Knowledge, preventive behaviors and risk perception of the COVID-19 pandemic: A cross-sectional study in Turkish health care workers.

The coronavirus disease 2019 (COVID-19) outbreak spread to over 100 countries with a total of 100,000 cases during the first week of March 2020. Health care workers, as those on the frontline of the COVID-19 pandemic, are more susceptible to infection. Inadequate related knowledge and preventive behaviors among health care workers might lead to delayed treatment and result in the rapid spread of the infection. Therefore, this study evaluated the knowledge of health care workers with regard to COVID-19. A cross-sectional study was conducted from June 10-18, 2020. Participants were general practitioners, specialists, and nurses working at the forefront of the pandemic. Their knowledge, preventive behaviors, and risk perceptions concerning COVID-19 were evaluated using an online questionnaire created by our medical specialists. The questionnaire consisted of 29, 5, and 4 items about COVID-19 knowledge, preventive behaviors, and risk perceptions, respectively. A total of 251 health care workers completed the questionnaire. The mean age of the participants was 33.88±8.72 years old, and the sample consisted of 68 males (27.08%) and 183 females (72.91%). While there was no difference between the percentage of correct answers given by female and male participants to knowledge-based questions (p>0.05), the percentage of correct answers to the questions on preventive behaviors was significantly higher in female participants than in males (p<0.001). The overall average percentages of correct responses were 91.66% for knowledge-based questions and 85.96% for preventive behavior questions. The scores for knowledge-based questions were higher for medical specialists, whereas nurses scored higher on preventive behavior questions. Government hospital staff showed a significant difference in preventive behaviors compared to that of university hospitals (p<0.05). In addition, there was a positive correlation between knowledge scores and preventive behaviors. Although all the participants (100%) knew that contracting COVID-19 can lead to death, only 66.93% of them were willing to get vaccinated themselves. The knowledge level of health care workers concerning COVID-19 was above 90%, but the level of competence in terms of preventive behaviors was found to be low, especially in males.

Introduction

An outbreak of viral pneumonia of unknown etiology occurred in the city of Wuhan in eastern China in December 2019 [1]. This viral infection has received extensive attention throughout the country, as well as around the world [2]. The causative agent of the disease, named COVID-19 by the World Health Organization (WHO), is a coronavirus subtype called severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) [3]. The incubation period between the ingestion of the virus and the onset of symptoms is 2–14 days (4 days on average) [1, 4]. COVID-19 causes fatal pneumonia similar to that generated by severe acute respiratory syndrome coronavirus (SARS-CoV) and Middle East respiratory syndrome coronavirus (MERS-CoV), which have sporadically occurred in countries all over the world in the past 20 years [4]. Although COVID-19 is similar in many ways to SARS-CoV and MERS-CoV, it is also different in other ways. It may not be as severe as SARS-CoV and MERS-CoV. The crucial transmission route that is currently agreed upon is human-to-human via direct contact or respiratory droplets [5-7]. However, the rapid increase in incidence indicates that the virus is more contagious than SARS-CoV and MERS-CoV [4, 5, 7]. Also, there is no proven treatment or vaccination against SARS-CoV-2. Therefore, global concerns about the virus have risen dramatically [5].

According to the Ministry of Health of Turkey, the first detected case of COVID-19 in Turkey was announced on March 11, 2020. The first virus-related death in the country occurred on March 17, 2020. Confirmed cases are rising each day due to the increase in the number of laboratories that can perform a diagnostic or rapid test [8]. The pandemic poses a great risk for health care workers (HCWs), who are often in direct contact with infected patients [3]. While no HCWs in China had the disease at the beginning of the epidemic, it was reported that 7% of patients were HCWs after January 12, 2020 [9]. On April 1, 2020, Turkey reported that almost 600 infections of COVID-19 were of health personnel, while the rate for other patients was 3.6% [8]. The battle against COVID-19 is continuing in Turkey. To improve this situation, HCWs must have robust knowledge, attitudes, and practices pertaining to COVID-19.

Many international studies have found that the knowledge and attitudes of HCWs regarding infectious diseases are moderate [7, 10]. For example, only a rather low percentage of HCWs strictly follow the correct universal protection methods [11]. It is extremely important to protect HCWs from risk factors. For one, the infection of HCWs will adversely affect the supply of health care services, causing a decrease in the health care system’s reaction to the epidemic and an uncontrolled increase in the incidence rate. Therefore, in this study, we determined the knowledge and protection levels of HCWs in relation to COVID-19 and evaluated their risk perceptions during the course of the pandemic.

Materials and methods

This cross-sectional study was conducted in Turkey. The study’s target population was HCWs working in pandemic hospitals in the center of Ankara. The 340 HCWs had established a common WhatsApp group to share current developments and news about the pandemic. Each participant had also shared their mobile phone number, email address, and further details to receive other information about the progress of COVID-19. We conducted our survey between June 10 and June 18, 2020, within this shared HCW WhatsApp group, which included doctors and nurses working at state or university hospitals, and 251 appropriate answers were received. The inclusion criteria were as follows: participants who were at least 18 years old, still working as HCWs (doctors and nurses), and with completed questionnaires. In line with measures to avoid the spread of COVID-19, the questionnaire was administered through the Internet.

Demographics

This information included age, sex, level of education, marital status, current work status, and place of work. Participants were also asked if they had received any training on how to protect their wards from a COVID-19 outbreak. The demographic information section was designed based on a previous study [10].

Knowledge of COVID-19

The scale for the level of knowledge consisted of a 29-item scale based on a previous study on MERS [10, 12]. In this section, there were three questions about COVID-19 etiology and basic science, eight about its transmission, eight about the incubation period and symptoms, four about treatment, and six about public prevention. For informational questions (vs. subjective questions), correct answers were given one point, and incorrect (and “I don’t know”) answers were given zero points.

