Knowledge, attitude, practice and clinical recommendations of health care workers towards COVID-19: a systematic review

Objectives: This study aimed to evaluate the knowledge, attitude, practice, and clinical recommendations of health care workers (HCWs) towards COVID-19. Methods: In this systematic review study, international databases (Web of Science, PubMed, and Scopus) were searched for the relevant studies published in English from the inception of databases until July 30, 2020. Hoy et al.’s tool was used to evaluate the quality of studies. All search steps, screening, selection of studies, quality assessment, and data extraction were performed separately by two researchers. Results: Out of 3460 articles searched, 28 articles conducted on 16,427 HCWswere included in the study. Most of the HCWs had good knowledge (72.2%), a positive attitude (70.9%), and good practice (78.8%) towards COVID-19. The most important clinical recommendation to improve knowledge, attitude, and practice (KAP) was to provide HCWs with a periodic training program regarding COVID-19. The most important source of information for HCWs on COVID-19 was social networks. Conclusions: Despite HCWs’ good knowledge, attitude, and practice (KAP), it is recommended to periodically review KAP and carry out further studies in different countries as well. It is also recommended to use social media to improve KAP.


Introduction
Nowadays, coronavirus is known as a public health emergency throughout the world. On March 11, 2020, the World Health Organization (WHO) declared the coronavirus disease (COVID-19) a global pandemic [1]. COVID-19 was first reported on December 1, 2019, in Wuhan, Hubei Province, China [2]. Coronavirus is a newly emerging disease whose many dimensions are still unknown. The pathogenesis period of coronavirus ranges between 2 and 14 days, and more than 80% of cases have mild symptoms [3]. The latest statistics reveal that coronavirus has infected more than 25,886,392 people until 1 September, 2020, and led to the deaths of more than 860,218 people worldwide [4].
One of the most important risks associated with this disease is the very rapid spread of the disease so that more than 200,000 people worldwide were added daily to patients with COVID-19 [4]. The most common routes of transmission are travel, social interactions, and infectious transmission. Health care workers (HWCs) are more susceptible to the development and transmission of the disease than other groups. Studies have shown that the prevalence of coronavirus among HCWs in the Netherlands [5], the United States [6], and Italy [7,8] was 15, 5.3, and 3.4-20%, respectively. Given that there is no definitive way to treat the disease, the only way to control the disease is to prevent it through adherence to standard precautions, increasing social distance, and washing hands [9]. With due attention to the newly emerging nature of coronavirus, the huge variety of the disease symptoms, different diagnostic tests, and the lack of vaccines and definitive coronavirus treatment, having sufficient knowledge, a positive attitude, and good practice to deal with the disease are of great urgency. Having sufficient knowledge regarding COVID-19 in HCWs who are exposed to patients with COVID-19 day and night is doubly important. Low level of knowledge and negative attitude towards COVID-19 directly lead to late diagnosis, poor practice, poor adherence to infection control principles, and a faster spread of the disease [10,11]. Despite the short time that has elapsed since the outbreak of the disease as well as conducting individual studies in this field, so far, there has been no comprehensive study in this regard. Determining the current status of HCWs' knowledge, attitude, and practice (KAP) towards coronavirus can greatly help policymakers to come up with a better plan to increase knowledge, create a positive attitude, and improve proper practice. Therefore, this study aimed to evaluate the knowledge, attitude, practice, and clinical recommendations of HCWs towards COVID-19.

Eligibility criteria
This systematic review was conducted using the Cochrane Handbook, and the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) [12] was used to report the study. In this study, cross-sectional studies on various health care workers (HCWs) published in English peer-reviewed journals were included in the study without any time limit. Qualitative, review and non-English studies were excluded. The outcomes measured in the included studies were knowledge, attitude, practice, and clinical recommendations of HCWS towards COVID-19.

Search strategy
International electronic Databases (Web of Science, PubMed, and Scopus) were searched for the relevant articles from the inception of databases until July 30, 2020. To provide a search strategy, the keywords were first identified with the help of Medical Subject Headings (MESH), Emtree, and combined with related words in published articles. A librarian who was experienced in work on systematic reviews contributed to determining the search strategy. The search strategy used for the PubMed was applied to search other databases as well. The PROSPERO was searched for ongoing reviews. The keywords used were: "knowledge" OR "attitude" OR "practice" OR "COVID-19" OR "coronavirus" OR "health care workers". We conducted the last search on 30 July 2020.

Selection of studies and data extraction
After searching databases, the articles were entered into EndNote software. Duplicate articles were removed after screening. In the next step, the titles of the articles were examined and irrelevant titles were removed. Then, the abstracts of the remaining articles were reviewed based on the inclusion criteria and irrelevant items were excluded. In the final step, the full text of the relevant articles was reviewed and the final included items were selected. First, the risk-of-bias (quality) of the included articles was assessed and the data were extracted. Selection of studies, screening, quality assessment, and data extraction was performed separately by two researchers.
The consensus method was used for solving controversies between two researchers in selecting the final included studies. Extracted items were included: id, author, year, country, study design, number of participants, target population, instrument (type, items, reliability, and validity), study outcome measure, sampling method, method of data collection, age, gender (male/female), main outcomes (knowledge/ awareness, attitude, practice), sources of information, and clinical recommendations to the improvement of HCWs KAP.

