Knowledge and Attitude towards 2019 Novel Coronavirus (COVID-19) Among Health Care Workers in Tripoli, Libya


 The rising incidence of COVID-19 continues to cause distress, worry, and fear amongst the public, mostly for healthcare workers, as they are the most vulnerable individuals at risk of contracting this new SARS-CoV-2 outbreak. This study measured levels of knowledge and attitude regarding COVID-19 among health care workers in Libya. A cross-sectional survey was conducted among healthcare workers in Libya between April 22 and June 16, 2020 using online pre-validate questionnaire. We obtained 272 valid participants from 28.7% nurses, 25.3% physicians, 34.2% pharmacists, and 11.8% other health care workers. The majority of respondents (54.4%) were from the western part of Libya, and most of participants (41.2%) used international health websites as a source of information. Most of the participants (89.3%) perceived that they had adequate knowledge about COVID-19, and (95.6%) of respondents affirmed that COVID-19 can be life-threatening disease. All participants agreed that the transmission of COVID-19 can be prevented by using standard and isolation precautions given by the health care authorities. In addition, most participants had good attitude toward the adequate information about COVID-19 in Libyan society. Readiness for the pandemic were low among government institutions as spotted from this study. Therefore, an effective educational training program should be implemented to ensure maintenance of appropriate practices during the COVID-19 pandemic.


Introduction
Coronavirus outbreak 2019 also known as COVID-19 is a speedily growing pandemic caused by a novel human coronavirus (SARS-COV-2) formerly known as 2019-nCov [1]. It was rst reported in December 2019 among patients with viral pneumonia symptoms in Wuhan, China [2]. On 11th March 2020, WHO stated the outbreak of COVID-19 as a global pandemic [3]. Since 12th September 2020, the virus has infected over 28,329,790 people, causing 911,877 deaths in 216 countries worldwide [4].
Globally, the United States of America has the highest affected with 695,350 cases and the highest number of deceases (32,427 deaths). While, African region is the least affected with 13,892 cases and 628 deaths, but the numbers are increasing [4]. Libya has so far con rmed 75 465 cases of COVID-19 as of 18th November 2020 [4].
Since the rst con rmed case announced in Libya on 24 March 2020, in Tripoli city, rising distress and anxiety expanded to other cities from the prospect of contracting COVID-19 and its outbreak [5]. The Health Care Workers (HCWs) as the rst line of protection and older persons were the most vulnerable to  infection that the majority of other people [6]. Throughout that time, there was also a serious de ciency of personal protective equipments given to the existing con ict and the country unrest.
Likewise, it was very important to focus on the need to understand the level of readiness of HCWs in order to manage with the outbreak of COVID-19 in the country. This circumstance inspired the necessity to conduct the current study aiming to explore the level of knowledge and attitude among HCWs towards the outbreak of COVID-19 in the country.
Presently, COVID-19 is an everyday dialogue topic in the social media and among the public, particularly among patients and HCWs. Therefore, to ensure the protection of HCPs in Libya from COVID-19, there is a crucial need to increase the understanding and alertness of COVID-19 among HCPs. This study aims to evaluate the knowledge and attitude of HCPs towards COVID-19. The outcomes may be useful in the preparation of health education programmes about this emerging infectious disease.

Study design
A cross-sectional questioner-based survey was conducted between April 22 and June 16, 2020, and was approved by the committee of faculty of Medical technology, the University of Tripoli, Libya. A pre-tested validated questionnaire was distributed online targeted all HCWs who were employed at one of the healthcare centers in Libya.

Questioner development and distribution
The online questionnaire was developed, with some adjustments, using the commonly asked queries from the WHO and the national center for disease control websites [7,8]. The questionnaire was designed in English and was pre-validated on 7 HCWs (2 physicians, 2 pharmacists, 1 nurse, 2 technicians) to determine adequacy and the simplicity of the questions, and it was then revised accordingly.
The questionnaire comprised 3 sections addressing knowledge and attitude of HCWs regarding COVID-19. The rst section enclosed demographic characteristics such as age, gender, occupation, place of resident, and respondents' source and su ciency of knowledge on COVID-19. The second section evaluated the knowledge of HCWs by asking queries on the etiology, symptoms, incubation period, risk group, consequences, source of transmission, prevention and treatment of COVID-19 (10 items).
A scoring scheme was used to measure the level of knowledge of each item; 2 points for each correct answer, 1 point for an incorrect answer. A level of ≥ 10 points (≥ 50% of total marks) was considered adequate knowledge. Respondents were categorized into 2 groups depending to their level of knowledge: de cient knowledge (< 10 points), and adequate knowledge (≥ 10 points). The third section of the questionnaire evaluated the attitude of HCWs regarding COVID-19 with a set of eight "yes or no" questions.

Statistical analysis
Data were presented frequencies and proportions, and were analyzed using Statistical Package for Social Sciences software (SPSS) software, version 22. Pearson's Chi-squared was used as the test of signi cance between categorical outcomes. The p value < 0.05 was considered signi cant.