Preventive behaviors

The scale for evaluating preventive behaviors was based on previous studies [10, 13]. A five-item scale was used to assess responses; it including three items about preventive action during daily routines, one question about reducing the use of public spaces in daily life, and one question about conventional therapy methods for prevention.

The choices were “yes” or “no,” and the participants were assigned one point for each positive behavior (wearing masks, using gloves, avoiding crowded environments, and using protective equipment in the workplace).

Risk perception

The ultimate purpose of risk assessment is to limit an outbreak, enable emergency interventions, and mitigate the impact using non-drug public health measures. This is particularly important for COVID-19, which does not have currently a specific treatment or vaccine. Risk assessment starts with detecting the event and continues until it is under control [14]. Four questions were prepared to understand the risk assessment levels of HCWs. The questions asked whether they would get the COVID-19 vaccine, what they thought about the seriousness of COVID-19, whether they believed it will be contained, and finally, their opinions on how long it will take to contain it.

Ethical considerations

This study was approved by the Dr. Abdurrahman Yurtaslan Ankara Oncology Educational and Research Hospital’s Clinical Research Ethics Committee (2020–06/644) and the Ministry of Health Scientific Research Platform. Respondents’ confidentiality and anonymity were ensured. The submission of the answered questionnaire was considered to be their consent to participate in the study.

Sampling

Before starting the study, the reviewed literature and the minimum sample size determined by the publication’s data were in accordance with the study’s original hypothesis [15]. The sample size was calculated through power analysis using the G * Power 3.1.9.2 program based on gender groups in the publication [15]. With a 5% significance level (alpha), 95% confidence interval, and 80% power (1-beta), the required sample size was calculated as being at least 51 patients for each gender group.

Statistical analysis

Descriptive data are given as average standard deviation, median, minimum, and maximum values, and continuous and discrete data are presented as percentages. The adherence of the data to a normal distribution was analyzed using the Kolmogorov–Smirnov test. The Mann–Whitney U test was used to compare the percentage of correct answers of participants with independent variables between two groups. The Kruskal–Wallis analysis of variance was used to compare independent variables for more than two groups. The groups originating from the differences were analyzed using the Kruskal–Wallis multiple comparison test. Chi-square and Fisher’s exact tests were used for comparisons of nominal variables between groups. A general linear model test was used to compare the corrected data, while a multiple regression analysis was used to analyze the relationship between the corrected data. The data were analyzed using SPSS version 21.0 (IBM, Armonk, NY, USA). A p value of less than 0.05 was considered statistically significant.

Results

A total of 251 HCWs responded to the questionnaire. The mean age of the participants was 33.88±8.72 years old (21–76). Overall, 72.91% of the participants were women, and 97.61% were university graduates. Of the health care professionals, 40.64% were nurses, 21.12% were general practitioners, and 38.24% were specialists. Of them, 40.24% were working in state hospitals and 59.76% in university hospitals. At the time of the survey, 68.92% of the health care professionals stated that they had received training about COVID-19.

The average percentage of correct answers to knowledge-based questions across all participants was 91.66±6.16 (65.5–100); it was 85.96±18.83 (25–100) for preventive behavior questions. The percentage of correct answers differed by occupation and place of work for knowledge-based questions; for preventive behavior questions, differences were found based on sex, education status, occupation, and workplace. There were no correlations between the age of participants and correct answers for either question group.

Medical specialists had a significantly higher percentage of correct answers to knowledge-based questions compared to general practitioners and nurses (p = 0.015 and p = 0.001, respectively), and public hospital employees significantly outperformed those working at university hospitals.

Regarding the preventive behavior questions, the percentage of correct answers was higher in females than in males, in high school graduates than in those with a university degree, in state hospital employees than in those working at university hospitals, and in nurses than in specialists. The rates of use of gloves, medical masks, N95 masks, visors/protective glass, disposable aprons/overalls, and aprons/jerseys were 95.62%, 92.82%, 35.85%, 20.72%, 12.35%, and 21.91%, respectively.

There were no differences in the rate of correct answers to knowledge-based and preventive behavior questions between those who had received COVID-19 training and those who had not (Table 1). Most participants (68.92%) stated that they had received training on COVID-19 at their institutions. This rate was higher at state hospitals (87.14%). However, more than half of the participants (53.44%) stated that they did not want to see patients with COVID-19 at their clinics. This rate was higher at university hospitals (58.71%).

Table 1

Responses according to sociodemographic and working characteristics.

		Participants	Knowledge Score	Preventive Behaviors Score
		n (%)	Mean±SD	Mean±SD
Sex	Female	183 (72.91%)	91.69±6.04	89.21±15.60
	Male	68 (27.09%)	91.58±6.54	77.21±23.55
	P value		0.917	<0.001
Education level	High school	6 (2.39%)	85.63±11.83	100.0±0.00
	University	245 (97.61%)	91.81±5.93	85.61±18.93
	P value		0.189	0.046
Occupation	Nursea	102 (40.64%)	90.26±6.75	91.91±13.24
	General practitionerb	53 (21.12%)	90.70±6.03	86.32±18.71
	Medical specialistc	96 (38.24%)	93.67±4.99	79.43±21.76
	P value		0.001	<0.001
	Posthoc test		a-c <0.01	a-c <0.001
			b-c <0.05
Workplace	State Hospital	101 (40.24%)	93.10±5.52	88.86±18.87
	University Hospital	150 (59.76%)	90.69±6.40	84.00±18.61
	P value		0.001	0.012
Education on COVID-19	Yes	173 (68.92%)	91.41±6.33	86.99±18.98
	No	78 (31.08%)	92.22±5.79	83.65±18.39
	P value		0.513	0.082

SD: standard deviation; statistically significant p values are in bold.

