Knowledge, Attitude, Practices and Risk of Psychological Distress among Frontline Healthcare Workers Towards COVID-19 in Second Wave
Correspondence Address :
Dr. Anand Bihari,
Statistician Cum Assistant Professor, Department of Community Medicine,
Government Medical College, Chakrapanpur, Uttar Pradesh, India.
Introduction: Frontline Healthcare Workers (F-HCWs) are at the front position for medical care against Coronavirus Disease 2019 (COVID-19) pandemic which has life-threatening potentials. Poor level of knowledge, practices and negative attitudes as well as high-risk of psychological distress among F-HCWs can directly lead to delayed diagnosis, treatment and poor infection control practices.
Aim: To assess the level of Knowledge, Attitude and Practices (KAP) as well as risk of psychological distress among F-HCWs for COVID-19 pandemic.
Materials and Methods: This descriptive, hospital-based, cross-sectional study was conducted at Government Medical College, Azamgarh, Uttar Pradesh, India, located in tertiary care centre in rural area) from October 2021 to December 2021 among 223 F-HCWs using convenient sampling technique. To assess the level of KAP as well as risk of psychological distress among F-HCWs a prevalidated structured questionnaire was used consisting 15 knowledge questions, six attitude questions, 15 practices questions and six questions on risk of psychological distress. Chi-square test was performed to examine the association between risk of psychological distress and level of KAP as well as with demographic characteristics of F-HCWs.
Results: Out of total 223 participants more than half of physicians (52.9%) and one-third of staff nurses (35.9%) were from age group of 25-35 years, respectively. Majority of both physicians (57.1%) and staff nurses (87.6%) were married and had nuclear type of family as of 64.3% and 74.5%, respectively. Most of the physicians (92.9%) had good level of knowledge but they had less positive attitude (84.3%) compare to staff nurses (92.8%). Majority of both physicians (64.3%) and staff nurses (58.2%) had no or low risk of psychological distress while only few of them had its high level.
Conclusion: In this study majority of F-HCWs reported overall ‘good’ level of knowledge, attitude and practices for prevention of COVID-19. As for as risk of psychological distress was concerned, majority of F-HCWs had its no or low risk.
Feeling nervous, Low risk, Mental health, Pandemic, Physicians, Staff nurses
World Health Organisation (WHO) declared Coronavirus Disease 2019 (COVID-19) a global pandemic on 11th March 2020 (1). As per WHO, till now, prevention is the only strategy to protect people’s health and prevent the spread of this outbreak. The World Health Organisation (WHO) has issued many guidelines on COVID-19 for various sectors of society, and has provided a range of education and training materials to Healthcare Workers (HCWs) to increase their awareness and preparedness for COVID-19 control and prevention (2). Standard recommendations to prevent the spread of COVID-19 include; wearing facemask, frequent cleaning of hands using alcohol-based hand-rub or soap and water, covering the nose and mouth with a flexed elbow or with disposable tissue while coughing and sneezing and avoiding close contact with anyone that has a fever and cough (2).
Healthcare workers are at risk of contracting infectious diseases, caused by blood, body fluid, airborne pathogens and they are exposed to highest level of risk when there has been sustained, close contact with a case of Severe Acute Respiratory Syndrome (SARS) or in high-risk transmission settings (3),(4). Healthcare workers are the main persons involved in the management of patients hence amongst the high-risk groups of acquiring the infection therefore, these at-risk groups should also be given adequate social and mental health supports (5). It was reported that statistical significantly higher levels of psychological distress (p-value <0.001), burnout (p-value=0.019) fear, stress, emotional, ethical, and social conflicts and tension in healthcare providers at workplace those who were providing direct patient care to infected patients or those who have survived infection (6),(7). HCWs play a very big role to control the spread of any communicable or non-communicable diseases as well as the impact of unintended consequences of any future pandemic.