Results
A total of 272 respondents have completed the online questionnaire. The age range of the participants was 21-57 years, with the highest range were in the 31-40 category of age (112,41.1%). The majority of respondents 148 (54.4%) were from the western part of Libya, followed by 89 (32.7%) and 35 (12.9%) from the eastern and southern region, respectively. Most of the health care workers 242 (89.3%) perceived that they had adequate knowledge about COVID-19. The main sources of COVID-19 information were the international health websites 112 (41.2%) and social media 72 (26.5%).  Table 2 exhibited the existing status of COVID-19 knowledge among health care workers. The majority, 263 (96.7%), were aware that the disease is a viral infection. A majority of participants (91%) in the eastern region knew that the COVID-19 is transmitted by close contact with infected person or animal. All participants knew that fever, cough and shortness of breath are symptoms of COVID-19. Only 39.9%, 23.6% and 31.4% of the participants answered the question 'incubation period is 2-4 weeks' correctly in western, eastern, and southern region in Libya, respectively.
On comparing the knowledge about the antibiotics are the rst-line treatment for COVID-19, the participants in eastern region showed non-signi cantly more awareness than other regions (91%, p = 0.964). On the other hand, around 260 (95.6%) of respondents a rmed that COVID-19 can be lifethreatening disease. As shown in Table 3, several items gained agreement amongst the participants. About 91.6% of male and 96.2% of female contributors agreed that COVID-19 is a dangerous disease. All participants agreed that the transmission of COVID can be prevented by using standard and isolation precautions given by the health care authorities. Around 91% of male and 82.9 of female participants agreed that COVID-19 can be reduced by active participation of health care worker in hospital infection control programme. However, only 63.5% of males and 72.4% of females agreed to take COVID-19 vaccine if were available.
There was difference among participants that intensive treatment should be given to diagnosed patients. By comparing males and females, the males (64.7%, P ≤ 0.05) showed signi cantly better attitude toward the intensive treatment for COVID-19 infected patients than females (33.3%). In addition, most participants had good attitude toward the adequate information about COVID-19 in Libyan society su cient. However, males had better attitude towards the available information about COVID in Libyan society su cient (59.9) than females (55.2%). About 39.5% of male and 15.2% of female respondents felt that the government institutions able to control the epidemic.

Discussion
Little studies were conducted in Libya among the HCWs to evaluate their knowledge and attitude about COVID-19. This survey study was conducted to evaluate of the participants' knowledge and attitude about risk perception of the COVID-19 outbreak. The distribution of the sociodemographic characteristics of the respondents showed a high percentage of males, nurses and most of them were from the western part of Libya. Nearly 89.3% perceived that they had adequate knowledge about COVID-19, and 41.2% con rmed getting knowledge about COVID-19 from the international health websites. This differs from the ndings of previously published studies, where social media was the main sources of information [9,10]. This shows that the educational policies and guidelines posted online by the international health organizations encouraged the HCWs to follow them.
Furthermore, our study indicated high rate of knowledge (91%) compared with recently published local study, where they reported the overall rate of respondents providing correct answers on the knowledge questionnaire was 26.5%, but slightly higher than the knowledge toward COVID-19 among US residents (80%) [10,11]. Another recent study demonstrated that 79.9% of healthcare workers had su cient knowledge on COVID-19 [9].
The results of this study suggest a good relationship between information available in the media about COVID-19 and the depth of knowledge among HCWs. For example, all participants knew about the preventive measures, 86.9% of all participants agreed that COVID-19 can be reduced by active participation of HCWs in hospital infection control programme, 96.7% were aware that the disease is a viral infection, 91% knew that the COVID-19 is transmitted by close contact with infected person or animal. These results are consistent with ndings from previous studies [12,13]. On the other hand, fewer participants were knowledgeable about the incubation period.
Our study reported high scores of attitudes toward COVID-19, which corresponds to a lower potential risk rate for COVID-19. In addition, all participants agreed that the transmission of COVID-19 can be prevented by using standard and isolation precautions given by the health care authorities. This speci es the signi cance of health education that could enhance the prevention behavior toward COVID-19 in society. Generally, most participants had a positive attitude towards active participation in infection control programmes and the role of guidelines in prevention of the infection. However, their believe in the ability of the government to control this epidemic were low. This could be explained by a lack of proper training about the preventive measurements provided by the authorities to them. Despite the healthcare situation and civil war in Libya, most participants reported good attitude toward the adequate information about COVID-19 in Libyan society su cient. A similar study conducted on a Chinese population reported an overall knowledge of 90% [14].

Conclusion
In conclusion, HCWs in Libya exhibited a high level of knowledge and positive attitudes towards COVID-19 pandemic. However, there is a visible variance in knowledge level between the professions. The low believes in the preparedness to control this pandemic highlights the importance of education and training programs for healthcare workers, to control and avert infection from COVID-19. However, the nonexistence of a planned and effective governmental strategy, along with a deprived healthcare infrastructure, renders our country exposed. Continued professional education is advised among HCWs in Libya to improving any de ciencies in knowledge.

Declarations
Competing Interest: Authors declare no competing interests