Table 2 shows the responses of the participants to the knowledge-based, preventive behavior, and risk perception questions. There was no correlation between the age of participants and the percentage of correct answers to the questions on knowledge and attitude (p>0.05).

Table 2

Correct answers to questions on knowledge, preventive behaviors, and risk perceptions.

Knowledge (True or False)	n	%
Have you heard of COVID-19? (T)	251	100
Does COVID-19 occur as a virus? (T)	250	99.60
Is COVID-19 transmitted by respiratory droplets? (T)	250	99.60
Can COVID-19 be transmitted while talking? (T)	227	90.44
Can COVID-19 be transmitted by shaking hands? (T)	238	94.82
Can COVID-19 be transmitted from animals to humans? (T)	119	47.41
Can diarrhea also appear in COVID-19 cases? (T)	237	94.42
Can COVID-19 lead to death? (T)	251	100
The incubation period for the virus is 4–6 days. (T)	240	95.62
Can COVID-19 patients recover completely? (T)	228	90.84
Can a COVID-19 patient have no complaints or symptoms? (T)	232	92.43
Does the COVID-19 contamination risk increase in crowded places? (T)	250	99.60
Can COVID-19 live on surfaces, such as door handles and tables, for a long time? (T)	204	81.28
Does hand washing protect against the virus? (T)	251	100
Does using a mask protect against the virus? (T)	242	96.41
The main symptoms of COVID-19 are a fever, a cough, shortness of breath, weakness, and muscle pain. (T)	251	100
A runny nose, nasal congestion, and sneezing are less frequent in COVID-19 infections. (T)	201	80.08
Currently, there is no effective treatment for COVID-19. (T)	211	84.06
Can a large proportion of COVID-19 infections be resolved without hospitalization? (T)	250	99.60
COVID-19 can be transmitted through close contact with or by eating wild animals. (T)	163	64.94
COVID-19 is transmitted from the infected patient via the respiratory tract. (T)	237	94.42
The purpose of the mask worn by non-hospital workers is to prevent them from getting infected with COVID-19. (T)	174	69.32
To avoid COVID-19, crowded areas and public transportation should not be used. (T)	251	100
Isolating patients with COVID-19 is effective for preventing the spread of the virus. (T)	251	100
The observation period of a patient with COVID-19 is 14 days. (T)	241	96.02
Older adults with chronic lung disease and obese people can have a more serious case of the disease. (T)	250	99.60
Other people will not be infected if a COVID-19-infected person does not have a fever. (F)	234	93.23
Young people and children do not need to take precautions to prevent infection. (F)	245	97.61
A COVID-19 vaccine exists. (F)	242	96.41
Preventive Behaviors (Yes or No)	n	%
Do you wear gloves? (Y)	188	74.90
Do you wear a mask when leaving the house? (Y)	241	96.02
Are you still going to crowded places? (Y)	230	91.63
Do you use alternative methods against COVID-19? (Y)	204	81.28
Risk Perception	n	%
1. Would you like to get a COVID-19 vaccine?
Yes	168	66.93
No	57	22.71
I don’t know	26	10.36
2. How do you judge the severity of COVID-19?
Very dangerous	174	69.32
Moderately dangerous	77	30.68
3. Do you believe COVID-19 will eventually be contained?
Yes	211	84.06
No	13	5.18
I don’t know	27	10.76
4. How long will it take before COVID-19 is contained?
1–3 months	44	17.53
3–6 months	102	40.64
6–12 months	105	41.83

Except for Question 3 (“Do you believe that COVID-19 will eventually be contained?”), the risk perception differed according to the percentage of correct answers to the knowledge-based and preventive behavior questions. For example, regarding Question 1 (“Would you like to get a COVID-19 vaccine?”), there were significant differences in the percentage of correct answers to the knowledge-based questions (hereafter, for clarity, CK%) among those who answered “yes,” “no,” and “I don’t know,” with it being significantly lower in those who answered “no” than in those who answered “yes” or “I don’t know” (p = 0.000 and p = 0.033, respectively).

For Question 2 (“How do you judge the severity of COVID-19?”), there were no differences in the CK% between those who replied “very dangerous” or “moderately dangerous,” but there were significant differences in the percentage of correct answers to the preventive behavior questions (CPB%) between these two groups, with it being significantly higher in the former group.

The results for Question 4 (“How long will it take before COVID-19 is contained?”) were similar, with no differences in the CK% between those who answered “1–3 months,” “3–6 months,” or “6–12 months,” but significant differences were observed in the CPB%, with it being significantly lower in the first group than in the other two groups (Table 3).

Table 3

Responses to the risk perception questions according to the percentage of correct answers to the knowledge-based and preventive behavior questions.

Risk Perception	Answer	Participants	Knowledge Score	Preventive Behavior Score
		n (%)	Mean±SD	Mean±SD
Question 1	Yesa	168 (66.93%)	92.63±5.49	85.71±18.87
	Nob	57 (22.71%)	89.11±6.00	83.33±20.23
	I don’t knowc	26 (10.36%)	90.98±8.73	93.27±13.34
	P value		0.001	0.087
	Posthoc test		a-b <0.001
			b-c <0.05
Question 2	Very dangerous	174 (69.32%)	91.69±6.57	88.36±17.76
	Moderately dangerous	77 (30.68%)	91.58±5.17	80.52±20.12
	P value		0.233	0.002
Question 3	Yesa	211 (84.06%)	91.71±6.15	86.26±18.44
	Nob	13 (5.18%)	93.63±4.85	86.54±21.93
	I don’t knowc	27 (10.76%)	90.29±6.69	83.33±20.80
	P value		0.310	0.766
Question 4	1–3 monthsa	44 (17.53%)	92.16±5.87	81.25±15.37
	3–6 monthsb	102 (40.64%)	91.65±5.56	86.03±20.98
	6–12 monthsc	105 (41.83%)	91.46±6.85	87.86±17.72
	P value		0.769	0.023
	Posthoc test			a-b <0.05
				a-c <0.05

SD: standard deviation; statistically significant p values are in bold.