Knowledge about disease may affect HCWs’ attitudes and practices, and incorrect attitudes and practices directly increase the risk of infection (8). Second wave of COVID-19 pandemic had very high infection and high mortality rate (9) therefore, it is necessary to ascertain and improve the level of knowledge, attitude and practices as well as to reduce the risk of psychological distress among Frontline Healthcare Workers (F-HCWs) whereby, infection and mortality rate due to it can be prevented in future. Therefore, this study aimed to assess the level of knowledge, attitude, practices and risk of psychological distress among F-HCWs regarding COVID-19 as well as to look for association between their socio-demographic characteristics and risk of psychological distress among them.
This descriptive, hospital-based, cross-sectional study was conducted at Government Medical College, Azamgarh, Uttar Pradesh, India, located in tertiary care cntre in rural area) from October 2021 to December 2021 among 223 F-HCWs using convenient sampling technique. The studied healthcare workers were assured of maintaining anonymity and confidentiality of collected data and they were informed that they had the right to withdraw from the study at any time, in despite of having given consent. Helsinki declaration of 1975, revised in 2013 was considered for the study (10). Approval was obtained from Ethical Committee of Institute (letter no.:1663/GMCA/IEC/2021 dated:19/9/2021). An informed written consent was taken from all the eligible participants prior to inclusion critera in the study.
Non probability method of convenient sampling technique was used to select 223 study subjects. Out of total 186 physicians and 202 staff nurses working at Government Medical College, only 70 physicians and 153 staff nurses participated in this study. Rest of the healthcare providers was on the duty in COVID-19 and non COVID-19 wards.
Inclusion criteria: F-HCWs who already had done their duty in COVID-19 ward and also had willingness to participate in the study.
Exclusion criteria: F-HCWs with severe illness and who were non willing to participate in the study.
Data on KAPs were collected by using predesigned, pretested and structured questionnaires. It was developed by researchers on the basis of a literature review of previously published relevant questionnaires, in keeping with the World Health Organisation (WHO) and Center for Disease Control and Prevention (CDC) recommendations (11),(12),(13). To assess the risk of psychological distress among F-HCWs, Kessler (K6) scale was used (14). Questionnaire was validated by expert and pretested on a sample of 15 F-HCWs who worked in COVID-19 ward and they were excluded from the final sample selection process. The cronbach’s alpha coefficient of knowledge, attitude and practices as well as questionnaire on psychological distress was 0.71, 0.80 and 0.70 as well as 0.81, respectively, indicating acceptable internal consistency. The results of the pilot survey were not included in the samples used for the actual study. The questionnaire used for collecting data to meet the purpose of the study, comprised of five parts.
Part-1 (Socio-demographic characteristics)
Included the socio-demographic characteristics of F-HCWs such as- age, gender, marital status, types of family, religion and caste.
The participants’ knowledge (15-items) was assessed about COVID-19.
• The 1st question allowed for multiple responses where they were asked for the most common symptoms of COVID-19 with a listed option assigned a score of one and zero. For this assessment, a participant was scored one who responded atleast three main symptoms of fever, dry cough and difficulty in breathing, otherwise zero.
• Remaining 14 questions were assigned a score of zero if the response was incorrect or ‘don’t know’ and one if the response was correct. Hence, the cumulative score for all 15 questions ranged from 0 to 15 points for each participant. Participants’ overall knowledge was graded using Bloom’s cut-off point as ‘good’ if the score was ≥80% (≥12 points) (15).
The participants’ attitude (6-items) was assessed which included questions about attitudes towards COVID-19 control, its threat to community, Importance of lockdown and responsibility of government, individual and community to prevent COVID-19. Each correct answer was given one point but an incorrect or do not know answer, given a score zero. Thus, total score of attitude of a participant was from zero to six. Participants’ overall attitude level was categorised, using Bloom’s cut-off point as ‘positive’ if the score was ≥80% (≥5 points) (15).
