Risk Perception of the Iranian Healthcare Workers Concerning the Covid-19 Crisis and the Factors Affecting it: A Cross-Sectional Study

Background: The emergent Covid-19 disease with conspicuous prevalence is putting the healthcare workers' job security at risk. The preventive behaviors in every individual have a close relationship with his/her risk perception of the risk factor. Hence the present study has been undertaken aiming at determining the Iranian healthcare workers' risk perception of the Covid-19 disease and the relevant effective factors. Methods: : This anonymous online survey was conducted in March-April, 2020 using targeted snowball sampling among the Iranian healthcare workers. The data was collected via online-social networks using a questionnaire containing demographical specifications (5 questions), risk perceptions (20 questions), with five sub-scales including cognitive, cultural, political, social and emotional factors. Data analysis was performed using SPSS v.16 software. Results: : From 165 participants, the youth (20-49 years of age) with 84% and the females with 60% constituted the majority of participants. The average risk perception score of the healthcare workers was 66.43±8.17. The Spearman correlation coefficient showed the significant direct relationship between the risk perception score and all the sub-scales at 0.01 significance level. The political and cultural factors had the highest correlation with the personnel risk perception (r > 0.75). Conclusion: Health workers did not have an excellent risk perception of the emergent Covid-19 disease.


Background
The rapid prevalence of Covid-19 pandemic with its high mortalities and implications poses important challenge for the world countries. Despite the development of preparation programs during the past decade against the epidemic of infection diseases, in uenza in particular at national and international level, there is a deep gap between the existing educational programs and routine preparation exercises (1).
The 'risk' refers to facing with and vulnerability to the potential of negative consequences arising from the inception of a danger, and the risk perception re exes the mental judgment of understanding of risks in the society and is considered in the general literature as the suitable behavior when confrontation with the risks. The experts consider the risk perception as the collection, selection and interpretation process of the signals received denoting the uncertain effects of the accidents (2)(3)(4)(5)(6). The risk perception is a mental psychological construct that is subject to the cognitional, emotional, socio-cultural, political and personal variabilities (7)(8)(9). The individuals' emotions and instincts affects their perception and they acquire this perception through observation, analysis of circumstances and scienti c consultation (10); risk perception has its roots in the beliefs, attitudes, cultural sensitivity and personal characteristics like Selfesteem and self-concept (11) and lies in a continuity from no risk to high risk (12) and can affect the decision making positively and negatively. The individual after the awareness and risk perception evaluates the present conditions (bene t and loss) and pursues the best selection to mitigate the risk to the lowest level possible (13).
To adopt healthy behavior, the individuals must be aware of the disease and see themselves vulnerable to it and believe that they can do something for prevention or treatment of it (14); The preventive behavior of the individuals as the output and their communications as the moderators have in uence on lowering the vulnerability and strengthening of their resilience, especially in viral diseases such as Covid-19 can play a key role (15,16). The importance of such behaviors doubles pertaining to the healthcare workers owing to the direct effects they can bring about for the health of the patients as well as the public health. The health sector personnel, with their perception of the risks, may choose behaviors encompassing the greatest bene t accessible to the society (17). The risk perception can act as a motivation for change of behavior in healthcare workers and play a crucial role in describing the reason, prediction of effects and conduction of their behavior along the line of achieving the objectives (14,18).
The public behavior responses play a signi cant role in controlling the prevalence of the emergent diseases (19,20). The results of studies related to SARS and H1N1 in uenza in different cultural environments showed the impact of the severity of perceived disease risk along with cultural differences, general responses and behavioral changes, as well as government intervention in the outbreak stage.
These factors varied according to the type of disease and its control method (21)(22)(23)(24). The prevention of Covid-19 prevalence requires the cooperation of three groups: cooperation of healthcare workers, the public and the collaboration of the states. For the purpose of prevention and mitigation of the disease, the adoption of sound decisions, correct and prompt control by the healthcare systems of the countries and making attempts for the accomplishment of protection, hygiene and personal measures are necessary in addition to adequate knowledge of this infectious disease (25,26). The high number of deaths as the consequence of the disease highlights the importance of the risk perception (27).
In all of the preparation programs of bio epidemic programs, the health care and treatment are considered as the backbone and the health workers are deemed as the main players of the responding programs. In the present conditions with no treatment of the Covid-19 disease, the best and most effective solution for the confrontation comprises patient spotting, separation and extensive experimental diagnosis tests. The extreme worry about the virus transmission by the healthcare workers is an unavoidable reality. In addition to the need for the suitable and adequate laboratory equipment, the employment of trained personnel with professional commitment and high risk perception could be the acceptable method of ensuring effective confrontation with the Covid-19 disease (28).The healthcare workers due to the nature of their profession have adequate and appropriate awareness of health promoting behaviors, although they may be short of the advantages for the development of these behaviors due to such factors as hard work, shift work, long monthly working hours, high job stress and lack of a regular care delivery system schedule. Accordingly, the risk perception of the disease can play a particularly more important role (29,30). Studies have reported that the potential reason of the gap between the knowledge and performance of the healthcare personnel in prevention of the diseases and promoting health lies with the lack of skill, moderation of the controllable factors, shortage of enough time for maintaining such behaviors and lack of disease risk perception (31).
Measuring the health workers' risk perception of the Covid-19 and the relevant in uential factors can provide the service providers, health policy makers as well as the health and hygiene instructors with great insights on facilitation of the behaviors aiming at self-effectiveness in improving the community health and selecting the best solutions for minimizing the risks arising from this disease. The present study thus was conducted with the aim of determining the risk perception status of the healthcare workers of Iran concerning the Covid-19 disease and the factors in uential on it.

