Knowledge, Attitudes, Anxiety, and Preventive Behaviors Regarding Covid-19 Affliction among Healthcare Workers in Pakistan

Introduction

On 31st Dec 2019, a strange infection-causing virus has been publically reported in Wuhan, China which was identified as a new strain named SARS-CoV-2(β-coronavirus enveloped non-segmented positive-sense RNA virus). The nucleic acid detection kit helped in identifying the confirmed cases and their spread from human to human. In 2002-03 the SARS-COV has drawn global attention due to 774 altogether deaths and now the Covid-19(SARS-CoV-2) emergency was finally declared a Public Health Emergency of International Concern (PHEIC) by the World Health Organization (WHO) [1].

SARS-CoV-2 belongs to the Coronaviridae Family whose subclass comprises four coronaviruses that is alpha-, beta- , gamma-, and delta-coronavirus. It is a positive-strand RNA virus whose genome encodes for four structural viral proteins, called spike(S), envelope(E), membrane(M), and nucleocapsid(N) that plays an important role in its entry and a major cause of pneumonia in humans. In particular, the receptor-binding and successful entry into the host cell is the responsibility of the S protein reason it is considered a significant therapeutic target. The viral assembly is done by M and E proteins and the N protein is essential for RNA synthesis [2].

Covid-19 is responsible for influencing people’s psychological health worldwide, resulting in stress, isolation, social distancing, avoiding gatherings, and working from home. These situations result in an increased risk of infection and chances to infect others. Strict Social distancing rules increased the demands of people and reduced social support. The panic caused by Covid-19 stigmatizes the first- line healthcare workers within the community and in their friends and family because of their work and the fear of getting infected by them [3].

The pandemic era is the most critical era for healthcare workers mainly Physicians, pharmacists, paramedics, and medical lab technologists to provide the best services to patients. They aimed to handle sensitive situations and manage the stress and anxiety associated. The most difficult thing for them is to maintain their health especially physical and mental [4].

Each day, new scientific information about Covid-19 and SARS-CoV-2 emerges. Healthcare workers (HCWs) are required to keep up with the latest testing, treatment, and guideline developments. According to studies, disinformation about Covid-19 is extremely common among HCWs, especially from social media [5].

Healthcare workers are fighting the Covid-19 affliction from the front lines, and as a result, thousands of them are getting the virus while treating Covid-19 patients around the world. The situation is even worse in underdeveloped nations with poor healthcare systems. According to reports, healthcare workers are frequently infected with Covid-19 as a result of the lack of healthcare providers and the increasing demand. For instance, Covid-19 infects 20% of healthcare providers in Italy, 26% in Spain, 16% in the USA, and 19.6% in the Netherlands, and the issue will get worse in subpar healthcare environments. Additionally, it may raise the prevalence of stress disorders, and anxiety among front-line healthcare workers [6].

The study aims to assess healthcare workers’ knowledge, attitude, anxiety, and, preventive behaviors toward Covid-19 affliction. The main objectives are to find out the consciousness and awareness of pandemic diagnosis and treatment strategies in healthcare professionals at individual levels, to analyze, the implementation of guidelines of SOP, and to assess the magnitude of psychological pressures like stress, and workload among the front-line health professionals to treat the patients and to assess how they analyze the impact of Covid-19 on environmental factors, professional strength, and community stigmatization.

Results

Out of 487 participants, 470 participated in this study with a 96.5% response rate.

Demographical Status

The respondents from the 25-30 age group were 231(49.1%) in number, while respondents from 31-35 were

146(31.1%), 36-40 were 54(11.5%), 41-45 were 27(5.7%), 46-50 were 9(1.9) and greater than 50 were only 3(0.6%) respondents. 197(41.9%) were male and 273(58.1%) were females. The educational status showed, 32(6.8%) respondents were intermediate, 205(43.6%) respondents were undergraduate, 229(48.7%) were graduate, and only 4(0.9%) were Post Graduate. In the healthcare domain 178(37.9%) were physicians, 67(14.3%) were nurses, 38(14.3%) were administrators, 122(26%) were pharmacists, 27(5.7%) were medical lab technologists, 17(3.6%) were non-physician specialist and 21(4.5%) were technicians. Out of 470 healthcare workers, 449(95.5%) were frontline healthcare workers and 21(4.5%) were non- frontline healthcare workers (Table 1).