With regard to the knowledge scores of the dependent variable, the multiple linear regression model was found to be significant, in which the independent variables were age, sex, education, place of work, profession, and educational status (R2 = 0.115, F = 4.494 p<0.001). When other variables are kept constant, working in the state hospital increases the knowledge scores by 2.013 points (p<0.05). In addition, if other variables are kept constant, the knowledge scores of those who are experts in their profession increase by 2.970 points compared to those of nurses (p<0.01). The knowledge scores of general practitioners were not found to be significant compared to those of the nurses (p>0.05) (Table 4).

Table 4

Multiple regression analysis results of explanatory variables for knowledge scores.

Knowledge Score
Parameter	Estimate (β)	Std.Error	95% CI		t	p value
Constant	84.717	3.112	78.586	90.847	27.220	0.000
Age	-0.021	0.048	-0.116	2.933	-0.437	0.663
Sex	1.034	0.964	-0.865	0.865	1.073	0.285
Education level	4.957	2.526	-0.019	9.934	1.962	0.051
Workplace	2.013	0.856	0.327	3.698	2.932	0.019
Occupation
General practitioner	0.229	1.160	-2.055	2.513	0.197	0.844
Medical specialist	2.970	1.013	0.974	4.965	2.932	0.004
Education on COVID-19	0.840	0.931	-0.993	2.674	0.903	0.368

Std: standard; CI: confidence interval

In relation to the preventive behaviors scores of the dependent variable, the multiple linear regression model was found to be significant, in which the independent variables were age, sex, education, place of work, profession, and educational status (R2 = 0.159, F = 6.587 p<0.001). As a result of multiple linear regression analysis, it was found that the explanatory factors for the preventive behavior scores were sex, place of work, and occupation variables. When other variables are kept constant, the female gender increases the preventive behavior scores by 8.407 points (p<0.01). When other variables are kept constant, the preventive behavior scores of those who are experts in their profession decrease by 9.957 points compared to those of nurses (p<0.01). The preventive behavior scores of general practitioners were not found to be significant compared to those of nurses (p>0.05) (Table 5).

Table 5

Multiple regression analysis results of explanatory variables for the preventive behavior scale.

Preventive Behavior Score
Parameter	Estimate (β)	Std.Error	95% CI		t	p value
Constant	80.596	9.686	61.518	99.675	8.321	0.000
Age	0.241	0.143	-0.041	0.523	1.686	0.093
Sex	8.407	2.868	2.757	14.057	2.931	0.004
Education level	-12.126	7.517	-26.933	2.680	-1.613	0.108
Workplace	7.195	2.546	2.180	12.211	2.286	0.005
Occupation
General practitioner	-0.736	3.450	-7.533	6.060	-0.213	0.831
Medical specialist	-9.957	3.014	-15.893	-4.020	-3.304	0.001
Education on COVID-19	3.022	2.770	-2.434	8.477	1.091	0.276

Std: standard; CI: confidence interval

Discussion

Today, every country in the world is facing the COVID-19 pandemic. This pandemic has caused health problems, as well as high levels of anxiety and serious psychological problems for many. Undoubtedly, these effects are exacerbated in the health care field. Knowledge, attitudes, and practices pertaining to infectious diseases can affect the severity of the disease itself, the extent of spread, and the overall mortality rate [10, 12, 16]. It is extremely important to protect HCWs in order to control the outbreak. When these professionals become infected, it adversely affects the supply of health care services, causing a decrease in the efficiency of the health care system’s reaction to the epidemic and an uncontrolled increase in the incidence rate. HCWs are on the frontline, and thus their knowledge and preventive behaviors are crucial to the success of any response. Increasing the knowledge of the disease is of great importance in reducing the level of anxiety of HCWs [17-19]. Thus, it is crucial to understand the current level of knowledge, preventive behaviors, and risk perceptions of HCWs.

This study addresses this knowledge gap regarding HCWs working in Turkey’s capital city. We surveyed HCWs on the frontline of the pandemic: 40.64% of the participants were nurses, and the rest were doctors. Most of the doctors were specialists (64.43%). The medical specialists had the highest knowledge scores (p<0.001), followed by general practitioners and nurses. This highlights the importance of the role of medical doctors in combating the coronavirus.

The average score on knowledge-based questions was 91.66%, a rather high rate, whereas the average preventive behavior score was 85.96%. This is similar to in some studies [15, 17] but higher than those scores reported in other previous studies [12, 18, 20, 21]. In line with the literature, we found that the increase in the participants’ knowledge level positively affects preventive behavior [10, 12, 18]. Overall, we found that roughly 69.32% of HCWs had received training on protecting themselves from the COVID-19 pandemic, such as through wearing preventive equipment during a patient triage at their institutions. This rate is low according to the literature [15, 17]. In our study, the main preventive behaviors outside of work were mask use (96% of HCWs) and the avoidance of crowded places (91.63%), while 74.90% used gloves. Regarding the use of protective materials during patient care, hospital gloves and medical masks were used at rates of 95.62% and 92.80%, respectively. Other protective materials (visors, protective glasses, and disposable aprons and uniforms, etc.) were used at a very low rate. Hence, it is crucial to implement strategies to increase professionals’ knowledge of the disease and improve the protection of HCWs. Training is the primary strategy needed. HCWs need education and support when working on the frontline of pandemics.