The participants’ practices (15-items) for prevention of COVID-19 were assessed by using Likert scale on frequency based questions. Responses of questions from 1 to 11 were very frequently, frequently, occasional, rarely and never where each weighing 4, 3, 2, 1 and 0 but questions number 12 to 15 were weighed 0, 1, 2, 3 and 4, respectively. Thus, the cumulative score for all 15 questions ranged from 0 to 60 points for each participant. Participants’ overall practices were categorised, using Bloom’s cut-off point as ‘good’ if the score was ≥80% (≥48 points) (15).
Part -5 (Psychological distress)
Included questions on the participants’ risk of psychological distress, which was assessed by using Kessler Psychological distress Scale K6 (14). It was developed to detect the general psychological distress, and has demonstrated good reliability and validity. It has six questions about their feelings during the past 4 weeks. It includes; so sad nothing could cheer you up, nervous, restless, hopeless, that everything was an efforts and worthless. There were five responses option for each question, ranging from “none of the time, a little of the time, some of the time, most of the time and all of the time, scoring; 0 ,1, 2, 3 and 4, was assigned to each response, respectively. Total score ranging 0-24, was calculated by summing up the responses to each question. Participants were classified for risk of psychological distress scoring (14):
• No or low risk: <5
• Mild/moderate risk: 5≤K6<13
• Hgh/severe risk: ≥13
All the preventive measures were taken during the course of study as per recommended guidelines (12),(13).
After compilation of data, analysis was done using Statistical Package for Social Sciences (SPSS) version 16.0, trial version. Descriptive statistics was used in the study to analyse the basic information regarding study. Mean, standard deviation and Chi-square test were used for data analysis. A p-value <0.05 was considered as statistically significant.
Out of total 70 physicians and 153 staff nurses; 37 (52.9%) and 55 (35.9%) were from age group of 25-35 years. As per gender, majority 58 (82.9%) of physicians were male whereas most of the staff nurses 144 (94.1%) were female. Majority of physicians 40 (57.1%) and staff nurses 134 (87.6%) were married and had nuclear type of family as of 45 (64.3%) and 114 (74.5%), respectively. Religion wise, most of physicians 62 (88.6%)as well as staff nurses 138 (90.2%) were Hindu while as per caste, majority 102 (66.7%) of staff nurses were from general category (Table/Fig 1).
Overall knowledge, attitude and preventive practices of physicians was 65 (92.9%), 59 (84.3%), 62 (88.6%), respectively. Overall knowledge, attitude and preventive practices of staff nurses was 134 (87.6%), 142 (92.8%) and 121 (79.1%), respectively. The mean of physicians’ knowledge (12.5±0.9) and practices (53.7±3.3) were higher than the mean of staff nurses’ knowledge (11.9±1.4) and practices (48.8±5.3). However, the mean level of attitude among staff nurses (5.1±0.7) was little higher than the physicians (4.9±0.6).The data shows that attitude of F-HCWs was found to be significantly associated (p-value=0.048) with type of F-HCWs (Table/Fig 2).
About two-third of physicians 45 (64.3%) and more than half of staff nurses 89 (58.2%) had no or low risk of psychological distress where its mean level among physicians was low (6.3±3.4) compare to staff nurses (6.5±3.8). Only few of them had high/severe risk of psychological distress where staff nurses 17 (11.1%) were affected more than physicians 5 (7.1%).The data shows that risk of psychological distress was found to be insignificantly associated (t-value=0.38, p-value=0.70) with type of F-HCWs (Table/Fig 3).
(Table/Fig 4), shows that majority of physicians and staff nurses who had ‘good’ level of KAP as of 44 (67.7%), 40 (67.8%), 40 (64.5%) and 76 (56.7%), 81 (57.0%) 70 (57.9%), respectively they also had low or no risk of psychological distress and only few of them had its high-risk. Statistically a significant (p-value <0.001) association was found between the level of knowledge and risk of psychological distress among physicians.
