Introduction

Coronavirus disease 2019 (COVID-19) is the emerging respiratory disease that is caused by a novel coronavirus. It was first reported in Wuhan, China in December 2019 [1, 2]. The main clinical symptoms of this highly infectious disease include fever, dry cough, fatigue, myalgia and shortness of breath. The advanced stage of COVID-19 is characterized by respiratory distress syndrome, septic shock, bleeding and coagulation dysfunction [3, 4].

Since, December 2019, the COVID-19 has spread from Wuhan city to other cities of China and ultimately around the whole world [1, 5]. The World Health Organization (WHO) has declared the COVID-19 outbreak a public health emergency of international concern on 30th January 2020 and a pandemic on 11th March 2020. To date (9th April, 2020), there are 1.4 million laboratory-confirmed cases of COVID-19 in the world and 85,582 deaths have been associated with it [6].

It has been reported that around 209 countries are affected due to COVID-19 in the world [5]. Pakistan is also been hit by this infection and the number of confirmed COVID-19 cases are increasing by every passing day. According to the Ministry of National Health Services, Regulation and Coordination (MoNHSRC) the confirmed cases of COVID-19 till 6th April 2020 were 4601 and the associated deaths were 66. The laboratory-confirmed cases of COVID-19 in Khyber Pakhtunkhwa (KPK) province were 620 and 22 deaths have been reported with it. In comparison with other provinces of Pakistan (death rates: Sindh 1.86%, Punjab 0.7%, Balochistan 0.4%), KPK ranks at first position regarding the associated death with (death rate of 3.4%) COVID-19 [7]. The Government of Pakistan has taken unprecedented measures to control the COVID-19 spread in Pakistan. These measures include, suspension of public transportation services, the closing of schools and universities and implementation of general lockdown in the country along with special measures to isolate the infected and suspected cases [7, 8].

The battle against COVID-19 is still ongoing in Pakistan. In order to achieve success against the spread of COVID-19, the adherence to the control measures by the Primary Health Providers (PHPs) and the public are very important. The knowledge, attitude and practices of the PHPs towards COVID-19 infection will play a vital role in controlling this pandemic [1, 9].

Aims

To facilitate the management and control of COVID-19 in Pakistan, there is an urgent need to understand the awareness of PHPs regarding COVID-19. In this study, we have investigated the knowledge, attitudes, and practices of PHPs towards COVID-19 in three tertiary care hospitals of Peshawar, KPK, Pakistan.

Methods

Study Design and Settings

A cross-sectional survey was conducted from March 15 to April 4, 2020 in three tertiary care hospitals, named as Hayatabad Medical Complex (HMC), Khyber Teaching Hospital (KTH) and Lady Reading Hospital (LRH), located in Peshawar, Pakistan.

Ethical Approval and Consent to Participate

This research involved online data collection from the participants. Every participant gave an online informed consent before filling the study questionnaire. The study was approved by the Ethical Committee of the Department of Pharmacy Practice, Bahauddin Zakariya University (BZU), Multan (reference number Acad/21/20/11).

Measuring Instrument

A self-administered questionnaire was developed and validated in a pilot study of 22 participants. The Cronbach’s alpha coefficient for the developed questionnaire was 0.76, which indicates acceptable internal consistency. This questionnaire consisted of four parts as shown in Table 1. The first part was regarding demographics including age, gender, occupation, residence, and workplace. The second part comprised of 14 questions regarding COVID-19 knowledge (K1-K14, Table 1). Each question had three possible answers, yes/no and “I don’t know”. The total knowledge score ranged from 0 to 14. A mean knowledge score ≥ 10 represent good knowledge. A correct response was assigned 1 point and incorrect/ I don’t know was assigned 0 points. The third part comprised of 11 questions regarding attitude toward COVID-19 (A1-A11, Table 1). These questions were answered on 3-point Likert Scale (disagree, neutral and agree) and a mean score equal or less than 11 was associated with a positive attitude. The final part was regarding prevention practices associated with COVID-19 and were answered on some time, often and never basis (P1-P9, Table 1). A mean score equal to or less than 8 was an indicator of good preventive practices and a score greater than 8 was associated with poor preventive practices.

