Factors associated with knowledge of health care workers toward COVID-19 in health facilities West Guji zone, Southern Ethiopia, 2020.

BACKGROUND: Coronavirus pandemic puts healthcare workers (HCWs) at high risk and challenges the abilities of healthcare systems to respond to the crisis. This study aimed to assess the level of knowledge of HCWs and associated factors in West Guji zone public health facilities in southern Ethiopia.
MATERIALS AND METHODS: A health facility-based quantitative cross-sectional study was undertaken from June 10 to July 10, 2020. Two hundred and eighty-three HCWs were involved in the study using a systematic sampling method. The instrument was pretested on 5% of the sample in Yabello Hospital. Data were analyzed using bivariate and multivariate logistic regression.
RESULTS: The HCW who had good knowledge was 84.7%. HCWs who had degree holders, masters and above holders, work experience of 2-4 years, and >4 years of experiences, had training on Coronavirus, and medical diseases were significantly associated with good knowledge of Coronavirus.
CONCLUSIONS: This study indicated that HCWs' knowledge about the Coronavirus was good. Improving the educational status of HCWs and giving updated training on the Coronavirus will improve HCW's knowledge of the Coronavirus. Copyright:

Introduction

Globally, on 30 January, the WHO declared an international public health emergency and called on all countries to make cooperative efforts to prevent the rapid spread of coronavirus disease 2019 (COVID-19).[12] As of February 14, 2021, the COVID-19 pandemic had resulted in 107,838,255 cases and 2,373,398 deaths worldwide, including 2,713,855 cases and 68,043 deaths in Africa and 145,548 cases, and 2177 deaths in Ethiopia.[3] Scientists and health professionals around the world are working together to accelerate research and develop new standards and standards to stop the spread of the coronavirus pandemic and to help treat infected people.[45]

Health care workers (HCWs) are at the front position of the response to the ending of COVID 19 pandemic and other pathogens, violence, harassment, stigmatization, discrimination, heavy workload, and the long-term use of personal protective equipment (PPE).[6] Hand washing and proper PPE are important to reduce the spread and risk of COVID-19 infections in hospitals.[7] Knowledge of HCWs on COVID-19 prevention methods such as maintaining hand hygiene, covering mouth and nose when coughing or sneezing, avoiding close contact with anyone showing symptoms of respiratory disease, and avoiding unprotected contact with farm or wild animals is critical to avoiding a fast-growing COVID 19 pandemic.[8]

In low- and middle-income countries, HCWs are at high risk of exposure to COVID-19[910] due to lack of preventive measures, inadequate protective equipment, and a lack of supportive working environments. The pandemic puts HCWs at great risk and challenges the capacity of health systems to respond to crises.[11] The situation in sub-Saharan Africa can be serious because of HIV, tuberculosis, malaria, poverty, poor quality of health services, and high access to health facilities.[12]

Although the Ethiopian Government has taken a number of steps to curb the rapid growth of COVID 19 cases, Ethiopia has the highest number of infections in East Africa. Lack of evidence, inadequate protection and supply of treatment and infrastructure, inadequate isolation and isolation centers, and misunderstandings among community members about the risk and source of HIV infection has affected the federal response efforts in most parts of the country.[13] Despite the measures taken to establish a health system, there was a dramatic increase in the number of patients.[14]

Many health care work is complicated by several challenges related to access, security, supply chain logistics, and financial stress.[15] HCWs are at the forefront of the fight against the COVID-19 pandemic, while most other public officials stay at home; As a result, thousands of HCWs are infected with COVID-19 around the world as they provide clinical services to COVID-19 patients, and the condition is worse in developing countries with poor health systems.[16] Therefore, this study was assess the level of HCWs’ knowledge about COVID-19 and associated factors in West Guji zone public health facilities in southern Ethiopia. This benefits all stakeholders including governmental and nongovernmental organizations, HCWs, health care planners, and health institutions by providing current knowledge about COVID-19 and can provide relevant information for planning interventions in the study area.