The physicians 26 (57.8%) and staff nurses 35 (39.3%) who had low or no risk of psychological distress were from age< 35 years (Table/Fig 5). As per gender, majority of physicians 38 (84.4%) and staff nurses 83 (93.3%) who had no or low risk of psychological distress were male and female, respectively. More than half of the physicians 25 (55.6%) and majority of staff nurses 80 (89.9%) who had low or no risk of psychological distress were married. It was also found that risk of moderate to severe psychological distress was more among married subjects compare to unmarried subjects. More than half of the physicians 27 (60.0%) and more than two third of staff nurses 62 (69.7%), who had low or no risk of psychological distress were belonged to nuclear family. All of the physicians 5 (100%) and most of the staff nurses 16(94.1%) who had high/severe risk of psychological distress were Hindu and it was also observed that most of the staff nurses 14 (82.4%) of general category had high/severe risk of psychological distress.
[Tables/Fig-6]a-c shows a prevalidated structured questionnaire was used consisting fifteen knowledge questions, six attitude questions, 15 practices questions and six questions on risk of psychological distress.
In current study, out of 223 F-HCWS (70 physicians and 153 staff nurses); more than half (52.9%) of physicians and above one third (35.9%) of staff nurses were from younger age group of 25-35 years, respectively. As per gender, majority of physicians (82.9%) were male where as most of the staff nurses (94.1%) were female. More than half of the physicians (57.1%) and majority of staff nurses (87.6%) were married and had nuclear type of family as of (64.3%) and (74.5%), respectively.
In this study, overall levels of knowledge, attitude and practices of 223 F-HCWs found to be 89.2%, 90.1% and 82.1%, respectively. Out of total subjects more than three fourth of them were assessed as ‘good’ where majority of physicians’ and staff nurses had KAP of 92.9%, 84.3%, 88.6% and 87.6%, 92.8%, 79.1%, respectively which is accordance to findings of previous study conducted by Elbqry MG et al., at Suez Canal University hospitals among 364 medical and paramedical staffs, and reported that most of them had satisfactory level of KAP as of 94.6%, 100%, 87.5% and 91.3, 94.4%, 91.7%, respectively (16). In similar study, conducted by Maurya VK et al., among 260 F-HCWs in Uttar Pradesh, reported that the knowledge (mean score: 9.77 out of 12 points), attitudes (mean score: 7.38 out of 10 points), and practices (mean score: 4.05 out of 5 points) among F-HCWs were relatively high (17).
As per study most of the physicians (92.9%) had good level of knowledge but they had less positive attitude (84.3%)compare to staff nurses (92.8%) and it was significantly (p-value=0.048) associated with type of F-HCWs which is comes in accordance with the study conducted in north India by Goel N et al., among 587 F-HCWs who revealed that overall knowledge (mean: 9.71 out of 12 points) among them was on higher side and positive attitude score in paramedical staff was significantly higher (mean: 1.8 out of 4 points) as compared to junior residents (mean: 1.7 out of 4 points) and specialists (mean: 1.6 out of 4) (18). Findings of current study are inconsistent with the findings of study conducted by Olum R et al., in Uganda who reported that overall mean levels of knowledge, attitude and practices among 136 HCWs were 82.4, 3.4 and 2.5, respectively where 69% and 74% HCWs had sufficient level of knowledge and practices but poor level of attitude (21%) (19). Another web based study conducted by Bhagavathula AS et al., among 453 HCWs, globally, revealed that healthcare workers had insufficient knowledge about COVID-19 pandemic but showed positive perceptions (78%) of COVID-19 transmission prevention (20). Sample size, timing and period of study and geographical variations might be responsible for the discrepancies in the findings. Some of the similar studies have been tabulated in (Table/Fig 7) (16),(17),(18),(19),(20),(21),(22).
In current study majority of the physicians (64.3%) had low or no risk of psychological distress compare to staff nurses (58.2%) and majority of physicians and staffs nurses who had ‘good’ level of KAP, they also had low or no risk of psychological distress which was much higher than the findings of previous study conducted at Suez Canal University hospitals (PHQ-4 scale was used) and reported that only 19.1% medical and 7.5% paramedical staffs had very low level of psychological stress (16). The findings of this study suggest that staff nurses had considerably greater levels of risk of psychological distress than physicians which might be explained by the fact that they were in closer contact with sick patients.
