Knowledge of COVID-19 among Health Care Workers at a Tertiary Care Hospital of Nepal: A Descriptive Cross-sectional Study

ABSTRACT Introduction: Health care workers are at higher risk of infection with the coronavirus disease as they are directly involved in the treatment of infected patients and perform aerosol-generating procedures. Proper knowledge of this disease can influence the positive attitude, good practices and enhance their safety. We aim to study the knowledge of COVID-19 among health care workers of the tertiary care hospital of Nepal. Methods: A descriptive cross-sectional study was conducted among health care workers of Shahid Gangalal National Heart Centre from May 20 to June 19, 2020. Ethical approval was taken from the Institutional Review Board (IRB No: 4-2020). Written informed consent was taken from all respondents. Correct answers were summated to reflect the mean knowledge, expressed as a percentage. Data analysis was done using Statistical Package for the Social Sciences version 21. Results: The mean general knowledge score was 95.7%. The mean medical knowledge score was 70.5%. Only 42 (56.8%) of physicians and 103 (53.6%) of nurses had a higher level of medical knowledge regarding COVID-19. Likewise, very few lab technicians 7 (21.9%) and none of the pharmacists had a higher level of medical knowledge. Conclusions: The healthcare workers of this centre have adequate knowledge regarding COVID-19. However, periodic training for all workers, especially the nurses and allied workers, may help to update the knowledge and hence enhance their safety and that of their patients.


INTRODUCTION
Health care workers (HCWs) are at risk of Coronavirus disease (COVID-19) because of prolonged and repeated exposure to patients and because HCWs work in a team and physical distancing is usually not possible among them. 1 HCWs of the cardiac centre are at even heightened as COVID-19 can manifest or precipitate as cardiovascular emergencies and also due to their involvement in aerosol-generating procedures (AGP). 2 Poor knowledge and misunderstanding have been found to lead to delayed treatment, 3 recognition, and handling of potential COVID-19 patients, ultimately leading to its rapid spread in hospitals. 4,5 Thus, this study aims to investigate the knowledge of COVID-19 among HCWs of tertiary level cardiac care hospital in Nepal. This will help to generate evidence that can support the hospital management to design interventions to ensure the safety of HCWs and patients at this time of the pandemic.

METHODS
This is a descriptive cross-sectional study conducted among HCWs of Shahid Gangalal National Heart Centre from May 20 to June 19, 2020. Ethical approval was taken from Institutional review board (IRB No: 4-2020), Shahid Gangalal National Heart Centre and written informed consent was taken from all respondents. Participants were enrolled using convenient sampling technique. The sample size was calculated using the formula, n= Z 2 x p x (1-p)/e 2 = (1.96) 2 x 0.5 x 0.5/(0.06) 2 = 267 Where, n= sample size Z= 1.96 at 95% Confidence Interval (CI) p= population proportion, 50% e= margin of error, 6% Taking a 10% non-respondent rate, the sample size became 294. However, data was collected from 305 HCWs.
The data was collected through a self-administered questionnaire, consisting of three sections: sociodemography, general knowledge, and medical knowledge. Correct answers were summated to reflect the mean knowledge, expressed as a percentage. The socio-economic status was analyzed using 5 household items (mobile, house, laptop, vehicle, internet). 6 Data analysis was done using Statistical Package for the Social Sciences (SPSS) version 21.

RESULTS
The mean basic score was 95.7%. All general knowledge factors were answered correctly by more than 90% of respondents except for the knowledge related to disease symptoms, which was correctly answered by 219 (71.8%) of respondents only. General knowledge about COVID-19 was assessed using 10 factors (Table 1).

DISCUSSION
COVID-19 has emerged as a significant public health concern, especially after the World Health Organisation (WHO) declared it as a pandemic on 11 th March 2020. 7 Nepal had its first COVID-19 case on January 24, 2020. CPR being one of the high-risk procedure to transmit COVID-19 infection, there have been some changes in the American Heart Association and European Resuscitation Guideline for CPR of suspected or known COVID-19 patients. 21 The study showed 77.8% of HCWs know CPR of such patients referring that a good percent of HCWs of this center has already updated themselves on those CPR guidelines.
This study revealed that the majority (87%) of HCWs gather their information through social media-Facebook, twitter etc. Interestingly, only 2.29% of HCWs referred to more authentic sources like classes, webinars, journals etc. for information. Since the knowledge of respondents in this study is quite high, they referring to social media for information shows that the use of social media is increasing and gaining trust globally. However, the government should be vigilant and scrutinize the use of social media ensuring only authentic and updated information about COVID-19 is disseminated. Also, the fact that decreased use of gadgets like mobiles can also decrease the transmission is known to only 65.9% HCWs, and their increased use of social media might increase the risk of disease transmission through these gadgets as it might act as fomites.
On average, the overall knowledge of the physicians and nurses is better than allied HCWs. However, only around half of the physicians and nurses had a higher level of medical knowledge. This highlights the need to impart further knowledge to the HCWs.
There are various limitations to this study. Firstly, this study was conducted among the HCWs in the cardiac centre of an urban area with good access to modern teaching-learning and internet facilities-webinar. So, the result might not be generalized to other multidisciplinary and rural centres. Secondly, only the knowledge was assessed and not skills. Knowledge is also obtained hands-on, meaning HCWs might be learning things while they practice. The 100% knowledge of HCWs regarding hand hygiene might be due to pre-existing proper hand hygiene practices in the center of study. 22 Conversely, the HCWs might have theoretical knowledge about the proper use of PPE, but may not be able to apply in practice (eg. unable to doff). Not being able to measure skill limits the study in being able to triangulate the knowledge and skills. The study was conducted among the HCWs only while knowledge of non-HCWs about COVID-19 is also important to prevent its transmission.

CONCLUSIONS
HCWs from this centre have a better knowledge of COVID-19 than previous studies, though it differs significantly among physicians, nurses, and allied HCWs. As the understanding of this disease is rapidly evolving, there is a constant need for updating the HCWs regarding new protocols and guidelines for COVID-19. Also, with a shortage of PPE, the knowledge of use/reuse of appropriate PPE becomes very important. As there is a possibility of long-term existence of SAR-CoV-2 but no definite treatment till now, COVID-19 might become an even bigger public health emergency in the future. This has increased the need to provide ongoing training on the use of appropriate PPE with the appropriate technique of donning and doffing and additional education and training to manage the surge if it occurs. Therefore, this study recommends the hospital management to arrange for periodic webinars, online modules, or other sources of authentic information for all HCWs, with special focus on allied HCWs.