Materials and Methods

Study design and setting

A facility-based cross-sectional study was conducted in West Guji Zone, Oromia Region. West Guji zone is one of among 20 zones in the Oromia Region. Bule Hora town is a capital city of West Guji zone which is located 467 Km far from Addis Ababa to the south direction at 5°35′ N Latitude and 38°15′E Longitude. The zone has also 196 kebeles the lower administrative body, of these 166 are rural, and 30 are urban kebeles. It has an estimated population of 1,389,821 of whom 681,012 are male and 708,809 are females. West Guji Zone has one general hospital, 2 primary hospitals, 42 health centers, and 166 health posts, and has 860 health care providers and 478 health extension workers. The study was conducted from June 10 to July 10, 2020.

Study participants and sampling

All selected health care providers in selected public health facilities at the time of data collection were included and those who were new employers recruited within the last 6 months were excluded. The sample size was determined by using single population proportion formula. By considering the level of knowledge of HCWs as 50% because to get maximum sample sizes. Ninety-five percent confidence interval (CI) and margin of error 5% between the sample size and the underlining population were considered. Finally, 283 HCWs were included in the study. Among the total of 3 Public hospitals and 42 health centers in the Zone, all hospitals were selected purposefully. In addition, 15 health centers were selected by simple random sampling technique. From all Hospitals, 208 HCWs were selected, and from all health centers, 214 HCW were selected by proportional allocation to sample size. Finally, a simple random sampling technique was employed to select 283 study participants. The dependent variable was the level of knowledge about COVID-19 and independents variables were sociodemographic factors, knowledge-related factors, chronic conditions, and behavioral factors.

Data collection tool and technique

The data were collected using a pretested structured self-administered questionnaire with data collector guidance. The questionnaire was initially prepared in English and then translated into Afaan Oromoo and Amharic then back into English by fluent speakers to check its consistency [Annex A and B]. The questions which assess the level of knowledge about COVID 19 and its associated factors among HCWs were adopted from similar previous studies.[56910] The Knowledge level was assessed by 12 components of knowledge-related questions, which was calculated by assigning one (1) point to each correct answer, and a zero (0) points to an incorrect/unknown answer. The total knowledge score ranged from 0 to 12, with higher scores indicating good knowledge, if they respond to at least 6 items/components of knowledge-related questions and if their response was below 6 items they had poor knowledge on coronavirus knowledge.

The collected data were coded, entered, and cleaned by Epi-DATA version 3.1 (Epidata Association, Odense, Denmark) and exported to Statistical Package for Social Science version 25.0(IBM, Armonk, New York, USA) for analysis. Descriptive statistics were used to describe the data. Binary logistic regression analysis was employed to examine the statistical association between knowledge and every single independent variable. Adjusted odds ratios with 95% CI will be estimated to assess the strength of associations and statistical significance was declared at a P < 0.05. Hosmer and Lemeshow test was done to check model fitness. Results were presented by using tables, figures, and texts.

Ethical consideration

Ethical clearance was obtained from Bule Bora University Institutional Review Board with a reference number; Ref. No (BHU/PRD/01/2012 E. C/2020) and verbal consents were obtained from all respondents [Annex A and B]. To get full co-operation, respondents were reassured about the confidentiality of their responses. Their voluntary participation and the right to take part or terminate at any time they wanted were assured. The data collectors were trained by the principal investigators on how to keep the confidentiality and anonymity of the responses of the respondents in all aspects.

Results

Socio-demographic characteristics of the respondents

Out of a total of 283 eligible HCWs, 275 respondents had participated in this study with a 97.2% response rate. Nearly two-third, 173 (62.9%) were male respondents. The mean age of respondents was 29.83 years with standard deviation (SD) ± 4.794, ranging from 20 to 56 years. The majority of the age respondents lie between 25–29 and 30–34, which accounts for 44.4 and 36.4%, respectively [Table 1].

