Preparedness and Approaches of Healthcare Providers to Tackle the Transmission of Covid-19 among North Shewa Zone Hospitals, Amhara, Ethiopia, 2020.

Coronavirus disease 2019 (COVID-19 is an emerging respiratory disease that is caused by a novel coronavirus and was rst detected in December 2019 in Wuhan, China. The disease is highly infectious, and its main clinical symptoms include fever, dry cough, fatigue, myalgia, and dyspnea. Health care providers are in front in ghting the coronavirus spread by making themselves the risk of contracting the disease. This study aimed to assess the preparedness and approaches of healthcare providers to tackle the transmission of COVID-19 among North Shewa Zone Hospitals. Methods Facility-based cross-sectional study was conducted from April to May 2020 among 422 healthcare providers in the North Shewa Zone, Amhara, Ethiopia using a self-administered questionnaire. Study subjects were selected through systematic random sampling based on their proportional distribution of sample size to each hospital. A structured questionnaire will be used to collect data. The data were coded and entered into the Epi data 4.2.1 version and the analysis was carried out in statistical package for social science 25 versions.


Introduction
In human history in 1918 Spanish ue was the reason for 50 million or more deaths. It has been the benchmark for other pandemics and emerging diseases. Another growing epidemic of novel coronavirus infectious disease (Covid-19), which is caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Coronaviruses comprise a large family of viruses that cause respiratory and intestinal infections in animals and humans, including the Middle East respiratory syndrome (MERS) and SARS. SARS rst emerged in the Guangdong province, China, causing the 2002-2003 epidemic. Since mid-December 2019, several cases of a pneumonia-like disease (with symptoms including fever, di culty in breathing, cough, and invasive lesions on both lungs) of unknown cause have emerged in the central Chinese city of Wuhan (1,2).
During this pandemic period mental health services with other countries affected by the COVID-19 pandemic, in a different population, vulnerable groups of the communities like elderly individuals, survivors of COVID-19 infections as re-infection is high, and frontline health care providers need proper psychological support. And su cient guidance and counseling are essential, especially in the developing world. With a timely and close collaboration with different nations and institutions, the mental health challenges caused by the COVID-19 pandemic can be adequately addressed (3).
Globally, there have been more than nearly 6 million con rmed cases, and more than 357,000 registered deaths. On March 3, 2020, the rst patient with COVID-19 was detected in Addis Ababa, Ethiopia. From then until May 28, 2020, another 831 COVID-19 cases were identi ed in Ethiopia (4).
Health care providers are in front in ghting the coronavirus spread by making themselves the risk of contracting the disease. Keeping the well-being in the working environment for a health care provider and an effective plan is essential in each phase of a pandemic (5).
As the coronavirus pandemic rises, trained health providers are a key resource to combat the infection.
They are the main priority in many countries, but those healthcare providers have many concerns during this period like availability of necessary equipment's in addition to this they have great concerns for their safety as well as their families because they are worried about transmitting the infection to their family members (6).
In Africa, the COVID-19 pandemic is rampantly is rising today, even though, there are key constraints to avert the progression of the pandemic, especially in human resources and shortage of personal protective equipment (PPE). In the area of limited or shortage of protective equipment, the risk of COVID-19 infection and dying will be high among frontline healthcare providers this will be a huge blow for countries and healthcare providers as a whole for all communities. Africa is known with limited resources, weak health system which will be made double burdened. As a result, the government is expected to full ll the necessary equipment and keep the safety of healthcare providers (7).
Personal protective equipment is the main protection for healthcare providers speci cally if the virus spreads to the community, as the numbers of patients with unknown contact history. In addition to this Safety of workplace and ful llment of Standards for protection, furthermore training how to use and remove personal protective equipment is needed to increase preparedness (8).
Health care providers are in the front line to face COVID-19 outbreak and as a result, they are at greater risk of exposure to bio-hazards that put them at risk of infection with an outbreak pathogen (COVID-19). Hazards include pathogen exposure, long working hours, psychological distress, fatigue, occupational burnout, stigma, and physical and psychological violence (9).
As the world is being hit hard by coronavirus disease 2019 pandemic, health care systems of countries in the world became stunned with a high demand for infectious patients' needs testing and care. Averting coronavirus pandemic infection is on the hands of health care workers (HCWs) and patients rely on the effective use of personal protective equipment (PPE). A serious shortage of all of this equipment is expected to develop or has already developed in areas of high demand. So, An increased demand for PPE relies on continuous and reliable supply as the hospitals are overwhelmed by a rapid increase in ill COVID-19 patients (10).
The ndings of this study will help in many aspects such as, better planning for awareness campaigns, guide different health authorities accordingly to modulate their policies as needed and to correct some untoward behaviors to stop the spread of the virus which may result in rapid control and containment of the ongoing pandemic. Therefore, this study aimed to assess the preparedness and approaches in tackling the transmission of COVID-19 among health care workers at North Shewa zone hospitals.