Healthcare Worker’s Answers to Covid-19 Affliction Related Questions

The main symptoms of Covid-19 are correctly answered by 61.5%. On inquiring about the absence of an effective cure for Covid-19, 91.7% of the participants responded that it is true. 17.7% responded that antibiotics are effective in the treatment of Covid-19 and 82.3% have the opposite opinion. Children and adults need to take measures to prevent the covid-19 virus infection was confirmed by 83.4%. A person can transfer the Covid-19 virus even if the fever was not present was acknowledged by 85.5%. Covid-19 spreads through respiratory droplets 92.8% agreed with it. Symptoms of coronavirus can appear between 2-14 days after catching an infection 92.6% agreed with it. The majority of Covid-19 infective patients will not develop illness but elderly patients having a chronic illness, DM, COPD, or pneumonia are likely to develop severe illnesses 87.2% of respondents agreed to it (Table 2). The overall knowledge result shows that 65.5% of the participants have good knowledge, 33.4% have moderate knowledge, and 1.1% had poor knowledge (Figure 1).

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The attitudes study revealed that 85.3% were able to test their patients for Covid-19 quickly and easily, and 14.7% weren’t. 51.9% treated 0-5 Pt., 28.5% treated 6-10 Pt., 15.7% treated 11-15 Pt., and 3.8% treated more than 15 Patients. 94.0% were concerned about patients avoiding testing or treatment due to financial or health insurance barriers. 78.5% agreed that the government has taken appropriate measures to support the medical supply chain and ensure that your hospital/clinic has the medical supplies necessary to address the COVID-19 pandemic. 6.2% have increased their use of telemedicine in response to Covid-19, 24.5% didn’t and, 64.9% were planning to do it. Among the adult, children, elderly and immuno-compromised, 83.0% thought adults, 3.0% thought children, and 14.0% thought elderly and immunocompromised exhibit a high complication rate (Table 2). The final HCW’s positive attitude was 93.4% and the negative attitude was 6.6% toward Covid-19 affliction (Table 2, Figure 2).

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Regarding anxiety, 19.4% wash their hands every 15 minutes, 12.3% every 30 minutes, 12.8% every hour, and, 55.5% when required. 72.1% of respondents felt anxious in gatherings due to Covid-19. 69.6% thought that following Covid-19 SOPs leads to OCD. Healthcare professionals needed mental assistance during this pandemic 67.0% agreed to it. 63.4% of respondents felt anxious about following Covid-19 SOPs. 65.3% were taking strict precautions against Covid-19. 64.5% of respondents said that their personal lives were affected by Covid-19. 78.1% of respondents felt depressed due to long working hours. 77.2% felt anxious about following SOPs around Covid-19 patients. 76.4% had a fear of lack of medication and uncontrolled viral spread. 71.7% were anxious about counseling patients against non- compliance to the COVID-19 vaccine. 70.0% were anxious about the scarcity of ventilators and 30.0% weren’t. 85.1% had 3-5h, 13.8% had 5-8h and, 1.1% had 8-10h of sleeping. Of the respondents, 60.4% suffer from problems regarding concentration on various things. 58.9% had disturbed eating problems. 23% used antidepressant medicines (Table 2). The comprehensive results demonstrate that among HCWs, 16.1% have low anxiety, 57.9% have moderate anxiety and 26% have severe anxiety regarding Covid-19 affliction (Figure 3).

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91.1% of respondents were practicing social distancing. 9.6% were using other workers’ phones, desks, and tools while 90.4% were not. 7.4% reuse mask while 92.6% don’t.

91.3% preferred to stay at home during quarantine and the rest 8.7% don’t (Table 2). On the whole, 93.8% demonstrate high conduct, and 6.2% exhibit low conduct (Figure 4).

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Mean Scores of Knowledge, Attitudes, Anxiety, and, Preventive Behaviors

The mean scores and standard deviation of knowledge, attitudes, anxiety, and, preventive behaviors were 6.77±1.17, 7.22±1.24, 12.29±3.73 and, 3.65±0.63 respectively.

Relationship between the Demographical Characteristics of the HCWs and their Knowledge, Attitudes, Anxiety, and, Preventive Behaviors

According to the results, which are displayed in the table, there was a clear association between the participants’ level of Covid-19 knowledge and their age, education, healthcare domain, and frontline HCW, with a p-value of <0.0001 for each, in order. With a p-value of 0.045, there was also a significant correlation between the respondents’ attitudes toward Covid-19 and their level of education. Additionally, with a p-value of <0.0001 for each, there was a strong positive relationship between the respondents’ anxiety and their education, healthcare domain, and frontline HCW

domain. With p-values of 0.045 and 0.003, respectively, there was a statistically significant positive correlation between the respondents’ conduct and their education and healthcare domains concerning their preventive behaviors regarding Covid-19 affliction (Table 4).