Table 1

Sociodemographic of Health care workers in West Guji Zone Public Health Facilities, Southern Ethiopia, 2020

Sociodemographic characteristics	Frequency (%)
Age of respondents
20-24	22 (8.0)
25-29	122 (44.4)
30-34	100 (36.4)
35-39	27 (9.8)
≥40	4 (1.5)
Marital status
Married	153 (55.6)
Single	106 (38.5)
Divorced	13 (4.7)
Widowed	3 (1.1)
Ethnicity
Oromo	191 (69.5)
Amhara	55 (20.0)
Burji	7 (2.5)
Others	22 (8.0)
Qualification of health care workers
Diploma	88 (32.0)
Degree	167 (60.7)
Masters	15 (5.5)
Specialist	5 (1.8)
Profession of health care workers
General practitioner	11 (4.0)
Health officer	39 (14.2)
Nurses	98 (35.6)
Midwifery	36 (13.1)
Laboratory	38 (13.8)
Pharmacy	39 (14.2)
Anesthesia	7 (2.5)
IESO	4 (1.5)
Others	3 (1.1)
Religion
Orthodox	73 (26.5)
Muslim	45 (16.4)
Protestant	127 (46.2)
Wakeffata	25 (9.1)
Others	5 (1.8)
Residence
Rural	74 (26.9)
Urban	201 (73.1)
Family size
1	76 (27.6)
2-3	98 (35.6)
4-5	66 (24.0)
≥6	35 (12.7)
Monthly income
≤4000	35 (12.7)
4001-8000	210 (76.4)
>8000	30 (10.9)

IESO=Integrated emergency surgical officers

Knowledge of health care workers about coronavirus disease 2019

Overall the level of HCW's knowledge regarding COVID-19 was classified as good knowledge and poor knowledge based on their responses. Of the surveyed HCWs, 84.7% (233) had demonstrated good knowledge about COVID-19. The mean of the knowledge was 9.90 with a 2.42 SD. The majority of HCWs, (260/94.5%) responded with the correct answers that the main clinical symptoms of COVID-19 are fever, fatigue, dry cough, and myalgia. Nearly two-thirds (176/64.0%) of the respondents responded to the correct answer Eating or contacting wild animals would result in the infection by the COVID-19 virus [Table 2].

Table 2

Knowledge of health care workers about coronavirus disease 2019 in West Guji Zone Public Health Facilities, Southern Ethiopia, 2020

Knowledge of health care workers about COVID-19	True (%)	False (%)	I don’t know (%)
The main clinical symptoms of COVID-19 are fever, fatigue, dry cough, and myalgia	260 (94.5)	15 (5.5)	0
Unlike the common cold, stuffy nose, runny nose, and sneezing are less common in persons infected with the COVID-19 virus	239 (86.9)	36 (13.1)	0
There currently is no effective cure for COVID-2019, but early symptomatic and supportive treatment can help most patients recover from the infection	233 (84.7)	38 (13.8)	4 (1.5)
Not all persons with COVID-2019 will develop to severe cases. Only those who are elderly, have chronic illnesses and obese are more likely to be severe cases	223 (81.1)	52 (18.9)	0
Eating or contacting wild animals would result in the infection by the COVID-19 virus	176 (64.0)	80 (29.1)	19 (6.9)
Persons with COVID-2019 cannot infect the virus to others when a fever is not present	196 (71.3)	74 (26.9)	5 (1.8)
The COVID-19 virus spreads via respiratory droplets of infected individuals	229 (83.3)	42 (15.3)	4 (1.5)
Ordinary residents can wear general medical masks to prevent the infection by the COVID-19 virus	225 (81.8)	43 (15.6)	7 (2.5)
It is not necessary for children and young adults to take measures to prevent the infection by the COVID-19 virus	229 (83.3)	42 (15.3)	4 (1.5)
To prevent the infection by COVID-19, individuals should avoid going to crowded places such as train stations and avoid taking public transportations	235 (85.5)	39 (14.2)	1 (0.4)
Isolation and treatment of people who are infected with the COVID-19 virus are effective ways to reduce the spread of the virus	234 (85.1)	40 (14.5)	1 (0.4)
People who have contact with someone infected with the COVID-19 virus should be immediately isolated in a proper place. In general, the observation period is 14 days	244 (88.7)	29 (10.5)	2 (0.7)

COVID-19=Coronavirus disease 2019

Regarding the experiences of HCWs, the majority of HCWs 159 (57.80%) had 2–4 years and the mean was 4.15 years with a SD of 2.86 years of experiences [Figure 1]. Nearly two-thirds of health workers 177 (64.4%) had training on COVID-19 and around one-third, 78 (28.4%) had experiences of outbreak management.

