Tackling Adverse COVID-19 Situation in India: A Perspective on Frontline Health-Care Workers

Abstract

Background: 

As of December 17, 2021, India has been reporting a daily increase of over 7447 in fresh COVID-19 cases, total over 3.4 crore cases. Lack of knowledge and perceptions among health-care workers (HCWs) can pose challenges to disease control. HCWs are high-risk group for COVID-19; Adequate knowledge and COVID appropriate behavior can help prevent and contain the disease. Only early diagnosis and quarantine with proper management help to limit the COVID-19 transmission.

Methodology: 

A cross-sectional study was carried for 30 days, from the September 16, 2020–October 15, 2020, in a block of Paschim Medinipur, West Bengal, with varying cumulative incidence of COVID-19 cases. A 36-item survey instrument on various domains was adapted for assessment of COVID-19 awareness.

Results: 

The survey was conducted among 115 frontline HCWs engaged in screening and treating COVID-19 patients. Survey results indicated that majority have good knowledge about the disease, its symptom, testing, management guidelines but lack of knowledge found on mode of organ damage and home isolation advices. Addressing their perceptions and placing additional focus on practices across all health facilities is recommended as a preparedness measure.

Conclusions: 

As the global threat of COVID-19 still continues to emerge, targeted interventions are required for HCWs, and further studies are warranted on field level HCWs.

Introduction

Globally, Overall, there have been over 271,963,258 confirmed COVID-19 cases, including more than 5,331,019 deaths, reported to World Health Organization (WHO) through the week ending December 17, 2021.^[1] As of December 16, 2021, India has been reporting a daily increase of over 7447 in fresh COVID-19 cases, thus pushing the country’s active case tally to over 84,565 cases and 4.77 lac deaths.^[2] COVID-19 disease has affected more than 300 countries worldwide with an average of 254,502 new cases and 5858 deaths per day, up to September 2020. There are only emergency use authorization therapeutics or vaccines for the treatment/prevention of COVID-19 till date. Hence, awareness among health-care workers (HCWs) about the disease, mode of transmission, safety precautions, and early diagnosis plays a great role.^[3] All individuals started practice use of face masks, physical distancing, hand-washing and other COVID appropriate measures for control of COVID-19 pandemic.

COVID-19 disease first appeared in Wuhan City, Hubei Province of China, in December 2019. Since that time, large outbreaks have been reported in other Chinese Provinces and many nearby countries to eventually spread in all continents. Thus, the WHO declared this outbreak as a global pandemic on the 12^th of March, with the continuous increase in reported cases.^[4] COVID-19 disease is caused by Severe Acute Respiratory Corona virus 2019. Till now only few studies have been conducted to find out needs and gaps in knowledge of frontline health workers e.g.: accredited social health activist (ASHA) and auxiliary nurse midwife (ANM) health workers.

Objective

1. To find awareness of COVID-19 among frontline HCWs
2. To find out the prevailing practice regarding COVID-19 infection prevention of study subjects
3. To assess social stigma, if any, faced by study subjects during COVID-19 pandemic.

Place of study

Dwarigeria Rural Hospital, Garbeta 3 block, Paschim Medinipur.

Methodology

This cross-sectional, observational analytical study was conducted among HCW in a block of Paschim Medinipur, West Bengal. One block was selected from 21 blocks of Paschim Medinipur by random selection method. The study was carried for 30 days, from the September 16, 2020–October 15, 2020. The participants were aged between 18 and 60 years and HCWs posted at Dwarigeria Rural Hospital, Garbeta III block, Paschim Medinipur.

The questionnaires were distributed online and offline to ASHA and field level Health workers. The questionnaire consisted of two main sections; the first section focuses basic socio-demographics such as age, religion, education status, family type, marital status and service duration of the participants. While the second section asked about the participants’ level of awareness (16 items), attitude and practice (13 items) and social stigma (7 items). The possible answers were “I agree/yes,” “I disagree/No” and “I don’t know.” Each correct response was given a score of one for right and zero for both wrong and do not know responses. The possible scores were the sum of all correct responses, 36 correct response scores 36 (maximum) and all wrong response would lead to score 0 (minimum) for each study subject. Data collection started from participants after due informed consent; Data was collected maintaining anonymity and confidentiality. Ethical approval was obtained from the Institutional Ethics Committee, Calcutta National Medical College.

Study tools

The survey questionnaire was designed in English language and then transformed into Local (Bengali) language and again transformed to English language. After Pretesting on few health workers, necessary modification done and data collection started. It covered the socio-demographic characteristics, knowledge and practice and stigma associated with COVID-19.