Quality assessment
Hoy et al. standard tool was used to assess the quality of the methodology of the studies [13]. This tool consisted of 10 items and evaluated the quality of the methodology of observational studies in two dimensions including external validity (target population, sampling method and procedure, and minimum non-response bias) and internal validity (data collection method, outcome definition, study instrument, and data collection procedure). The quality of the studies was separately assessed by two researchers. Tables were used to display the results.

Study selection
After searching the databases, 3,460 articles were found, of which 2,829 articles remained after deleting duplicates. Out of 2,829 articles, 2,788 articles were excluded due to not meeting the inclusion criteria. Of the remaining 41 studies with reviewed full-text, 28 studies were included in the systematic review study, and 13 studies were excluded from the study. Of the 13 articles excluded, there were 2 reviews, 6 letters to the editor, 2 qualitative studies, and 3 articles published in the non-English language ( Figure 1).

Study characteristics
Of 28 cross-sectional studies conducted on 16,427 HCWs were entered into the systematic review. All the studies were carried out in 2020. Most of the studies were conducted in Turkey (n=5), China (n=3), and India (n=3). Out of 28 studies, 15 studies were performed on a set of HCWs and there were also some studies conducted specifically on dentists or physicians (n=3) and nurses (n=2). In all the studies, the tools used were researcher-made. The most common type of sampling method used in studies was convenience sampling (n=19). The mean age of participants was 32.8 years. In most studies (n=26), the gender of participants was specified. Out of 14,465 participants in 26 studies, most of them were women (n=8671) ( Table 1).

Tools
Different tools were used in all 28 included studies. In most studies (n=26), the tools used were researcher-made. In all studies, the content of the tools was developed using national, the World Health Organization (WHO), and the Centers for Disease Control and Prevention (CDC) guidelines. In the included studies, several researchers were provided with tools in a pilot program to determine the validity of the tools. Moreover, Cronbach's alpha was used to determine the reliability of the tools. It ranged from 0.71 to 0.81 in different studies. In 25 studies, the number of items was mentioned. The number of questions in tools ranged from 5 to 45 questions (Table 1).

Knowledge, attitude, and practice of HCWs towards COVID-19
Out of 28 studies, 26 studies evaluated the level of knowledge of HCWs towards COVID-19. The level of knowledge/ awareness in each study were expressed as the percentage of participants with sufficient knowledge towards COVID-19. Of 26 studies, 25 studies conducted on 14,097 individuals showed the percentage of participants with sufficient knowledge. Knowledge was expressed at sufficient, moderate, and poor level in the included studies. The level of knowledge of HCWs in different studies ranged from 26.5 to 96.89%. Based on the general classification of the level of knowledge, a score of 1-33, 33-66, and 66-100% suggested poor, moderate, and good knowledge, respectively. In most studies (n=17, 68%), participants had good knowledge of COVID-19, and in 7 studies (28%), they had moderate knowledge towards COVID-19. Moreover, in one study, participants had poor knowledge. In general, 72.2% of participants had sufficient knowledge of COVID-19. In one study, the mean level of knowledge was reported at 6.26, indicating poor knowledge of HCWs towards COVID-19.
Out of 28 studies, 16 studies evaluated the attitude of HCWs towards COVID-19. In 15 studies, the level of attitude was expressed as the percentage of participants with a positive attitude towards COVID-19. In different studies, 16.7-96.4% of participants had a positive attitude towards COVID-19. In general, in most studies (n=10, 66%), more than 70% of participants had a positive attitude towards COVID-19. Furthermore, in 4 studies, less than 50% of participants had a positive attitude towards COVID-19. Overall, the results revealed that more than 70.9% of HCWs had a positive attitude towards COVID-19. In one remaining study, the mean level of attitude was reported at 8.43, indicating a positive attitude towards COVID-19.
Out of 28 studies, 9 studies evaluated the practice of HCWs towards COVID-19. In the included studies, HCWs' practice was reported as the percentage of participants with good practice towards COVID-19. The participants' paper-based,         (2) Knowledge,    practice score was reported to be between 24.2 and 96%. In most studies (n=8, 88.8%), participants performed good practice. In general, 78.8% of HCWs had good practice towards the adherence to COVID-19-related infection control principles ( Table 1).

Source of information and clinical recommendation to improve KAP of COVID-19 among HCWs
Out of 28 studies, 23 studies reported clinical recommendations to improve KAP among HCWs. The most important clinical recommendations to improve HCWs' KAP towards COVID-19 were: Continued education program for HCWS about coronavirus (n=11), providing the sufficient quantities of PPE and training of all HCWs (n=10), and Participate in online webinars provided by the CDC and WHO to update awareness about COVID-19 (n=3) ( Table 2). Concerning the resources of information for HCWs used to improve KAP, the most important sources of information were social media (n=7), television (n=7), and newspapers (n=6) ( Table 1).