Figure 1

Percentage of health care workers experiences of west Guji Zone public health facilities, 2020

Chronic and behavioral related factors

Regarding the psychologic distress of HCWs, 38 (13.8%) had a previous history and 18 (6.5%) had Parental history of psychological distress. Out of study participants, 45 (16.4%) of HCWs ever had any medical illness. The medical illnesses were; diabetic mellitus 24 (8.7%), chronic hypertension 22 (8%), asthmatic disease 7 (2.5%), chronic bronchitis 6 (2.2%), renal disease 6 (2.2%), and anemia 6 (2.2%). This study revealed that 183 (66.5%) practiced PPE. Ninety-one (33.1%) of HCWs had travel history for the past 2 weeks before the survey. Five (1.8%) of them were had ever smoked tobacco/cigarettes. Concerning alcohol use, 74 (26.9%) drunk alcohol with the frequency of 40 (14.5%) once or twice a week, 35 (12.7%) one to three per month, 4 (1.5%) occasionally, and 2 (0.7%) every day of study participants, 14 (5.1%) used psychoactive drugs.

Factors associated with knowledge of health care workers about coronavirus disease 2019

HCWs who had degree holders were 2.31 (95% CI = 1.75–7.55) and masters and above holders were 4.56 (95% CI = 3.78– 13.51) times more likely to have good knowledge than diploma holders. HCWs who had 2–4 years and >4 years of experiences were 2.61 (95% CI = 1.85–9.65) and 3.02 (95% CI = 2.47–8.02) times more likely to have good knowledge on COVID-19, respectively than those who are <2 years of experience. Having trained on COVID-19 were 3.62 (95% CI = 2.80–11.707) times more likely to have good knowledge about COVID– 19, and HCWs who had medical diseases were 2.38 (95% CI = 1.97–13.32) times more likely to have knowledge on COVID-19 than HCWs after controlling confounding variables [Table 3].

Table 3

Bivariate and multivariate logistic regression analysis of factors associated with knowledge of health care workers about coronavirus disease 2019 in health Facilities west Guji Zone, southern Ethiopia 2020

Variables	Knowledge		COR (95% CI)	P	AOR (95% CI)	P
	Good	Poor
Sex
Male	144	29	1		1
Female	89	13	1.379 (0.681-2.792)	0.372	0.938 (0.543-7.566)	0.746
Level of education
Diploma	71	17	1		1
Degree	143	24	2.47 (1.730-12.975)	0.001	2.310 (1.746-7.553)	0.001
Master and above	14	6	3.81 (2.236-9.834)	<0.001	4.562 (3.781-13.509)	<0.001
Residence
Rural	61	13	1.264 (0.617-2.588)	0.522	0.830 (0.256-2.625)	0.85
Urban	172	29	1		1
Marital status
Married	129	24	1		1
Single	93	13	2.443 (0.779-7.665)	0.126	0.490 (0.304-2.942)	0.230
Divorced and widowed	11	5	3.252 (0.974-10.861)	0.055	0.714 (0.535-8.463)	0.982
Working experiences (years)
<2	70	14	1		1
2-4	91	19	1.358 (1.449-2.043)	0.011	2.608 (1.853-9.657)	0.042
>4	72	9	2.600 (1.651-3.934)	0.006	3.023 (2.472-8.023)	0.021
Pschoactive drug use
No	223	38	1		1
Yes	10	4	0.426 (0.127-1.428)	0.167	1.75 (0.793-4.179)	0.680
Alcohol use
No	170	31	1		1
Yes	63	11	1.044 (0.495-2.202)	0.909	0.680 (0.833-3.657)	0.532
Had medical illness
No	193	37	1		1
Yes	40	5	2.171 (1.847-10.612)	0.003	2.38 (1.97-13.32)	0.021
Previous history of psychologic distress?
No	203	34	1		1
Yes	30	8	0.628 (0.266-1.485)	0.289	0.76 (0.336-3.608)	0.542
Training on COVID-19
No	88	24	1		1	1
Yes	145	18	2.197 (1.129-4.276)	0.021	3.62 (2.800-11.707)	0.034
Previous outbreak managements experience
No	158	39	1		1
Yes	70	8	1.534 (0.568-4.144)	0.399	1.722 (0.768-3.844)	0.432

COVID-19=Coronavirus disease 2019, COR=Crude odds ratios, CI=Confidence interval, AOR=Adjusted odds ratio