Study variables

Socio-demographic characteristics including age, education level, service duration and family type was considered as independent variables, whereas the level of awareness, attitude, and practice and stigmatization was considered as dependent variables.

Study design

For the study period every field level staff satisfying the inclusion and exclusion criteria were approached and incorporated into this cross-sectional research study by complete enumeration. Out of 104 ASHA and 41 ANM posted over 24 sub centers in the selected block, only 126 consented and participated in this study, 11 incomplete responses were discarded and 115 filled responses were analyzed.

Inclusion criteria

HCWs who visit community on daily basis for their work.

Exclusion criteria

1. Frontline HCW who are currently ill with COVID-19 and in isolation
2. HCW who are admitted at Hospital for any other disease.

Methods of data collection

The questionnaire was distributed and responses were collected from them on the end of days’ work.

Data analysis

Statistical analysis was performed using Microsoft Excel 2016 software.

Ethical considerations

Confidentiality of personal information was maintained throughout the study by making participants’ information anonymous and asking participants to provide honest answers. Eligible HCWs’ participation in this survey was voluntary and was not compensated. Electronic informed consent was shown on the initial page of the survey. Data collected by explaining the confidentiality and nature of investigation and written responses were collected in printed questionnaires.

Results

A total of 126 HCWs participated, of whom 11 incomplete responses were discarded and 115 completed responses were studied; those completed study questionnaire including 12 ANMs and 103 ASHA distributed through 24 sub centers of Dwarigeria Rural Hospital area. Figure 1 shows age distribution of study participants and Table 1 shows socio demographic characteristics of study participants:

Figure 1: Age characteristics of Frontline Health Workers in Dwarigeria Rural Hospital (N = 115)

Table 1: Sociodemographic characteristics of frontline health workers in Dwarigeria Rural Hospital (n=115)

Our study showed 43.6% people in age group of 25–34 years, 29.9% within 35–44 years and 45–54 years 17.1% and more than 55 years only 1.7%, mean age 35 years. 55.6% people have experience of field work <5 years, whereas 23.9% has work experience of more than 10 years, mean service experience 5.6 years. Our study subjects are of 86.1% Hindu religion and all female, 40.9% from nuclear family and rest 59% are from joint family.

Educational status was as following: secondary (class 10) 30.4%, Higher Secondary (up to Class 12) 47%, graduation and above 22.6%. About socio economic status, according to B G Prasad Socio Economic scale modified for 2020, 71.3% people are within Class II (3766–7532), Class I (7533 or above) 5.2%, Class III (2260–3765) are 22.6% and Class IV (1130–2259) are 0.9%.

The study was conducted within the first 8 months of the declared COVID-19 pandemic affecting our lives. Table 2 shows gross summary of our findings. Broadly query was on awareness about COVID infection and virus itself. The population showed good awareness about the disease itself despite inability to correctly naming the causative organism type. They were aware about the mode of spread and incubation period.

Table 2: Knowledge, practice, and social stigma of COVID-19 among study participants

Considering this group of people to be the primary source of information to general population this awareness shows a favorable attitude in ongoing COVID-19 pandemic. Queries also extended on communicability, spectrum of presenting symptoms, common perception about severity of symptoms as also mortality and morbidity associated with disease. Precise knowledge regarding availability of government health facility and service was inquired into. Self-protective COVID preventive measures were inquired both with a COVID and general infective disease perspective to assess generalizability of common preventive and protective measures. Further query was placed regarding services extended on behalf of government to these warriors to assess if any area of dissent.

Next domain of knowledge assessed was presenting symptom. While most correctly identified the varied presenting symptoms well as comorbidities affecting severity 2 areas namely isolation and danger signs identification had a relatively larger number of incorrect information though not dangerously high. Assessment of severity of presenting symptoms was adequate however precise reason causing death was not well known among study population. Considering the wide spectrum of the now known causes of COVID death such confusion is justifiable. Regarding decision and information about patient care at home or admission large percent opined at home in keeping with isolation norms. Wearing of face mask by affected within home also is unknown to 16.2% HCWs. The concept of safe homes was not widely discussed or availed in our study settings. However, the correct norm of isolation and protection in isolation was again a grey area of information. Most were aware of the nearest government facility. This maybe a drawback of the study as the study population are mostly government employees of employees of government agencies. Most could correctly state proper hand washing technique. In general, the study population was satisfied with information, facility and protective gear supplied.

