 50.6% were male and 47.7% had a MBBS or bachelor's degree in relevant professions. With regard to profession, majority were nurses (62.2%), followed by doctors (20.6%) and other (17.2%) allied health personnel, i.e., dentists, trainee nursing students, and hospital attendants. In terms of types of health-care facility, 71.8% of the participants were working in a government health-care facility, followed by 22.2% in private health-care facility. More than 70% of the participants reported no past experience of management of COVID-19 patients or management of SARS, MERS-CoV, or H1N1 during their professional experience. Around half of the health personnel (47.4%) had work experience of <5 years. Further, in terms of source of information on COVID-19, majority (77.52%) of the health personnel gained information through the Internet/social media, followed by journal/reading textbook or attending institutional lectures (54.62%) on COVID-19. However, around half (50.64%) of the participants got updated information on COVID-19 by going through daily newspapers and news on television or radio. The sociodemographic details of the health personnel are summarized in Table 1.

Knowledge of health personnel on COVID-19
The frequency and percentage of correct knowledge response and attitude and practice are described in Table 2. In terms of the origin of COVID-19, 50.9% of the people think that virus may have originated from bat, while 30.7% were not sure about the origin of virus. However, only 18.3% confident that bats did not play any role in its origin of the virus. With regard to transmission of virus, more than 95% of the participants were aware of route of transmission (95.9%) and main clinical symptoms (95.3%). 65.1% of the participants believe that eating or contacting wild animals would not lead to infection while 23% were not sure about it. According to 68% of the participants, young adults have no chance of getting infected with COVID-19 while 17.1% were not sure and 14.9% of the participants believed that young adults are prone to get infected with COVID-19.
Regarding on prevention and control measures, more than 99% of the participants (99.9%) believe that chain of infection is broken by hand hygiene as an important standard precaution. Further, more than 60% of the participants felt that a person with history of contact with COVID-19-confirmed case should be quarantined while 37.1% believed that they should be kept in isolation, while 24% of the participants were not sure about immediate prevention and approaches to control the transmission of COVID-19.
Regarding management of COVID-19, 96.9% of the participants were aware that until now, there is no vaccine to prevent the disease while 15.2% of the participants supposed that BCG vaccine may help in prevention of deadly virus and indicate a need to take a shot of BCG vaccine for health personnel [ Table 2].

Attitude of health personnel toward COVID-19
Findings show that 63.7% of the participants were confident that transmission of COVID-19 will be controlled successfully while 21.5% were still not sure about the control around the globe. Majority (81.8%) of the participants were agreed that transmission may be prevented by strictly adhering to standard precautions including wearing mask, whereas 12.9% believed that using standard precautions may not be helpful to prevent the transmission. Similarly, 94.6% of the participants were agreed that authentic information regarding disease profile and outbreak must be shared among peers and colleagues to make them aware about the facts and other relevant issues related to virus. Majority (91.9%) of the health personnel show responsibility and behave in more civilized way to stop further transmission of disease [ Table 2].
Further, 82.2% of the participants reported that they stopped calling other people to their homes. However, a small proportion of participants visited crowded places frequently (3.1%) and did not maintain social distance (1.7%) during COVID-19 outbreak. The results are summarized in Table 2. The association of sociodemographic variables with level of knowledge of COVID-19 are shown in Table 3.
The mean knowledge score was 7.24 (SD ± 1.4, range: 3-10), with a correct response rate of 72.4% (7.24/10 × 100) in the knowledge questionnaire. The knowledge level found significantly associated with participants' qualifications (P < 0.05), their types of the health-care facility (P < 0.05), and occupation (P < 0.05). However, knowledge score did not show any significant association to participants' age, gender, or years of professional experience, the experience of treating COVID-19 patients, and past experience of treating SARS, MERS-CoV, or H1N1 patients in their professional life.
Further, findings represent that adequate knowledge of health personnel on COVID-19 is significantly associated with working with government health-care facility (OR: 3.662, CI: 1.624-8.285, P < 0.002) in comparison to health personnel working at semi-government health facility.  Table 5].

Discussion
Currently, the most discussed topic in media and community is COVID-19, especially among sick individuals and their caregivers. Health personnel are seemed to have an increased risk of infection. To the best of our knowledge, this is the first study in Indian scenario assessing the knowledge, attitude, and practice of health personnel toward COVID-19. We further assume that study findings will be useful in developing of IEC programs aimed at prevention and control of this deadly emerging infectious disease.
The findings of our study revealed acceptable knowledge and favorable attitude of health personnel toward COVID-19. The present study reported that majority of the health personnel have adequate knowledge  [15] and China [13] had reported a correct response rate of 90%.
Source of information about COVID-19 for majority of the participants was the Internet and social media, journals and lectures, and television. Our findings were similar to the findings reported in similar studies. [10,12] These findings are of concern for clinical use and emphasize the need to access the authentic source for extracting the information on novel coronavirus.
About the route of transmission and preventive measures, findings reported that 96% of the health personnel knew about the routes of transmission and clinical symptoms (95%) and nearly 100% were aware of hand hygiene as the most important preventive measure to break the chain of transmission of coronavirus. Earlier published research presented a close similar finding on precautionary measures, hygiene issues, and hallmark symptoms of MERS. [16] Health personnel were aware about unavailability of vaccine for disease prevention. Similar findings are reported in earlier published studies on coronavirus disease. [10,16] The study findings reflect a favorable attitude of health personnel toward COVID-19. About 63% believed that the COVID-19 epidemic will finally be successfully controlled globally. Health personnel show an excellent response (81.8%) for using standard precautions and use of mask to prevent the transmission of COVID-19. Similar findings represented in previous studies conducted on COVID-19 and MERS for the use of standard precautions and wearing mask to break the transmission of deadly virus. [10,17] Similarly, there was a high response rate for  Health personnel were aware about preventive measures to be taken for avoiding getting infected such as avoiding visit to crowded places and using mask. These findings could be better represented and better understood in shadow of the risk-taking behavior of an individual. [18] Further, health personnel knowledge on COVID-19 documented a significant association with occupation, profession, and types of health-care facility. Our findings are similar to a study conducted among Chinese residents. [13] The strength of our study is due to the significant sample size of health personnel during the early days of this emerging infectious disease with an over-representative of experienced medical and nursing graduates working in different types of health-care facility across the nation.
Since COVID-19 can be transmitted through droplets or close contacts, an online survey was conducted to reduce the chances of transmission and could be considered a major limitation for the study. However, an overwhelming response of health personnel enabled researchers to completed the survey on a serious global threat. Strictly speaking, the findings of this study can only be extrapolated to Indian health personnel and shall be used cautiously to the general population.

Conclusions
The current study findings represent a good knowledge, favorable attitude, and practice, followed by health personnel during pandemic of COVID-19. This highlighted the need of focused education and training program for health-care professional across the nation to enforce and update COVID-19 knowledge to encourage an optimistic attitude and follow safe practices during ongoing outbreak. However, united efforts of the Indian government and Indian citizens for control of Covid-19; India will surely win the war against COVID-19. However, a limited sample size warrants more studies on the same issue to study KAP toward COVID-19 among health-care professional and Indian citizens.

Financial support and sponsorship
Nil.

Conflicts of interest
There are no conflicts of interest.