Discussion

This study assessed the level of knowledge of HCWs and associated factors towards COVID-19 in public health facilities in the West Guji zone, southern Ethiopia. HCWs who had good knowledge were 84.7%. This study was consistent with the finding in a multicenter study in Ethiopia 88.2%,[17] Northwest Gondar Ethiopia (94.2%),[18] Lebanon (90%),[19] and Nigeria (88.75%).[20] However, a study conducted in Rural Cross River State, Nigeria (6.7%–53.3%),[21] Addis Ababa Ethiopia (26.5%),[22] Uganda (69%),[16] Ethiopia Amhara region (70%),[23] India 70.91%,[24] a systematic review (72.2%),[25] and systematic review conducted on HCWs and the general population (59%)[26] were lower than this study. The reasons for the difference might be due to sampling size, study design, study area and the reason for a higher proportion of good knowledge was probably due to better preparedness for the worst.

Unlike the present study, many different studies show that socio-demographic factors age, sex, marital status, and residence were statistically significant associations with good knowledge about COVID– 19.[162327] The possible reason might be because health care providers having sufficient knowledge toward the route of transmission, characteristics of the disease, diagnosis, treatment, and prevention of COVID-19 will help to reduce comorbidities due to COVID-19. Knowing the transmission and prevention of COVID-19 also makes it easier for health care providers to know who and when patients died from COVID-19 because they are aware of the severity of the disease. The difference is might also due to the study area and socio-cultural difference.

This study revealed that HCWs who had more working experiences have good knowledge about COVID– 19 than those with fewer experiences. A similar finding was reported in a study done in China,[28] Nepal,[27] Cyprus,[29] and India.[30] This indicates HCWs who have more work experience played a fundamental role in fighting any new emerging diseases and respond to this crisis with more self-confidence. The level of HCWs’ education was significantly associated with knowledge related to COVID-19. This study was consistent with the study done in Northwest Ethiopia,[31] China and India.[323334] The possible justification might be HCWs who have higher educational levels might have better opportunities to access better information, read different research articles, and participate in different training than those with diplomas.

The study indicates HCWs who had training on the COVID-19 pandemic were statistically significantly associated with good knowledge about COVID– 19. This study is in line with a study conducted in some parts of Ethiopia in Amhara,[23] Low resource setting[35] and Addis Ababa,[22] and Nepal.[27] It implies that HCWs who had training on COVID– 19 will protect them self's and family, teach others about the mode of transmission, prevention methods, and sign and symptoms of COVID– 19. Availability of PPE, water, and soap supply to all health facilities are also very important components to fight this pandemic disease.

The current study identified that HCWs who had medical diseases were more knowledgeable about COVID-19 than others after controlling confounding variables. This is in line with a study conducted in a multi-center study in Ethiopia.[17] On the other hand, a study conducted in Nepal[27] indicates health workers with a medical disease had inadequate knowledge of COVID-19. The reason might be there was consistent evidence that specific conditions increase a person's risk of severe COVID-19 illness such as chronic kidney disease, obstructive pulmonary disease, obesity, Immunocompromised state, serious heart conditions, such as heart failure, coronary artery disease, or cardiomyopathies, sickle cell disease and type 2 diabetes.[36]

Limitation and recommendation

The demerits of this study were, the cross-sectional study design was employed, which has limitations in establishing a causal relationship, The responses provided were self-reported and may subject to recall bias and this study lacks the level of practice of coronavirus prevention measures. Government and nongovernmental organizations should give training on COVID 19 for health care work for depth understanding and further studies should be done by using a mixed method of data collection approach to assessing the availability and accessibility of PPE and the level of HCWs’ practice about coronavirus prevention and control.

Conclusions

This study indicated that HCWs’ knowledge about COVID-19 was good. Factors significantly associated with good knowledge were high educational status, working experiences, had training on COVID-19, and having medical diseases. Thus improving the educational status of HCWs and giving updated training on COVID-19 will improve HCW's knowledge.

Financial support and sponsorship

Bule Hora University fund this research to starting from the design of the study, data collection, analysis, interpretation of data, and writing the manuscript.

Conflicts of interest

There are no conflicts of interest.