Table 1 Questionnaire to evaluate the level of knowledge, attitudes and practices about COVID-19 among PHPs of three tertiary care hospitals in Peshawar, Pakistan
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Data Collection

The questionnaire was developed using Google Docs (Google LLC. USA) and its online link was shared with the PHPs through email and via online social media. The questionnaire contained a brief introduction to the background, objective, procedures, voluntary nature of participation, declarations of anonymity and confidentiality, and the notes for filling in the questionnaire.

Statistical Analysis

The statistical package for social science (SPSS) version 25.0 (IBM Corp. Armonk, NY) was used to analyze the data. Descriptive statistics including frequency, percentage, mean, and standard deviation were used to describe sample characteristics, level of knowledge, attitudes, and practices. Chi-square test (χ2) was used for categorical variables and for scale variables, student t-test and Mann–Whitney U test were used.

Results

A total of 114 participants completed the survey, amongst which 74(66.7%) were male and 37(33.3%) were female. The mean age (± standard deviation) of the participants was 26.0 ± 2.0 (range: 22–33). Ninety-two (82.1%) respondents were having a bachelor or master’s degree. Most of the participants were un-married 71(63.4%) and most of the respondents were from HMC 65(57.5%). Other demographics characteristics are shown in Table 2.

Table 2 Demographics characteristics of the participants (n = 114)
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The participants of the survey had a good overall knowledge of COVID-19. The mean COVID-19 knowledge score was 12.7 ± 0.89 (range: 0–14) showing that 90.7% of participants had knowledge about the COVID-19. Knowledge score was significantly different across the professions (p = 0.003), and hospitals (p = 0.007). The knowledge scores of PHPs regarding COVID-19 can be seen in Table 3. Almost 90% of the participants knew the term COVID-19 and its mode of transmission. Most of the participants knew the signs and symptoms (84%) and risk factors (72%) associated with COVID-19. The results related to the participant’s knowledge can be seen in Table 4.

Table 3 Knowledge, Attitude and Practices scores of PHPs about COVID-19
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Table 4 Knowledge about COVID-19
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The majority of the respondents showed a positive attitude towards COVID-19 infection. Their mean score was 8.9 ± 4.1, suggesting that 90% of the respondents had a positive attitude toward the COVID-19 infection as shown in Table 3. Most of the participant agreed that COVID-19 can be transmitted through coughing and sneezing (74.3%) and can be prevented by, wearing a mask (88.3%), washing hands (81.7%), isolating the infected patient (95%), restricting travel to infected areas (85.6%) and avoiding touching nose, eyes, and mouth (97.3%). Concerning the use of the antibiotics in the prevention of COVID-19, around 2% of respondents were in its favor and 68.8% were against the statement as shown in Table 5. The attitude toward COVID-19 significantly differed with age (p < 0.0001), marital status (p = 0.0001), profession (p < 0.0001), hospital (p = 0.02) and residential place (p = 0.001) (Table 3).

Table 5 Attitude toward COVID-19
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The mean practice score of PHPs toward COVID-19 was 7.3 ± 1.2, which suggested that overall COVID-19 preventive practices were good. Most of the respondents were, eating thoroughly cooked food, keeping themselves warm and hydrated, avoiding close contact with the people having cough and flu-like symptoms and wearing personal protective equipment during interaction with COVID-19 patients. Most of the participants were taking care of proper hand hygiene before and after interaction with COVID-19 patients. Almost 100% practiced social distancing of one meter from patients and other healthcare workers (Table 6). There was a significant difference across the age (p < 0.0001) educational level (p = 0.001), hospital (p = 0.04) and residence (p = 0.02) of the participants as shown in Table 3.