Study design, setting, Area and Population
The institution-based cross-sectional study design was conducted in North Shewa zone hospitals, Amhara Regional State from April to May 2020. North Shewa is one of the zones in the Amhara regional state. North Shewa has 11 primary Hospitals (of which the two are private Hospitals) and one comprehensive specialized hospital. According to zonal health Department data, more than 2000 health care worker provider serves around 3 million people in North Shoa Zone.
All healthcare providers who were working in hospitals at the North Shewa zone were source population whereas, all healthcare providers who are working in selected hospitals of North Shewa Zone during the study period were the study population. Selected healthcare providers who in selected hospitals working in the hospital of North Shewa Zone were study units.

Eligibility criteria
Inclusion criteria: All health professionals who are working in the selected hospitals whereas HCP who are seriously ill and annual leave were excluded.

Sample size determination
The sample size were calculated using a single population proportion formula with assumption of 95% con dence level, marginal of error 5%, and 50% n = Z (α /2) 2 p (1 -p)/d 2 Where n = minimum sample size: Z (α / 2)2 = 95% Con dence level: Sampling technique and procedure North Shewa Zone has 12 Hospitals, among these 5 Hospitals were selected by lottery methods. Then, the possible number of respondents in each of the Hospitals of the study area were allocated proportionally based on the number of Health workers. Study participants who ful ll the inclusion criteria were selected by systematic random sampling every two intervals using the list of the workers from each hospital by using the monthly payroll as a sampling frame. The total number of the healthcare worker in the selected Hospitals was 860.

Data collection tools and procedures
The data were collected through a self-administered questionnaire and observation for the practice of standard precaution in ghting against COVID-19 pandemic using checklists. The questionnaire was distributed to the participants by the principal investigators responsible for data collection. The principal investigators also responsible for the respondents with explanations when requested by the respondents.
The data collection tool was designed from risk communication & community Engagement action plan guidance of WHO COVID-19 preparedness & response and related literature (11,12). Participants from all healthcare professions were selected for the study. The questionnaire was divided into 2 parts. The rst part comprised of demographic information of the respondents. The second part assessed the preparedness of healthcare care providers with 26 items of question. Their response was evaluated with four domains: strongly agree, agree, disagree, strongly disagree response. The 3rd part determined the personal protective equipment availability towards COVID-19 with 5 items of the question with a yes-no response.

Data Quality Assurance
The data collection tool was pretested three days before the actual data collection on 5% of the calculated sample size of 21 health care providers on Debre Sina primary hospital and necessary adjustment was made. The collected data were checked for completeness, accuracy consistency, and clarity. Codes were given to the questionnaire and participant during data collection so that any identi ed errors were get traced back using the codes.

Data analysis
Data was entered using Epi-Data version 4.2.1 and analyzed using SPSS 25 statistical software. The descriptive analysis runs rst with proportion and summary statistics to describe the study population concerning relevant variables by considering statistical assumptions. Socio-demographic pro les of variables frequency distribution, summary measures such as mean and standard deviation was calculated for outcome variables. When frequencies become smaller than expected, variables were recategorized or merge of the levels was done.

Result
Result From a total of 422 samples, 404 healthcare workers completed the questionnaire with a response rate of 95.7%. Of them, Nurses 166(41.1%), physicians 77(19.1%), midwives 60(14.9%), laboratory technicians 39(9.7%), pharmacists 29(7.2%), and other professionals 33(8.2%). Nearly half of the 207(51.2%) were in the age group between 25-29 years with a mean age of 29.1 ± 5.2 years and more likely to be males (63.1%). Above half of them had work experience of fewer than ve years (64.1%). Nearly half of them were single 213(52.7) and more likely to be orthodox 360(89.1%). The above two-thirds was a rst degree in level of education (Table 1).