Discussion
Today, coronavirus is regarded as the most important health, economic, psychological, and social challenge. This study aimed to evaluate the knowledge, attitude, practice, and clinical recommendations of HCWs towards COVID-19. To do so, databases were searched for the relevant studies up to July 30, 2020. Of 28 cross-sectional studies conducted on 16,427 HCWs in more than 18 countries entered into the final stage of the systematic review. In most studies, researcher-made tools were used. Regarding knowledge, the results showed that in most studies, HCWs had good knowledge of COVID-19. In general, 72.2% of participants had sufficient knowledge of COVID-19. According to researchers' searching, so far, there has been no review study in this regard. However, in a systematic review generally conducted on infection control, the results demonstrated that in most included studies, participants had sufficient knowledge of the infection control principles [42], which is in line with the findings of the present study.
Regarding individual studies, the results of the present study also confirm the findings of individual studies conducted on medical students in Jordan [43], Philippines [44], and India [26], which can be due to the similarities in methodology and the level of communication on coronavirus topics among most of the medical students. Unlike the present study in which the level of knowledge towards COVID-19 was 72.2%, in studies conducted on the general population in Turkey (36%) [45], India (63%) [46], and Iran (4.8-7.3%) [47], participants had low knowledge regarding COVID-19. The reason for such discrepancy may reside in differences in the study populations and the sample size of the studies reviewed.
Concerning attitudes in different studies, between 16.7 and 96.4% of participants had a positive attitude towards COVID-19. In general, in most studies, more than 70% of participants had a positive attitude towards COVID-19, which corroborates with a systematic review study regarding general infection principles among nurses. Furthermore, the results of the present study are consistent with those of the individual studies on the general population in Malaysia (83.1%) [48], Indonesia (96%) [49], the exact cause of which is unknown; however, it may be due to health policies and training groups involved in increasing knowledge about COVID-19. In Alobuia WM's study conducted on the general population in the United States (27-52%) [50], it was found that participants had a negative attitude towards COVID-19, which is inconsistent with the findings of the present study. It can be due to a lower level of knowledge regarding COVID-19 in the general population, the unknown nature of coronavirus, the sudden outbreak of coronavirus in the world, and the difference in the type of study population in the two studies. Regarding practice, in most studies, participants performed good practice. Overall, 78.8% of HCWs had good practice towards the adherence to COVID-19-related infection control principles, which is inconsistent with the findings of the review study on nurses [42], which indicated that nurses performed a moderate to poor practice regarding infection control. Moreover, this result confirms the findings of M. K. Al-Hanawi's study conducted in Saudi Arabia [51].
Providing HCWs with COVID-19-related training programs as well as with the PPE equipment and the required practical skills and taking part in online webinars to increase the level of knowledge towards COVID-19 were among the most important clinical recommendations to improve HCWs' KAP towards COVID-19. The clinical recommendations presented are consistent with the results of previous studies [42,52,53]. The most important source of information for HCWs to improve KAP was social networks. With due attention to the increasing prevalence of the disease and the lack of definitive treatment and since the only way to control the disease is to create social distance and be quarantined, social networks play a substantial role in increasing the level of knowledge towards COVID-19 [54][55][56]. Since the outbreak of the coronavirus, countries have applied various social networks such as Facebook, Twitter, Instagram, and WhatsApp to raise the level of knowledge among HCWs and the general population [23,57].

Limitations and strengths
The most important limitations of this study are as follows: (1) All the included studies were descriptive, and a nonrandom sampling method was used to select the participants. When interpreting the results, the specific limitations of these studies should be taken into account, which may limit the generalizability of the results as well. (2) In some of the studies included, there was incomplete information, so the authors were contacted to receive the information. (3) Another limitation is the language of studies-only studies in English entered the final stage. (4) And the use of researcher-made tools in various studies is another limitation, which did not allow us to conduct a meta-analysis.
Despite the limitations stated, there are also some strengths associated with this study. Firstly, according to the best information provided by the researchers, this study was the first systematic review in this field. Secondly, in this study, all possible dimensions of knowledge, attitude, practice, sources of information, and related clinical recommendations were also discussed.

Conclusion
The results of this study revealed that in most of the included studies, HCWs had good knowledge, a positive attitude, and good practice towards COVID-19. The most important clinical recommendation was to improve the KAP by providing relevant training programs. Moreover, social networks were the most important source of information applied. With due attention to the limitations of the present study, it is recommended that future studies with a larger sample size be conducted periodically in different countries. The results of the current study can be applied to HCWs and health policy-makers to improve KAP.
Research funding: None declared.
Author contributions: All authors have accepted responsibility for the entire content of this manuscript and approved its submission.

Conflict of interest:
The authors declare that they have no conflicts of interest.
Informed consent: Not applicable. Ethical approval: Not applicable.