Knowledge Attitude and Preventive Practices of COVID-19 among Health Workers, Liberia, 2020

Himiede Sesay^1,&, Godwin Etim Akpan¹, Peter Adebayo Adewuyi¹, Obafemi Joseph Babalola¹, Lily Sanvee Blebo¹, Faith Kamara Whesseh¹, Maame Amo-Addae¹, Liberia Field Epidemiology Training Program Intermediate cohort four^2,3

 

¹Liberia Field Epidemiology Training Program, ²Ministry of Health, Liberia, ³National Public Health of Liberia

 

 

^&Corresponding author
Himiede Sesay, Liberia Field Epidemiology Training Program, Apartment 4, Harmon Compound, Opposite Last Mile Health Office, Congo Town, Monrovia, Liberia. hsesay@afenet.net

 

 

 

 

The declaration of COVID-19 as a pandemic by the World Health Organization in March 2020 exacerbated demand on health care delivery systems in screening and managing ill people [1]. Some health systems were on the verge of collapse. The frontline health workers were under pressure to provide services that could have exposed them to infectious diseases [2]. To reduce the risk of infection, it is important that health workers have good knowledge, exhibit a positive attitude and demonstrate good preventive practices toward the infectious disease. Due to the novelty of the disease, WHO and other agencies published guidance on preparedness, infection prevention, and control of the disease [3]. Previous studies have attributed the increased rate of infection among health workers to poor knowledge and preventive practices [4, 5].

 

The number of health workers infected with COVID-19 has been increasing since the beginning of the pandemic [6]. Different reasons have been adduced for the increase in infection. Each country had been making effort to understand the drivers of health work infection in their region. However, I can say that the reasons for the infection are multifactorial and probably included poor knowledge and poor practice. Understanding the health worker´s knowledge, attitude, and practice toward COVID-19 is the necessary first step to mitigating the burden of infection on the workforce. This study was aimed at determining the level of knowledge, attitudes, and preventive practices against COVID-19 among health workers in Liberia to guide the national response to the pandemic.

 

 

Setting

 

The study was conducted in Liberia which has a current estimated population of 5.2 million [7]. The country has a total of 831 health facilities which are divided into public (government-owned) and private (non-government owned private-for-profit, and private-for-non-profit). Of the 831 health facilities, 457 (55%) are public hospitals and 374 (45%) are private hospitals. However, for surveillance purposes, the health system is broken down into national, county, district, health facility, and community levels. Liberia is one of the West African nations with a fragile health system which was hard hit by the 2014 West African Ebola Virus Disease (EVD) outbreak. The impact of the outbreak on healthcare workers involved with the response was grave and therefore, lessons learned from that response have improved knowledge of disease surveillance [8].

 

Study design and population

 

This study employed an analytical cross-sectional design during the second wave of COVID-19 (February 2021) in Liberia.

 

Sample size

 

We calculated our desired sample size using the formula a for a single independent proportion, with the following parameters Z= 1.96, assuming a prevalence of 50% knowledge of COVID-19 among HCW [9, 10], degree of freedom of 5%, and a design effect of 1.5 giving a minimum sample size of 576. After adjusting for the 0.9 non-response rate, the desired sample size was 640.

 

Sampling method

 

We used a multi-stage sampling technique to select our respondents from health facilities.

 

Stage 1: Selection of health facilities

 

We obtained a list of all health facilities by county from the Ministry of Health. In each county, we stratified the health facilities into public and private. A list of random numbers was electronically generated in open epi software and using a simple random sampling technique and probability proportionate to the size (PPS) of health facilities we randomly selected health facilities in each stratum. Sixteen public and 14 privates were selected to participate in the survey. A health facility was defined as one that caters to ≥40 people weekly, have a clinical laboratory, a capacity for admission and a referral system [11].

 

Stage 2: Selection of respondents

 

In each of the selected health facilities, the list of health workers was obtained. Based on the number of health workers each facility had, a random numbers list was generated. Using the number list a simple random sampling technique was carried out to select respondents.

 

Data collection tool

 

Data for the study were collected using an interviewer-administered structured questionnaire on Android Tablets with an installed Kobo toolbox application (Kobo Collect version 1.28.0). The questionnaire comprised four parts: Demographics, Knowledge, Attitudes, and Practices of COVID-19 among health workers in Liberia. The study tool was developed using information gathered from studies that assessed knowledge attitudes and practice related to COVID-19 and WHO´s guidelines for assessing risk for COVID-19 among healthcare workers [12-14]. The tool was pre-tested in health facilities not selected for the study for over a period of two weeks. Feedback from the pre-test exercise was used to modify the questionnaire where necessary.

 

Data collection methods

 

Data collectors were 16 trainees of the Liberia Intermediate Field Epidemiology Training Program. Prior to conducting the study, trainees (data collectors) were trained on data collection tools to enhance their knowledge and skills required to conduct the survey in an accurate and reliable manner. These trainees were divided into 8 groups of 2 members each. Upon arrival at a health facility, each group approached the health facility administrator or Officer in Charge (OIC) and explained the purpose and sought permission for the study approval. When permission was granted, they requested the list of HCWs from which the selected health workers were approached and a questionnaire was administered once informed consent was obtained.