Preparedness of HCP
Assessment of self-satisfaction of healthcare providers revealed that nearly three fourth 301(74.5%) of study participants feel unsafe working in their working place. Two-third of 260(64.4%) of them responded that they feel anxious while working with febrile patients (Table 2). Below, the graph shows the type of personal protective equipment and its varieties (Fig. 1).

Discussion
This study assessed preparedness and approaches of the health care provider in tackling COVID-19 among health care providers working in hospitals of the North Shewa zone. Nowadays, humankind in the world is facing devastating COVID pandemic which needs all institutions, communities, organizations both governmental and non-governmental organizations need to collaborate to avert the progression of the diseases. As a result, research to nd a new way to combat it, and we are urged to conduct research.

Preparedness and Emotions of healthcare providers
During a catastrophic global pandemic such as the COVID-19, it is common for every person to experience intense suffering from anxiety depression, predominantly as a result of social isolation. Physicians, nurses, and other frontline health care professionals are particularly exposed to negative mental health effects during caring for patients. The ongoing COVID-19 pandemic is also taking a massive toll on the mental and emotional well-being of front-line health care workers around the world. Healthcare providers will suffer longer duration shifts, work-life balance disturbances and worries about taking the disease relatives will be led to intense stress and anxiety, physical and mental fatigue, and burnout for this group of individuals. Besides, healthcare providers concerned about their well-being and their families and friends. As a result of the COVID-19 pandemic, many health care providers are facing physical separation and increased in care demands, equipment shortages, and the higher risk of COVID-19 infection. These factors can all lead to decreased mental stability and will increase the chance of stress and anxiety.
Preparedness of health care provider assessed by 26-items of question. The self-satisfaction of healthcare providers revealed that nearly three fourth 301(74.5%) of study participants feel unsafe working in their working place. Two-third of 260(64.4%) of them responded that they feel anxious while working with febrile patients. nearly half 191(47.3%) of the HCP agreed that they are feeling hopeless they might eventually get COVID-19 at work. Two-third of HCP 262 (64.9%) agreed that they feel threatened if one of their colleagues contracted COVID-19.
The majority of the HCP 339 (83.9%) responded that they feel that they should limit their social activities due to COVID-19. Above three-fourth of HCP 319 (79%) agreed that they feel they will transmit COVID-19 to their family members. Below half of the 179(44.3%) feel that their families will avoid them since they are working in hospitals. Above half 227 (56.2%) of the HCP feels that their family will not look after them if they will be infected with COVID-19 and 177(43.8%) agreed that if they are infected with COVID-19 their family will not look after them. Nearly two-thirds of 243(60.1%) of the respondents didn't feel con dent in telling their family and friends if they are infected with COVID-19. From the total participants, 339 (83.9%) and 240(59.4%) of HCP feel that their institution didn't support them and loses control in the COVID-19 crisis respectively.
For HCP in North Shoe Zone, safety from infection was the main concern. From this study

Conclusions
Protecting healthcare workers is a public health priority. In this study of healthcare providers working in North Shewa zone hospitals. We are reported limited access to essential personal protective equipment during the COVID-19 pandemic. The poor perception of healthcare professionals about not having enough support from medical institutions and public health authorities raises the need to urgently implement strategies to protect healthcare workers in the time of the COVID-19 pandemic.
As the pandemic continues, important clinical and policy strategies are needed to support health care workers. Ethical clearance was obtained from the Debre Berhan University Research Ethics and Publication Committee before conducting the study. Further permission was obtained from each hospital administration. Any information related to personal identi cation of the study participants was not recorded to maintain the con dentiality of the study. Written consent was obtained from all health care providers.

Consent for publication
Not applicable Availability of data and material Data support these ndings are contained within the manuscript and will share upon request to the corresponding author. Figure 1 showing availability of personal protective equipment's in hospitals of North Shewa zone Amhara, Ethiopia 2020.