In this study, the prevalence of mild/moderate to high/severe risk of psychological distress among physicians and staffs nurses was found to be 35.7% and 41.8%, respectively, that is nearly similar to findings of previous study conducted by Wang Y et al., among 4184 healthcare trainees at Sichuan University in China, and reported that 30.9% participants had clinically significant (k6≥5) risk of psychological distress (21). However, a study conducted by Altwaijri Y et al., among 1843 HCWs in Saudi Arabia (used K6 scale) and revealed that 80.0% of HCWs who were directly engaged (n=395) with the care of COVID-19 patients had high prevalence rate of mild/moderate and severe psychological distress (22). Findings of another study which is inconsistent to present study, revealed that 57.4% and 49.1% of medical and paramedical participants had moderate level of psychological stress and about one fourth of them had its severe form (16). There was a significant association between COVID-19 risk of psychological distress and good level of knowledge of physicians which is accordance to previous study (16). In current study, it was found that as age increases, the risk of mild/moderate and high level of psychological distress among F-HCWs also increases that was inconsistent to the findings of previous study which revealed, the older age groups (40-70 years old verses 20-29 years old) had decreased odds of experiencing higher distress (22). As per gender, female subjects (staff nurses) had higher level of moderate to high-risk of psychological distress compare to male (physicians) which is accordance to the previous study where women were more likely than men to experience increasing psychological distress (22). In this study demographic characteristics of F-HCWs were not associated significantly with risk level of psychological distress, which indicates that COVID-19 pandemic and its related national preventive policies affect the mental health of hospital workers non discriminatively.
In current study, decreased risk of psychological distress among F-HCWs might be due to improving level of KAPs, psychological supports and confidence level (after getting vaccine against COVID-19), effective communication and proper information dissemination as well as conduction of study in late phase of the pandemic when mortality and morbidity were reduced. These all conditions might have contributed to a significant difference in level of KAP and mental health of the F-HCWs.
There were some limitations in the present study. Firstly, it was a descriptive cross-sectional survey from a single centre with small study subjects. The data did not indicate changes in psychological distress from the pre-pandemic period; rather, they characterise its trouble during second wave of COVID-19. Secondly, the response rate was low among the F-HCWs, and those who did not participate might have been with highest stress levels at work. Thirdly, it was asked only about feelings of psychological symptoms once in the late phase of the pandemic, so longitudinal studies are needed in the future, as symptoms may change over time. Fourthly, there were no more researches that used this scale (k6) to assess the risk of psychological distress related to COVID-19 among healthcare workers. The generalizability of these findings to other hospitals and medical populations remains unclear and, therefore, needs more investigation.
In this study overall level of knowledge, attitude, and practices among majority of the physicians (92.9%, 84.3%, and 88.6%, respectively) and staff nurses (87.6%, 92.8%, and 79.1%, respectively) were as ‘good’ regarding COVID-19 infection prevention. As for as risk of psychological distress was concerned, more than half of the physicians (64.3%) and staff nurses (58.2%) had low or no risk and only few physicians (7.1%) and staff nurses (11.1%) had its high-risk. However, improvement is still required. Therefore, to improve the level of KAP and to reduce the risk of psychological distress among HCWs there must be conduction of educational professional programs time to time and continuous provision of psychological support to all of them.
Authors would like to thanks all participants, all faculty members who supported this research, junior residents, interns and non teaching staffs of Community Medicine Department, Government Medical College, Azamgarh, Uttar Pradesh, India.
Date of Submission: Jun 01, 2022
Date of Peer Review: Jun 10, 2022
Date of Acceptance: Aug 27, 2022
Date of Publishing: Sep 01, 2022
• Financial or Other Competing Interests: None
• Was Ethics Committee Approval obtained for this study? Yes
• Was informed consent obtained from the subjects involved in the study? Yes
• For any images presented appropriate consent has been obtained from the subjects. NA
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