 

Measurement of variables

 

The outcome variables for this study were knowledge of COVID-19, attitude toward COVID-19, and COVID-19 preventive practices. We assessed knowledge with 8 questions that explored the cause, transmission, signs, and symptoms of COVID-19. Each correct response was scored 1 point while an incorrect answer was scored 0 points, giving a maximum attainable score of eight. A respondent who scored six and above was categorized as having good knowledge else the respondent was categorized as having poor knowledge.

 

Attitude was assessed using 10 questions on a five-points likert scale, with a perfect score of 50. A respondent who scored ≥40 was categorized as having a good attitude else the respondent was categorized as having a poor attitude.

 

A correct answer was scored 1 point while an incorrect answer was scored 0 points. A respondent who scored four points and above was categorized as having good COVID-19 preventive practices else the respondent was categorized as having poor preventive practices.

 

Our independent variables: were age, sex, highest qualification, category of health workers (clinician & non-clinician), duration in the present job, health facility type (GOL & Non-GOL), and history of previous training. clinicians (Doctors, Physician Assistants, Pharmacists, Nurses, Midwives, Laboratory Technicians, and Nurse Aides) and non-clinicians (Laboratory Aides, Registrars, Cleaners, Securities, Dispensers, Electricians, Drivers, and Administrators).

 

Data analysis

 

Data collected was cleaned in Ms Excel 2016 and exported to Epi info version 7.2 for analysis. We summarized the socio-demographics findings in frequencies and proportions also, calculated median age and interquartile range. The sources of COVID-19 information mentioned by respondents were described based on multiple responses provided.

 

We explored the association between the independent and dependent variables using an odd ratio, 95% confidence interval, and chi-square test with a p-value of <0.05. To evaluate the strength of the association those independent variables with a p-value of <0.2 were modeled in multiple logistics regression. The crude and adjusted odds ratio and 95% confidence interval were reported. Results were presented in tables.

 

Ethical considerations

 

Institutional Review Board (IRB) clearance for the study was obtained from the University of Liberia ethics board with approval number FWA00004853. Written informed consent was obtained from each respondent and confidentiality was maintained in data management.

 

 

Ninety-eight percent (630/640) of the targeted respondents were interviewed. The median age of the respondents was 39 with range 16-84 years, age category 30-39 years accounted for 40% (249/630) of respondents. Fifty-six percent (352/630) of the respondents were females while 61% (386/630) had attained more than secondary education. Also, 50.6% (319/630) were clinicians, while nurses accounted for 45.1% (284/630) and 59% (372/630) represented health workers from public facilities. Fifty-eight percent (365/630) had stayed on the job for 5-10 years Table 1.

 

The proportion of health workers that had good knowledge was 55.4% (349/630). Assessing the means of communication information, radio accounted for 83.5% (516/618) followed by friends with 28.5% (176/618), and television with 33.2% (162/618). However, 24.9% (154/618) of health workers mentioned social media as the means of COVID-19 communication Figure 1

 

Respondents with higher education were more likely to have good knowledge. Those that have post-secondary education were (aOR: 10, 95%CI: 3.53-26.66) associated with good knowledge. Clinicians in the study population were less likely to have good knowledge of COVID-19 (aOR: 0.5, 95%CI:0.37-0.93) compared to non-clinicians. Health workers who had previously been trained were 8.5 times (aOR=8.5, 95%CI: 5.53-13.08) associated with good knowledge among respondents Table 2.

 

The proportion of health workers with good attitudes was 29.8% (188/630). Health workers who had post-secondary education (aOR: 3.7, 95%CI: 1.19-11.48) or secondary education (aOR: 3.1, 95%CI: 1.02-9.36) were more likely to have a good attitude compared to respondents with no formal education or only primary education. Also, clinicians who participated in this survey had a good attitude towards COVID-19 prevention (aOR: 0.8, 95%CI: 0.50-1.19). Health workers in public health facilities were less likely to have a good attitude (aOR: 0.7, 95%CI: 0.45-0.96) compared to health workers in private facilities. Also, a good attitude among respondents was associated with health workers being previously trained in Infection Prevention and Control (IPC) (aOR: 2.6, 95% CI: 1.78-3.77) compared to those who had not been trained in Infection Prevention and Control Table 3.

 

The proportion of health workers with good preventive practices was 50.9% (321/630). A predictor of good preventive practices of COVID-19 infection among our study participants was health facility type. Those who work in public health facilities were less likely to have good preventive practices (aOR: 0.5, 95%CI: 0.41-0.83), and also a health worker who had previously been trained in Infection Prevention and Control was associated with good preventive practices (aOR: 4.4, 95%CI: 3.09-6.33) Table 4.

 

 

Findings from our study revealed that only half of the health workers had good knowledge of COVID-19 preventive practices 11 months into the outbreak, this signifies that despite risk communication messaging, the ongoing public awareness had not yielded the desired result eleven months into the outbreak. This could be due to the composition of our study population which comprised more non-clinicians compared to clinicians. Similar findings have been reported in other studies though the level of knowledge varied among the different cadre of health workers [3, 10] contrary were studies from Uganda and Egypt that mentioned the knowledge of respondents to be good [13, 15].