Considering all the variables, it was determined that HCWs working in state hospitals and specialist doctors had better knowledge scores, and that women, HCWs working in state hospitals, and specialist doctors had better preventive behavior scores. Response rates did not differ by sex for the knowledge-based questions but did differ for the preventive behavior questions. In line with previous studies, females practiced more preventive behaviors [22, 23]. The participants’ knowledge score average with a university or higher education level was significantly higher, but the expected high performance with regard to preventive behaviors was not observed. This situation suggests that the information is not reflected in terms of its application and that preventive behaviors should be audited regularly. One of the reasons for this may be the excessive workforce and a lack of adequate protective equipment support in our country.

In a previous study that measured knowledge and attitudes during the MERS outbreak, another disease belonging to the corona family, both scores increased with age [18, 22]. It was believed that this was due to both work and social experiences, which generally increase with age. In our study, no correlation was found between knowledge and preventive behavior and age. This is meaningful as we have not experienced a similar pandemic before.

The purpose of risk assessment is to limit the epidemic using various measures to control COVID-19, which does not currently have a specific treatment or vaccine. The risk perceptions of HCWs and society will be effective in controlling such infections. Most of the participants (69.32%) thought the COVID-19 infection to be hazardous, but the vast majority (84.06%) believed that this pandemic would be contained. Despite this, 58.17% of them did not think that it could be controlled within 6 months. In this study, the participants were not as optimistic as Chinese residents, maybe because pandemics are not common in our country [20]. This observation may be due to a lack of perceived information and knowledge relating to the COVID-19 pandemic. A recent study showed that both a high acceptance rate of a vaccine (90.60%) and a belief that one will eventually contract the disease (99.10%) demonstrate a definite inclination by individuals towards a vaccine as a prevention strategy [24]. However, only 66.93% of our participants were willing to get vaccinated against COVID-19. We may speculate that, although HCWs possess immense knowledge about the COVID-19 pandemic, they might have concerns about the adverse effects of the vaccination and other novel treatments.

One limitation of this study is that it only surveyed HCWs in a certain region, and therefore the results cannot be generalized. However, this study was carried out quickly to gain some early insights into perceptions and knowledge with regard to the pandemic. A study with a larger sample size will generate better results. Another limitation is that the questionnaire was prepared within a limited timeframe and when the pandemic was not very widespread in the country. It should also be kept in mind that the study results depend on participants’ memories and honesty. So, this should be considered a preliminary study, and its results can be used to focus on effective risk communication and education on epidemic control.

In conclusion, we identified the knowledge and behavior statuses of HCWs who are at the frontline of the COVID-19 pandemic. According to our results, HCWs had a high level of knowledge of COVID-19. Nevertheless, preventive behaviors against the global threat of this pandemic were not found to be at such a high level. It is necessary to monitor the implementation of preventive behaviors during the pandemic and provide the necessary, appropriate responses. More comprehensive studies should be conducted in the fight against the COVID-19 virus, which entails many obscurities. We suggest governments should publish guidelines based on practices modified according to the progression of the pandemic. Concurrently, improving risk perception and increasing preventive behaviors as well as commencing online sessions to help health professionals to evolve in terms of their understanding of the current guidelines and to protect themselves and others from being infected, will help diminish the spread of COVID-19.

SPSS data of the survey.

(SAV)

Click here for additional data file.

26 Aug 2020

PONE-D-20-23431

Knowledge, Attitudes and Practices of Turkish Healthcare Workers About SAR2-CoV-19 During Pandemic

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Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #1: Partly

Reviewer #2: Partly

Reviewer #3: Yes

Reviewer #4: Yes

Reviewer #5: No

**********

2. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: Yes

Reviewer #2: No

Reviewer #3: Yes

Reviewer #4: Yes

Reviewer #5: No

**********

3. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #1: Yes

Reviewer #2: No

Reviewer #3: Yes

Reviewer #4: Yes

Reviewer #5: Yes

**********

4. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #1: No

Reviewer #2: No

Reviewer #3: Yes

Reviewer #4: Yes

Reviewer #5: No

**********

5. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: Review: The title of the article is not grammatically correct. Overall, substantive editing will be needed to address grammar, spelling, and syntax. The methods are not clear and require substantial improvements, the tables and order of reported information in the results might support a better understanding of the results, and both the introduction and discussion are confusing to read; primarily because of superfluous information that in no way relate to the topic or findings of the study.

Introduction: The context and scope are not clearly defined in the manuscript. The first two paragraphs and the introduction in general do not align well with the scope of the paper.

Methods: The methodology is unclear, was it a snowball sampling approach? Is Google Form used in other studies? Please report and cite how effective Google Form is and what protections there are to avoid double counting and ensure that people who are not HCWs are taking the survey. In demographics, can you clarify “the current status”? For the COVID-19 related knowledge questions, were these yes/no options or true/false questions. This is later defined in the results but should be adequately described in the methods section. The Cronbach’s alpha reported is quite low. This makes sense because you are measuring different domains. As you report the findings, it is unclear what these items actually measure. The composite score is not a single factor and therefore doesn’t really make sense to assess this way. Were there differences observed between domains?

Results: Table 1 should not include composite scores unless the instrument is better described in the methods. There is little information about what is included in the “knowledge score” or “preventative behaviors score”. Given that the details of these composite items are not outlined is difficult for me to understand exactly what the outcome is measuring (as it is written in Table 1). Table 2 and 3 are more informative and define the items – this is great, but comes too late in the manuscript to help follow the first portion of the results section. However, given that this is the first mention of the items it is confusing to read in the order it is placed. Consider updating the methods to better provide information about the items included in the analysis.