Discussion

According to the study’s demographics, the majority of respondents (49.1%) are between the ages of 25 and 30, indicating that they are youthful and active. Females outnumbered males by 58.1% to 41.9%. The majority (48.7% graduated) had completed their studies and were undergraduates (43.6%). Among other healthcare workers, physicians have the largest percentage (37.9%). The majority of them (91.1%) were frontline healthcare professionals.

According to this research, the knowledge of HCWs regarding the Covid-19 Affliction was good i.e. 65.5% including the clinical symptoms of the disease and viral transmission via respiratory droplets of infected individuals. This study is comparable to the studies conducted in Yemen in 2020 and Saudi Arabia in 2021 where it is 69.8% and 67.8%

respectively [8, 9] and lower (74.9%) than the findings of research conducted in Southern Ethiopia in 2021 [10] and in Punjab Province of Pakistan in 2020 (75.5%) [11] Yet greater than studies performed in India in 2021 (54.7%) [5] and Saudi Arabia [12]. In this survey, the knowledge of healthcare workers regarding Covid-19 was substantially correlated with age (P<0.0001), education (P<0.0001), healthcare domain (P<0.0001), and frontline HCW (P <0.0001). The association in this study of knowledge can be compared with a study done in Yemen in 2020 [13].

Regarding attitudes, 93.4% HCWs possess a good attitude which is significantly associated with educational status (P=0.045). This research is relatable to the studies conducted in Pakistan (86.5%) in 2020, Yemen (85.1%) in 2020, and Southern Ethiopia (84.2%) in 2021 [11, 8, 10]. However lower in studies conducted in Northeast Ethiopia (67.3%) and 53.4% in Nepal [14].

The study enlightens the participants’ knowledge, attitudes, anxiety, and preventive behaviors regarding Covid-19, which is needed to eradicate Covid-19. Most (65.5%) HCWs were aware of the Covid-19 Affliction, 93.4% have a positive attitude, 57.9% from moderate anxiety, and 93.8% are taking proper preventive measures and were well prepared to fight against Covid-19. This study reports mild (16.1%), moderate (57.9%) and severe anxiety (26%) among healthcare workers in twin cities of Pakistan therefore, and there is a need to take care of the mental health and well-being of healthcare workers who are caring for patients during this pandemic. This study reports mild (16.1%), moderate (57.9%) and severe anxiety (26%) among healthcare workers in twin cities of Pakistan therefore, and there is a need to take care of the mental health and well-being of healthcare workers who are caring for patients during this pandemic. In the Frontline HCWs, the mental illness risk was more as compared to non- frontline healthcare workers. In the emergency department, a frontline doctor committed suicide which is reported in The New York Times on 27th April and alarming news for the medical fraternity worldwide [15].

Regarding the anxiety of HCWs in this study, 16.1% suffered from mild anxiety, 57.9% suffered from moderate anxiety and 26% suffered from severe anxiety with significant association with the education (P <0.0001), healthcare domain (P <0.0001), and frontline healthcare worker domain (P<0.0001). It can be linked with the study performed in Yemen where the percentage of mild anxiety was 21.3, the percentage of moderate anxiety was 51 and the percentage of severe anxiety was 27.7% with a significant P value related to education was 0.004, and a study, in southern Ethiopia, in which the increase in several confirmed cases, lack of adherence to preventive measures, increased risk of infection among friends and families, and lack of specific medicines was increasing the level of anxiety among health care workers which was calculated as 21.5% [3].

The HCWs had good conduct regarding Covid-19 affliction (93.8%) and associated with education (P= 0.045) and healthcare domain (P=0.003) which is relatable to a study performed in Yemen (87.7%), Nepal (81.5%) and Pakistan (73.4%) [8, 14, 11].

The difference in the outcomes may be due to the population size, study methodology (cut-off marks), sampling size, and risk of infection, stressful work environment, and job concerns.

Limitations

This study has also limitations. The study is limited because the cross-sectional study design was used, which lacks in developing a causal relationship with the respondents and there is a need for longitudinal studies addressing these issues more appropriately. The responses provided were self- reported questionnaires to calculate knowledge, attitudes, anxiety, and preventive. Despite these limitations, this study gives valuable information about the knowledge, attitude, anxiety level, and preventive measures of healthcare workers regarding Covid-19 affliction in the twin cities of Pakistan.

Conclusion

The knowledge, attitudes, anxiety, and preventative behaviors of HCWs in twin cities of Pakistan related to the Covid-19 affliction study are relatively positive; however, anxiety problems in the present research must be resolved to effectively counter the Covid-19 affliction [16].

To improve the knowledge and reduce the mental distress in healthcare workers the management of hospitals and the government of Pakistan needs to take healthcare workers in confidence and make sure that they are getting medical coverage for themselves and their families. Online counseling and mental health support through trained psychologists are recommended [17].