Methods
This online cross-sectional survey was carried out during 25 Mar-5 Apr, 2020 time span, about 1 month afterwards the o cial announcement of Covid-19 prevalence in Iran. The target society was all of the healthcare worker members of the social media (Telegram and WhatsApp) groups. Targeted and snowball sampling was implemented and participation was voluntary.
According to our method, the link of the online questionnaire about general risk perception of the Covid- The questionnaire used in this study is a modi ed version of the Risk Perception Questionnaire whose validity and reliability have recently been con rmed in a study in Iran. (32). English language version of the questionnaire was attached. (Supplementary le 1). The Cornbrash's alpha coe cient of the questionnaire in this study was equal to 0.725 which is con rmed.
The scoring was performed based on the below responses: strongly agree (5 scores), agree (4 scores), no idea (3 scores), disagree (2 scores) and strongly disagree (1 score). The minimum and maximum acquired score of the questionnaire was 20 and 100 respectively. The interpretation of as the scores was as follows: The scores 20-39 denoted the weak risk perception, the scores 40-59 indicated the moderate risk perception, scores 60-79 showed the good and 80-100 was interpreted as showing the excellent or desirable risk perception.
The questionnaire was made available online at the Internet address of the user members of medical staff groups of the Telegram and WhatsApp social networks: https://samadi.porseshnameonline.com/form/q2 Excel output was prepared from the questionnaires and the information was entered into SPSS v.16 and the analysis was made.