Discussion: Line 218 to 227 don’t have much value and contribute very little to this topic. There have been updated guidelines for mask use, please update the citation and information. The section that discusses use of face coverings and other masks don’t directly relate to the findings and seem out of place. Agreement to use one does not speak to efficacy and guidance of use. Paragraph between lines 270-279 are out of place and not relevant to the findings.

Reviewer #2: The authors have tried to assess the knowledge and preventive behaviors of health care workers (HCWs) in Turkey. However, the work requires major corrections and i will suggest the work be given o professional English language editors.

Kindly consider the following:

Title- Typographical error. SARS not SAR2. Consider revising the topic to : Knowledge and preventive behaviors of Turkish Health Workers to the COVID-19 Pandemic.

Introduction

Line 36- change "sporadic countries" to "sporadically in several countries"

Line 36 - Change are to were

Line 42- Since this is your first use of the Interquartile range (IQR), please define it first.

Line 44-45- Consider revision of the statement

Line 50- change first detected to index case

Line 53- In my opinion, a rapid test is still a type of diagnostic test, so please revise the statement

Line 53-54 - Consider removing the statement entirely "The battle against coVID-19..."

Line 54-56 - Consider revision of the paragraph "To guarantee...."

Line 57 - Change the word "leading force" to other synonyms like front-line workers/ personnel

Line 58- Include the word "COVID-19" before the word "related"

Line 59- Could you please explain how the lack of COVID-19 related knowledge leads to the overestimation of the situation, boost stress and anxiety and intermit medical decision.

Line 60- Use HCW(s) instead of healthcare workers as this has been introduced earlier in line 55.

Line 60- change exerted to implemented or instituted

Line 59-61 - consider revising the sentence "Precautions to be exerted..."

Line 62-63 - Consider revising the sentence "The COVID-19 contagion..." or remove it entirely.

Line 64- For consistency, please use HCWs instead of medical staff.

Line 63-65- Consider revising the sentence "therefore an essential study of medical staff knowledge..." or remove it entirely.

Line 66-69 - Consider rephrasing the aim of the study

Materials and Methods

I would suggest you include a sub-heading in line 71 (Study design- Just my suggestion)

Line 71- change the preposition "on" to "in'

Line 71 - change "their" to "the"

Line 72- Include the word "COVID-19" after relevant

Line 72- Change "this group" to "Participants in this study"

Line 73- Change includes to included (past tense)

Line 74- tautology of face and encounter (remove one and leave the other)

Line 73-75 - Consider revising the sentence "These workers are the first ones "

Line 76-78 - Consider revision of the statements. I would suggest " A structured questionnaire was administered via online social media platforms... "

Line 78- Remove 'The response rate' and take it to the results section.

Line 79 – Google forms are used to administer surveys not to design them

Line 86 – Include platforms after media and “remove to the contacts of…[[[[ ”

Line 156 – Include ‘graduates” after University

Line 161 – Rephrase the statement that started with “Conversely”

Line 180 - It is 78.35% not %78.35

Line 221-223 is repletion of results. Consider removing it entirely

Line 271 – Use A N95 not “An N95”

My concerns:

� The population of HCWs in Turkey is 1,016,401 (Anadolu Agency, 2020). Do you think 305 respondents is representative of this population?

� Could you kindly educate me on how you calculated the statistical power for the validity of a survey instrument and got 51 responses?

� Did you calculate the odds ratio in the multivariable logistic regression?

� How did you grade the responses? Who (or which group) had poor, average or satisfactory knowledge and behavior among your respondents?

� There was no mention of practices in result (So, I suggest you remove practices from the topic).

� What is the minimum threshold for reliability of variable in a survey instrument (using Cronbach’s alpha)?

Discussion:

Please revise the entire discussion.

Supplementary data: 6 files were indicated but only figure 1 was included on page 22.

Reviewer #3: I have reviewed the manuscript titled “Knowledge, Attitudes and Practices of Turkish Healthcare Workers About SAR2-CoV-19 During Pandemic” submitted to “PlosOne” for publication. In this paper, authors have conducted a survey study to investigate the level of COVID-19 related knowledge in health care workers in Turkey. This is a well conducted study and the manuscript is well presented and fits within the scope of the journal; it needs some major improvements; there are a few suggestions that authors may consider improving it further:

The use of English language is reasonable, however, there are a number of punctuation and grammatical errors; that should be corrected and rephrased using academic English for a better flow of text for reader. Authors may consider proofreading this manuscript.

Line 28: “In”?

I have no more comments regarding the introduction, methods and results as all sections have been well presented. The discussion section can be further improved. Surprisngly, authors missed inclusion of many recent studies that are similar to the subject. Here are a few examples;

COVID-19 Pandemic and Role of Human Saliva as a Testing Biofluid in Point-of-Care Technology. European Journal of Dentistry. 2020 Jun 3.

Knowledge and Attitude of Dental Practitioners Related to Disinfection during the COVID-19 Pandemic. Healthcare 2020, 8, 232.

Fear and practice modifications among dentists to combat Novel Coronavirus Disease (COVID-19) outbreak. International Journal of Environmental Research and Public Health. 2020 Jan;17(8):2821.

Author may discuss finding of such studies in context to improve the discussion.

There are a number of statements in the discussion require reference citations; please make sure, appropriate citations are in place.

What authors’ suggestions to further improve the level of COVID-19 related knowledge among HCW?

Line 308: educatşonal? Please correct

Reviewer #4: The authors evaluated personality variables, specific concerns, propose to self-isolate, and personal safety among healthcare workers practicing in Turkey during the current COVID-19 pandemic. The study is interesting and needs minor revision.