 

Health workers with postsecondary education were ten times more likely to have good knowledge of COVID-19 compared to those with primary or no education. This could be because the majority of these respondents were more likely to have access to internet services and other information sources. This group was more likely to be doctors and nurses which suggests that they could have good knowledge. This was contrary to a study in Uganda that mentioned there was no change in knowledge despite academic qualifications [16]

 

Clinicians are twice more likely to have good knowledge compared to non-clinicians. This could be because, nurses, pharmacists, doctors, and lab technicians were more likely to make an extra effort to learn more about the new disease than non-clinicians. They are more likely to make contact with a suspected or confirmed case of COVID-19 in the line of their duty. This provides extra motivation for them to learn more about the disease compared to the non-clinicians. Also, clinicians already have existing fundamental knowledge about infectious diseases making it easier for them to add new knowledge about the novel disease [3, 4, 6, 13].

 

Having previous IPC training was a predictor of good knowledge of COVID-19 among health workers. The relationship between previous training and better knowledge of COVID-19 has been reported in an earlier study [6, 17].

 

Generally, the attitude among respondents in this study was observed to be poor. The attitude was unexpected, considering the lessons learned from the Ebola outbreak which had a huge death toll among health workers due to the negative attitude towards the disease. It was expected that healthcare workers could have had a better attitude towards the desire since they have a higher risk of being infected with the disease. However, the unavailability of required medical supplies, logistics, and infrastructure could result in health workers´ poor attitude toward preventing COVID-19 infection. The poor attitude among health workers has earlier been reported in a study in Nepal [18, 19]. Studies from Egypt and Nigeria reported a higher proportion of good attitudes observed among health workers [12, 15]. Health workers who had not received previous training on IPC were less likely to have a good attitude to the COVID-19 infection[18].

 

Poor attitude to COVID-19 prevention was associated with low education. Low education could result in lower risk perception which could affect the attitude toward disease-preventive practices. The relationship between education, preventive practices, and attitude toward COVID-19 has earlier been reported by Amro et. al who stated having satisfactory knowledge is a criterion for building positive preventive practice and devising a positive attitude [20].

 

Generally, preventive practices among health workers were poor. The poor preventive practices observed in this population could be due to the misconception of the disease by health workers that it was an ordinary flu that could be treated with other local home remedies. The findings were different compared to the levels of preventive practices observed by researchers in Nepal[13, 18]. While those who had participated in recent IPC training had good preventive practices compared to those who had never participated in IPC training which is similar to a study in Nepal [21].

 

 

We conclude that almost a year into the COVID-19 pandemic, knowledge, attitude, and preventive practices towards COVID- 19 among healthcare workers in Liberia were still suboptimal. The Ministry of Health and the National Public Health Institute need to focus on infectious diseases educational programs that improve the knowledge, attitude, and practice of the healthcare workers not just towards the pandemic but to strengthen the entire public health workforce towards stronger health security.

 

 

The authors declare no competing interests.

 

 

HWWS conceptualized the work and contributed to the design, formal analysis, interpretation of data, and development of draft manuscript. MAA supervised the entire study, solicited ethical approval, and review initial manuscript, PAA supervised the study, supported formal analysis, interpretation of data, and review of draft manuscript. OJB supported development of study by conducting literature search, analysis and interpretation of data and revision of initial manuscript, LSB contributed to the design, ethical approval, analysis, and interpretation of data and revision of the draft manuscript, GEA contributed to the design, developed electronic data collection tool, and review draft manuscript, FKW contributed to the design, analysis and interpretation of data, and review of the initial manuscript. Liberia Field Epidemiology Training Program Intermediate cohort four was involved in the design, data collection, analysis, interpretation of data, and drafting of a preliminary report.

 

 

We would like to thank the Ministry of Health and the National Public Health Institute of Liberia for their support in conducting this research. The United States Centers for Disease Control and Prevention for funding and technical support. Also, our special thanks to all health workers in both Government and Private health facilities who participated in this survey and the Liberia Field Epidemiology Intermediate cohort four for data collection (Emmanuel Dwalu, Tete Kpeoh, Facia Gaydour, Trokon Roberts, Horatius Gaye, Boye Nuyelleh, Moses Blackie, Thomas Kowel, Janjay Glay, Georgia Sneh, Hawa Smith, Mustapha Sombai, Aloysious Zinnah Momo, Blamo Kamara, Maxwell Collins, Rukiatu Bah.

 

 

Table 1: Sociodemographic characteristics of health workers, Liberia February 2021

Table 2: Factors associated with good knowledge of COVID-19 among healthcare workers, Liberia, February 2021

Table 3: Factors associated with good attitude of COVID-19 among healthcare workers, Liberia, February 2021

Table 4: Factors associated with good preventive practices of COVID-19 among healthcare workers, Liberia, February 2021

Figure 1: Means Sources of communication of COVID-19 information among health workers, Liberia February 2021

 

 

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