Result
A total of 165 participants, the youngsters (aged 20-49) constituted 84% while 60% of all the participants were female. Most research units (89%) had a bachelor's degree or higher ( Table 1). The distribution of research units included 19 provinces based on the residence; among them, the residents of Tehran province with 25.9% had the highest and residents of Golestan province with 0.6% represented the lowest frequency of participants (Fig 1).  *T-test, **Anova The average score of the healthcare workers risk perception was 66.43% (±8.17) with and maximum score of 43 and 94 respectively. The correlation coe cient of the Spearman showed the relationship of the risk perception score with all the sub-scales direct and signi cant at 0.02 percent (Table 3). This study was undertaken with the aim of determining the risk perception status of the healthcare personnel concerning the Covid-19 disease and the relevant effective factors afterwards about 1 month past the prevalence of the disease in Iran. Results indicated that the average score of risk perception of the healthcare workers (66.43 ±8.17) was at higher level compared with the risk perception of other Iranian groups (9). In the meantime, this could be attributed probably to the time gap of 1 month relative to the previous research during which the stresses may have been eased and the workers' awareness of the emergent Covid-19 disease may have been increased. In any case, it is expected that the risk perception of the healthcare workers about the Covid-19 disease must rest at the excellent and desirable level so that they could provide the best e ciency towards the prevention and treatment of the disease, hence the education and taking measures as to heightening the risk perception level of the healthcare workers seems necessary. The results of studies in other countries are consistent with the fact that health workers, despite having high knowledge, had low risk perception and performance in the prevention of Covid-19 disease. Various reasons for this action have been stated, high workload, lack of protective equipment and lack of access to the guidelines (37,38).
In comparison to the other risk areas like the environmental risks, the individuals perception status of the related risks arising from the emergent infectious diseases is relatively limited (39). Since the observation of the health predictive measures is directly effective in prevention of the disease expansion. Therefore, the best part of the programming of the instructions is performed at the society level from the top to the bottom and has a strong focus on the observation of the governments' instructions, all based on the risk perception principles and preparation for countering the epidemic(1).
In examining the factors effective on risk perception of the healthcare works about the Covid-19 it was determined that: Among the demographic factors, only the level of education was effective on the risk perception. The inverse relationship between education level and risk perception score is a signi cant nding. Although risk perception score is expected to increase with the increase of education level, but as was mentioned in the de nition, the risk perception is a complex and subjective construct, and it is necessarily different from awareness. Studies showing that the increase in knowledge and awareness is associated with a reduction in risk perception often attributed it to a reduction in the risk concerns (24,40,41). Also there are reports of increasing the risk perception related to the increased vulnerability (42). This nding seems to indicate the unknown aspects of the relationship between knowledge, understanding and perception which is consistent with the results of the study conducted by Rolison and Hanoch (2015) in the US, con rming that more knowledge was associated with lower risk perception (43).
This study did not reveal any relationship between risk perception on the one hand and age or gender on the other hand, although some studies have reported a relationship between the older ages or female gender and higher risk perception that seems to be related with the type of risk and the understudy population, for which further studies are recommended (18,41,42) Political factors showed the greatest correlation (r=0.787) with the personnel risk perception. This relationship may be due to the nature of Covid-19 epidemic and the necessary top-down management of the risk based on which the healthcare workers must act within certain principles and regulations' framework. Policy guidelines are essential for managing all aspects of risk perception and performance of healthcare professionals, especially at the primary health care level (44). When knowledge is limited, trust plays an important role in judging and perceiving the emerging diseases (45,46).
Also, the medical staff risk perception was directly and signi cantly related to cultural-religious component (r = 0.758). Since more than 98% of Iranians are Muslims, this relationship is not far-fetched.
The majority of participants (86.2%) agreed that preventive measures complied with the Islamic religious precepts. But only 42.6% agreed that the cultural affairs authorities' views were complied with the scientists' views. The inconsistency between the political and cultural affairs' authorities is a noteworthy point which was consistent with Chester (2008) study results (47). This component provides new horizon of promoting public perception of the risks threatening society, However, more research is needed.
In this study, the social, cognitive and emotional factors were effective with less correlation in medical staffs' risk perception of the Covid-19 disease. Due to the emergent nature of the disease and the lack of necessary knowledge about it, the cognitive factors low scores are justi able, but probably because the epidemic has overshadowed all social and professional relationships of the health care workers, social and emotional factors had limited effect on the risk perception scores.

Conclusion
In general, the health care workers, due to the nature of their profession, need a higher perception of the epidemic risk of infectious diseases, but the statistical results showed that despite more exposure compared with the general population of Iran, they have no greater perception of the risks posed by the emerging Covid-19 disease. Among the 5 factors, knowledge, cultural, emotional, social and political factors affecting the risk perception of Covid-19 disease, political and cultural factors had the highest correlation with the score of Covid-19 disease risk perception of Iranian health workers, followed by social, cognitive and emotional factors being effective with less intensity. Improving cognitive, social, and emotional components can increase the health care workers' risk perceptions of the Covid-19 disease.
Study Limitations: The following items can be mentioned: 1) Due to the time sensitivity of corona virus prevalence conditions, the researchers used online and social group methods to collect data, which may overshadow the generalizability of the results.
2) The small size of the sample relative to the spread of the information acquisition areas is another limitation of this study, which can be justi ed due to the high occupancy of the health care workers in the present special circumstances. Despite the above limitations, this study has provided a basic knowledge about the risk perception of health care workers from 19 provinces and the factors affecting it. It is hoped that future research on comprehensive interventions at the national level by the Ministry of Health are conducted in order to identifying and promoting the risk perception of the Covid-19 disease by the health care workers of Iran country.

Declarations
-Ethics approval and consent to participate: This study was con rmed by the ethics committee of Sabzevar University of Medical Sciences under number IR.MEDSAB.REC.1399.075.
Consent to participate: Informed consent was obtained from all individual participants included in the study.
-Consent to publish: Not applicable -Availability of data and materials: The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.
-Competing interests: The authors declare that they have no competing interests -Funding: Nil -Authors' Contributions: ES has been involved in designing the work, interpreting the results, and was a major contributor in writing the manuscript. FG has been involved in designing the work, interpreting the results, and was a major contributor in writing the manuscript. RZ has participated in data collection and writing articles. FB participated in data collection and EN participated in data analysis. All authors read and approved the nal manuscript.