In the text, change outbreak to pandemic

The authors wrote “determined mid-level competence in terms of preventive behavior”. What is consider a mind-level?

Explain in the text which is convenient personal protective equipment (PPE)

The description of title of all tables needs to be improved to reflect the data analyzed in the tables.

The layout of all tables needs to be reformulated, since the sides of tables should be open, without internal lines.

It is not clear if when the question “training on how to protect you from the COVID-19” was donned, if it was explained which type of training the authors had referred.

Discussion

The authors suggested “During the pandemic, it is crucial to implement strategies that will increase knowledge and improve the protection of HCWs, and training is the main point of these strategies”. Write in the manuscript the strategies that are crucial

Conversely, only 66.2% of our participants willing to have themselves COVID-19 vaccine implemented. This answer should be more discussed and compared to data available in the period that this study was conducted.

All results that were signifcative in the multiple linear regression shoud be disccused.

In the abstract the authors wrote: the most commonly defined sources of knowledge were Television (69.8%), Twitter (34%), followed by Instagram (24.5%), Facebook (23.6%). However, this data was not discussed. The authors should discussed the influence of social medias and TV as objects of information in the context of COVID-19.

Finally, the authors must make one more update in the current literature, considering the number of articles that are published on the topic daily.

Reviewer #5: Study is flawed by the methodology, science behind the study, analysis and discussion was largely a repeat of the introduction. I have provided detailed guideline on what authors can do to improve the study if they wish to

**********

6. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files.

If you choose “no”, your identity will remain anonymous but your review may still be made public.

Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy.

Reviewer #1: No

Reviewer #2: No

Reviewer #3: No

Reviewer #4: No

Reviewer #5: No

[NOTE: If reviewer comments were submitted as an attachment file, they will be attached to this email and accessible via the submission site. Please log into your account, locate the manuscript record, and check for the action link "View Attachments". If this link does not appear, there are no attachment files.]

While revising your submission, please upload your figure files to the Preflight Analysis and Conversion Engine (PACE) digital diagnostic tool, https://pacev2.apexcovantage.com/. PACE helps ensure that figures meet PLOS requirements. To use PACE, you must first register as a user. Registration is free. Then, login and navigate to the UPLOAD tab, where you will find detailed instructions on how to use the tool. If you encounter any issues or have any questions when using PACE, please email PLOS at figures@plos.org. Please note that Supporting Information files do not need this step.

Submitted filename: Reviewers comments.docx

Click here for additional data file.

4 Nov 2020

Thank you for the editors' comments. We have altered the whole manuscript contingent upon the statistics changes. We hope that this manuscript will lead the healthcare workers with a novel perspective.

Submitted filename: Response.docx

Click here for additional data file.

29 Dec 2020

PONE-D-20-23431R1

Knowledge, preventive behaviors and risk perception of the COVID-19 pandemic: A cross-sectional study in Turkish health care workers

PLOS ONE

Dear Dr. Dursun,

Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process.

Please submit your revised manuscript by Feb 12 2021 11:59PM. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at plosone@plos.org. When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file.

Please include the following items when submitting your revised manuscript:

A rebuttal letter that responds to each point raised by the academic editor and reviewer(s). You should upload this letter as a separate file labeled 'Response to Reviewers'.

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If you would like to make changes to your financial disclosure, please include your updated statement in your cover letter. Guidelines for resubmitting your figure files are available below the reviewer comments at the end of this letter.

If applicable, we recommend that you deposit your laboratory protocols in protocols.io to enhance the reproducibility of your results. Protocols.io assigns your protocol its own identifier (DOI) so that it can be cited independently in the future. For instructions see: http://journals.plos.org/plosone/s/submission-guidelines#loc-laboratory-protocols

We look forward to receiving your revised manuscript.

Kind regards,

Livia Melo Villar

Academic Editor

PLOS ONE

Additional Editor Comments (if provided):

Dear Author,

I recommend major revision of this paper as suggested by the reviewers,

Sincerely,

[Note: HTML markup is below. Please do not edit.]

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. If the authors have adequately addressed your comments raised in a previous round of review and you feel that this manuscript is now acceptable for publication, you may indicate that here to bypass the “Comments to the Author” section, enter your conflict of interest statement in the “Confidential to Editor” section, and submit your "Accept" recommendation.

Reviewer #1: All comments have been addressed

Reviewer #2: (No Response)

Reviewer #3: (No Response)

Reviewer #5: (No Response)

**********

2. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #1: Partly

Reviewer #2: Partly

Reviewer #3: Yes

Reviewer #5: No

**********

3. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: N/A

Reviewer #2: I Don't Know

Reviewer #3: No

Reviewer #5: No

**********

4. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #1: Yes

Reviewer #2: Yes

Reviewer #3: Yes

Reviewer #5: Yes

**********

5. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #1: Yes

Reviewer #2: No

Reviewer #3: Yes

Reviewer #5: No

**********

6. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: The resubmission of this manuscript has addressed several comments and also improved the language in the text. However, there are still a few typos in the document as well as concerns that the logical translation may not accurately describe the authors intent. There appears to also be a lack of consistency (e.g., on how many decimals are used for percentages) throughout the manuscript. Generally, it reads as though different people wrote different sections. One example of this is that there is no mention that a KAP survey is being implemented in the methods section, though the discussion makes strong mention of a KAP approach.