Finally, social stigma affecting these frontline workers was looked into as objectively as permissible by questions designed to throw light indirectly, measuring the extent and effect of stigmatization. The domain of social stigma showed despite countrywide news of harassment of health workers, in the rural background of this study there seems to be no such injustice. The participants were at peace with the community they serve with no untoward behavior pattern indicating social outcry. Possibly most of HCW were members of the locality promoting kinmanship rather than stigmatization.

Table 3 shows that the knowledge about COVID-19 proportionately increases with age and duration of service as per correlation analysis. Regarding practice and attitude of COVID appropriate behavior, acceptable practice was found to be proportionate with age and duration of service. Regarding facing stigma, it was inversely proportionate with age and duration of service in our study. Though these results were not statistically significant due to various reasons, the direction of correlation found in our study is similar in various studies across world.

Table 3: Relation between sociodemographic variables and knowledge, practice, and stigma associated with COVID-19

Discussion

At present COVID-19 is a global topic of worry in the media and public, especially among all HCWs. Since COVID-19 pandemic declaration, all shareholders and policymakers in our country are in regular touch to control the situation and gradually implement vaccination services. Though daily cases are gradually decreasing as of now, still COVID-19 remains a significant public health threat and people need to maintain all safety regulations for self and the society. We conducted this study to assess any gaps, if any, existing among frontline HCWs.

Most of the study^[5–12] showed good knowledge regarding Covid 19 knowledge among HCWs like our study; whereas Alahdal H, Basingab F et al^[6] showed that 58% showed a moderate level of awareness regarding COVID-19. In a study by Gambhir RS, Dhaliwal JS et al^[13] showed that, one third of subjects were not fully aware regarding PPE usage & disposal and more than 60% of subjects were knowledgeable regarding recent WHO guidelines for health care workers while dealing with COVID-19 patients. A study by Bhagavathula AS, Aldhaleei WA et al^[14] showed that, significant proportion of HCWs had poor knowledge of its transmission (n=276, 61.0%) and symptom onset (n=288, 63.6%) and showed good perceptions of COVID-19. In a study by Modi PD, Nair G et al^[15] showed that, among the HCWs good knowledge, only 45.4% of the responders were aware of the correct sequence for the application of a mask/respirator, and only 52.5% of the responders were aware of the preferred hand hygiene method for visibly soiled hands.

In our study it is found that increase with age and duration of service is associated with proportionate increase in knowledge and practise and inversely proportionate with stigmatization found in our study. Similar finding is seen in study by Grewal VS, Bandyopdhyay K et al^[10] showed that only practice demonstrated a significant association with increasing qualification of the participant (P < 0.001) and Al Sulayyim, H.J, Al-Noaemi et al^[12] showed that, HCWs knowledge score was significantly associated with profession (P = 0.034), educational level (P = 0.033), and availability of the infection control in the workplace (P = 0.006).

Among the study who assessed practice, Alahdal etal.,^[6] 95% presented a high attitude and 81% presented an adequate practice regarding COVID-19; also, males (60%) showed better knowledge compared to females (57%), but females (82%) showed better practice than males (80%). In a study by Behera and Bawa.^[9] showed that good practice associated with knowledge across pediatric surgery department. In a study by Grewal etal.^[10] showed that practice which demonstrated a significant association with increasing qualification of the participant (P < 0.001). Our study had similar findings that good practice is associated with increased age and increased duration of service.

Regarding stigmatization, our study found that participants facing sigma was though very few in numbers, inversely correlated with age and duration of service experience.

Conclusions

With the onset of pandemic by virtue of practical problems encountered most of the HCW had some idea regarding Covid 19 relateded protocols. During household visit or via self-exposure, all HCWs have most of the knowledge regarding this disease. In our study, we found good knowledge and perception about COVID-19 prevention practices than most of the published studies. In our study, significant findings were that 38% participants do not know the disease is viral but is aware of the disease and 26.5% were unaware of the chances of mortality. These two domains of knowledge were severely affected in our study area and need to be stressed during further awareness sessions. We recommend more IEC activities in the home isolation protocol domain and continued awareness of COVID-19.

Limitations

We used WHO training material and Government of India standard operating procedures for COVID-19 to develop a questionnaire. This questionnaire was pretested, and open-ended questions were limited to reduce information bias. However, this is a cross sectional study conducted among HCWs during a time when an alarming number of cases were detected globally. This study data validity depends on participants honesty and recall ability, thus may be subject to recall bias. Despite this limitation our findings provide valuable information about the knowledge and practices and social stigma faced of HCWs during the time of pandemic.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.