Part 1

Socio demographic information

Questions	Possible responses	Skip
Sex of the respondents	1. Male
	2. Female
Age of the respondents	__________________
Residence?	1. Rural
	2. Urban
Current marital status of the HCW	1. Married
	2. Single
	3. Divorced
	4. Widowed
Ethnicity	1. Oromo
	2. Amhara
	3. Burji
	4. Others specify_____
Religion	1. Orthodox
	2. Muslim
	3. Protestant
	4. Wakeffata
	5. Others
Educational level of HCW	1. Diploma
	2. Degree
	3. Masters
	4. Specialist
Profession of the HCW	1. General practioner
	2. Health officers
	3. Nurses
	4. Midwifery
	5. Laboratory
	6. pharmacy
	7. Anesthesia
	8. IESO
	9. Others specify_______
Family size	______________
Monthly income	___________________

HCW=Health care workers, IESO=Integrated emergency surgical officers

Part 2

Knowledge related to coronavirus disease 2019 questionnaires

Questions	Possible responses
Work experience	______________year(s)
Previous experience of outbreak management	1. Yes, 2. No
Did you trained for COVID 19?	1. Yes, 2. No
Items or components of knowledge-related questions used to measure level of knowledge of healtd care workers	Yes	No	I don’t know
The main clinical symptoms of COVID-19 are fever, fatigue, dry cough, and myalgia
Like the common cold, stuffy nose, runny nose, and sneezing are common in persons infected with the COVID-19 virus
Currently there is no effective cure for COVID-19, but early symptomatic and supportive treatment can help most patients recover from the infection
Not all persons with COVID-19 will develop to severe cases. Only those who are elderly, have chronic illnesses and obese are more likely to be severe cases
Eating or contacting wild animals would result in the infection by the COVID-19 virus
Persons with COVID-19 can infect the virus to others when a fever is not present
The COVID-19 virus spreads via respiratory droplets of infected individuals
Ordinary residents can wear general medical masks to prevent the infection by the COVID-19 virus
It is necessary for children and young adults to take measures to prevent the infection by the COVID-19 virus like adults
To prevent the infection by COVID-19, individuals should avoid going to crowded places such as train stations and avoid taking public transportations
Isolation and treatment of people who are infected with the COVID-19 virus are effective ways to reduce the spread of the virus
People who have contact with someone infected with the COVID-19 virus should be immediately isolated in a proper place. In general, the observation period is 14 days

COVID-19=Coronavirus disease 2019

Part 3

Chronic disease related factors

Questions	Possible responses	Skip
Have you previous history of psychologic distress? (before 6 months)	1. Yes, 0. No
Have you parental history of psychological distress? (before 6 months)	1. Yes, 0. No
Have you ever had any medical illness?	1. Yes, 0. No	If 1 → 403
If yes Q402, select medical illnessess you had?
Chronic HTN	1. Yes, 0. No
DM	1. Yes, 0. No
Cardiac disease	1. Yes, 0. No
Anemia	1. Yes, 0. No
Seizure disorder	1. Yes, 0. No
Asthma	1. Yes, 0. No
Other specify	……………
Do you have a family or relatives with suspected/confirmed COVID 19?	1. Yes. 0. No
Do you had a family or relative passed due to COVID-19?	1. Yes 2. No

COVID-19=Coronavirus disease 2019, HTN=Hypertension, DM=Diabetes mellitus

Part 4

Behavioral related factors

Questions	Possible responses	Skip
Appropriately practicing PPE	1. Yes
	0. No
Travel history for past 2 weeks	1. Yes
	0. No
Have you ever smoked tobacco/cigarette?	1. Yes	If no skip to Q 503
	2. No
How often do you smoke?	1. Every day or nearly every day
	2. Once or twice a week
	3. 1-3 times a month
	4. Occasionally, <1 a month
Have you ever consumed alcohol (beer, areke, tella, tej)?	1. Yes
	2. No
How often do you drink alcohol (beer, areke, tella, tej)?	1. Every day/nearly every day
	2. Once or twice a week
	3. 1-3 times a month
	4. Occasionally, <1 a month
Have you ever used psycho active drugs?	1. Yes
	2. No

COVID-19=Coronavirus disease 2019, PPE=Personal protective equipment