Reviewer #2: (No Response)

Reviewer #3: I am afraid, my comments are not responded; may be authors did not get the comments previously. Therefore, I am pasting the same comments again and would like to request the editor to give another oppurtunity to authors to respond to comments; many thanks:

Comment:

I have reviewed the manuscript titled “Knowledge, Attitudes and Practices of Turkish Healthcare Workers About SAR2-CoV-19 During Pandemic” submitted to “PlosOne” for publication. In this paper, authors have conducted a survey study to investigate the level of COVID-19 related knowledge in health care workers in Turkey. This is a well conducted study and the manuscript is well presented and fits within the scope of the journal; it needs some major improvements; there are a few suggestions that authors may consider improving it further:

The use of English language is reasonable, however, there are a number of punctuation and grammatical errors; that should be corrected and rephrased using academic English for a better flow of text for reader. Authors may consider proofreading this manuscript.

Line 28: “In”?

I have no more comments regarding the introduction, methods and results as all sections have been well presented. The discussion section can be further improved. Surprisngly, authors missed inclusion of many recent studies that are similar to the subject. Here are a few examples;

COVID-19 Pandemic and Role of Human Saliva as a Testing Biofluid in Point-of-Care Technology. European Journal of Dentistry. 2020 Jun 3.

Knowledge and Attitude of Dental Practitioners Related to Disinfection during the COVID-19 Pandemic. Healthcare 2020, 8, 232.

Fear and practice modifications among dentists to combat Novel Coronavirus Disease (COVID-19) outbreak. International Journal of Environmental Research and Public Health. 2020 Jan;17(8):2821.

Author may discuss finding of such studies in context to improve the discussion.

There are a number of statements in the discussion require reference citations; please make sure, appropriate citations are in place.

What authors’ suggestions to further improve the level of COVID-19 related knowledge among HCW?

Line 308: educatşonal? Please correct

******************************************************************************

Reviewer #5: There are methodological issues with the current manuscript and some reports of 100% survey returned despite using online distribution platform, lack of incentive and participation was voluntary and no professional body helped with providing emails of members is unusual.

**********

7. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files.

If you choose “no”, your identity will remain anonymous but your review may still be made public.

Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy.

Reviewer #1: No

Reviewer #2: No

Reviewer #3: No

Reviewer #5: No

[NOTE: If reviewer comments were submitted as an attachment file, they will be attached to this email and accessible via the submission site. Please log into your account, locate the manuscript record, and check for the action link "View Attachments". If this link does not appear, there are no attachment files.]

While revising your submission, please upload your figure files to the Preflight Analysis and Conversion Engine (PACE) digital diagnostic tool, https://pacev2.apexcovantage.com/. PACE helps ensure that figures meet PLOS requirements. To use PACE, you must first register as a user. Registration is free. Then, login and navigate to the UPLOAD tab, where you will find detailed instructions on how to use the tool. If you encounter any issues or have any questions when using PACE, please email PLOS at figures@plos.org. Please note that Supporting Information files do not need this step.

Submitted filename: Reviewers comments 2.docx

Click here for additional data file.

Submitted filename: Review_2.docx

Click here for additional data file.

9 Feb 2021

Thank you for your evaluation.

Submitted filename: Response.docx

Click here for additional data file.

30 Mar 2021

Knowledge, preventive behaviors and risk perception of the COVID-19 pandemic: A cross-sectional study in Turkish health care workers

PONE-D-20-23431R2

Dear Dr. Dursun,

We’re pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it meets all outstanding technical requirements.

Within one week, you’ll receive an e-mail detailing the required amendments. When these have been addressed, you’ll receive a formal acceptance letter and your manuscript will be scheduled for publication.

An invoice for payment will follow shortly after the formal acceptance. To ensure an efficient process, please log into Editorial Manager at http://www.editorialmanager.com/pone/, click the 'Update My Information' link at the top of the page, and double check that your user information is up-to-date. If you have any billing related questions, please contact our Author Billing department directly at authorbilling@plos.org.

If your institution or institutions have a press office, please notify them about your upcoming paper to help maximize its impact. If they’ll be preparing press materials, please inform our press team as soon as possible -- no later than 48 hours after receiving the formal acceptance. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information, please contact onepress@plos.org.

Kind regards,

Livia Melo Villar

Academic Editor

PLOS ONE

Additional Editor Comments (optional):

Dear Author,

After reading the revised version and comments of the reviewers, I recommend the acceptance of this paper,

Best regards,

Livia

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. If the authors have adequately addressed your comments raised in a previous round of review and you feel that this manuscript is now acceptable for publication, you may indicate that here to bypass the “Comments to the Author” section, enter your conflict of interest statement in the “Confidential to Editor” section, and submit your "Accept" recommendation.

Reviewer #3: All comments have been addressed

**********

2. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #3: Yes

**********

3. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #3: Yes

**********

4. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #3: Yes

**********

5. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #3: Yes

**********

6. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #3: Dear Authors, Many thanks for the revision and incorporating all suggested changes to the manuscript

**********

7. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files.

If you choose “no”, your identity will remain anonymous but your review may still be made public.

Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy.

Reviewer #3: No

1 Apr 2021

PONE-D-20-23431R2

Knowledge, preventive behaviors and risk perception of the COVID-19 pandemic: A cross-sectional study in Turkish health care workers

Dear Dr. Dursun:

I'm pleased to inform you that your manuscript has been deemed suitable for publication in PLOS ONE. Congratulations! Your manuscript is now with our production department.

If your institution or institutions have a press office, please let them know about your upcoming paper now to help maximize its impact. If they'll be preparing press materials, please inform our press team within the next 48 hours. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information please contact onepress@plos.org.

If we can help with anything else, please email us at plosone@plos.org.

Thank you for submitting your work to PLOS ONE and supporting open access.

Kind regards,

PLOS ONE Editorial Office Staff

on behalf of

Dr. Livia Melo Villar

Academic Editor

PLOS ONE