Table 6 Practice toward COVID-19
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Discussion

To our knowledge, this is the first study in Pakistan that has assessed the KAP of PHPs toward the COVID-19 infection. The participants of this study had good overall knowledge about COVID-, as we found an overall correct response rate of 90.7% on the knowledge questionnaire. The knowledge score was significantly different across the professions (p = 0.003) and the hospitals (p = 0.007). Most of the respondents showed an optimistic attitude toward COVID-19. The mean attitude score suggested that 80% of the respondents had a positive attitude toward the COVID-19 infection. The attitude toward COVID-19 significantly differed across the age (p < 0.0001), profession (p < 0.0001) and hospital (p = 0.02). Despite this, the PHPs adopted good preventive practices regarding COVID-19. The mean practice score of 7.3 ± 1.2, suggested that the preventive practices regarding COVID-19 among the PHPs were acceptable.

Knowledge greatly reflects the practice of individuals as it provides a base for good practice [10]. The knowledge of PHPs regarding COVID-19 is of paramount importance as they are on the frontline in dealing with the COVID-19 outbreak. The Physicians, Pharmacists, and Nurses are the professionals who are in direct contact with the COVID-19 infected patients and they must be fully aware of the associated risks with this infection. In the presented study the correct knowledge response rate was 90%, this finding was consistent with studies conducted in China (90%) [1] and Kenya (88%) [9], but was higher than that of Jordon (40%) [11]. One study from China reported that 89.5% of the participants knew COVID-19 which was in line with our study [12]. The knowledge of the Iranian general population about COVID-19 was 87% which is consistent with our study [13]. Another study from China reported that 88% of the healthcare workers knew COVID-19 (knowledge score: 8.17 ± 1.30), this finding was in line with our study [14].

The present study demonstrated that most of the respondents showed a positive attitude toward COVID-19. Almost 80–90% of the respondents agreed that infection can be prevented by wearing masks, washing hands, using sanitizer and soap, restricting travel to infected areas, isolation of infected patients and avoiding touching nose, eyes, and mouth, which was consistent with studies reported from China (94%) [1] and Iran (90%) [13]. Another study from China stated that 93.3% of the participant agreed with the statements that COVID-19 transmission can be prevented by washing hands with soap frequently, isolation of COVID-19 positive patients and acceptance of isolation after getting COVID-19 (attitude score: 1.86 ± 0.43, range: 1–4) which was in line with our findings [14].

The adaption of preventive practices is the only solution to defeat the COVID-19, as to date, there is no specific treatment and prevention for the novel coronavirus [15]. In the present study preventive practice adopted by the PHPs were appreciable. The majority of respondents often practiced thoroughly cooked food (92%), keeping themselves warm and hydrated (69.6%), avoiding close contact with the people having cough and flu like symptoms (76%) and wearing personal protective equipment during interaction with COVID-19 patients (88.4%). Most of the participants had performed hand hygiene before and after interaction with COVID-19 patients (99.1%). Almost 100% practiced social distance of one meter from patients and other healthcare workers. This figure was consistent with the reported studies from China, where 96% of the respondents were practiced preventive practices by avoiding crowded places and wearing masks [1] and Jordon, where 87.5% of the participants adopted preventive practice by washing hands with alcohol or soap, wearing personal protective equipment (PPE) and putting a mask on confirmed or suspected patients [11]. Another study from Iran reported that 89% of the participants practiced preventive measures regarding COVID-19 (mean ± SD: 32.1 ± 2.9, range: 12–36) these numbers are consistent with our study [13]. The good PHPs practices seen in this study may be attributed to the various directives issued by the Government Agencies and by the awareness campaigns ran on the social and electronic media.

Limitations of the Study

In the present study, all the participants were from Peshawar, which is the provincial capital of KPK and they all had easy access to the internet but it is pertinent to mention that a considerable number of PHPs are working in basic health units (primary health care settings) of rural areas of Pakistan have very limited access to the internet and their knowledge, attitude, and practices (KAP’s) regarding COVID-19 were not evaluated in this study. This may be a limitation of this study.

Conclusion

The findings from the current study suggested that PHPs have good knowledge, optimistic attitude and reasonable practices regarding COVID-19 infection. Moreover, focused training programs for PHPs can improve the understanding of risk and preventive strategies related to COVID-19 infection, which in turn can improve the confidence of PHPs to provide appropriate care to their patients as well as to protect themselves from this infection. Hopefully, by designing effective COVID-19 prevention and management programs at Government level, countries like, Pakistan can manage the spread of COVID-19 infection.