It is a web-based national survey involving 603F-HCWs working at different hospitals or clinical settings. The vast majority of the participants were female, nurse, and from the private hospital. In this survey, F-HCWs reported adequate knowledge with a positive attitude and adopted the appropriate practice. Factors associated with adequate knowledge were male gender, nurse and doctor, source of information as websites and IPC training, whereas only online course was associated with a positive attitude; similarly, factors associated with the appropriate practice were master's degree or above and online course.
In this survey, around 76% of F-HCWs illustrated adequate knowledge regarding COVID-19. However, it is relatively higher than the previous study conducted in Uganda. There was only 69% sufficient knowledge and a bit lower than a Chinese study conducted by Zhang et al.  in Henan China, where 89% of the participants showed sufficient knowledge regarding the COVID-19. Moreover, a similar result was reported by a previous study carried out on MERS among F-HCWs of Saudi Arabia . There are variances in the knowledge of F-HCWs while battling the outbreak in different countries. It could be due to differences in the cut-off points. Olum et al. used 80% as a cut-off point to determine the level of knowledge, whereas Khan et al.  and we used 70%. In Zhang et al.'s study, the reason for a higher proportion of knowledge was probably due to better preparedness for the worst. It might be because the Henan province is a neighbouring province and was one of the severely affected places next to Wuhan.
Papagiannis et al. reported that the high level of knowledge was significantly associated with positive attitude and practice among F-HCWs. We also had a similar correlation between knowledge, attitude and practice. However, previous studies have reported varying levels of perceived knowledge, attitude, and practice among the F-HCWs. Some studies have reported that the male participants to have a significantly higher knowledge . In contrast, some have reported that female participants have higher knowledge than their male counterparts. Some studies have reported that doctors have better knowledge and a positive attitude than others. However, some reported the nurses to have better practice.In this survey, male participants, doctors, having a master's degree or above showed better knowledge and a positive attitude. Despite having a higher level of education, the F-HCWs did not show any appropriate practice. The reasons for inappropriate practice could be associated with the training they get, the working environment they have, etc. Because most of our hospitals did not provide sufficient sanitizers, PPEs, and even some hospitals, deducted the regular salary of the staff in such a hars situation.
IPC training and online courses for F-HCWs are essential to update their knowledge and play a vital role in infection prevention . WHO has started training sessions and online classes regarding prevention and control of COVID-19 to increase awareness and preparedness for the F-HCWs. Adequate knowledge, positive attitude, and appropriate practice were present in the participants who attended IPC training and online courses. However, the knowledge was higher in those participants who took IPC training but was not associated with a positive attitude and appropriate practice. Nevertheless, those who took online courses regarding COVID-19 had a positive attitude and appropriate practice. Such results may be due to the fact that training is often organized by the institutions, and irrespective of their interest, participants are requested to attend the training. However, online courses are taken by those who have real interest, enthusiasm, and motivation towards the disease. So, they not only give full attention but also try to implement in their daily activities.
Globally, thousands of F-HCWs are already infected, and hundreds have lost their lives. The risk of COVID-19 infection among F-HCWs is higher than the general population . Among the countries, the United States has reported 16%, the Netherlands has 19.6%, Italy has 20%, and Spain has 26% infection rate among F-HCWs [16, 23]. Inadequate knowledge increases the risk of infection and might jeopardize their and their family's lives. So, continuous knowledge update for this ever-changing pandemic by adequate training or course is crucial for the F-HCWs to tackle the COVID-19. The national and international authorities are continuously providing updates regarding COVID-19. However, social media was the most commonly used source of information than official websites (Ministry of Health and population, WHO, and CDC). Although the F-HCWs reported adequate overall knowledge, there were still knowledge gaps among different groups. Our participants mostly used online social media, radio, and television to gather knowledge, and they reported correct answers regarding the symptoms and prevention. Still, most of our participants were not sure about the confirmatory diagnosis as per the standard protocol. That is the defect of relying on only social media, not the standard source of information.
Despite having adequate knowledge, only 54.7% of F-HCWs had a positive attitude in this survey. Similarly, some previously published literature also revealed the lower rate of positive attitude by the F-HCWs in different countries [25, 26]. On the other side, Chinese study demonstrated a positive attitude among the majority population towards COVID-19. Perhaps, the Chinese were well trained and mentally prepared.
The vast majority of F-HCWs always fear infecting others, including their family, friends, and society [12, 20, 27]. We also found a similar result of almost 88% of participants having a fear of infecting others while asking if they were worried about transmitting the virus to their family, friends & society. However, such fear is entirely normal and acceptable to help the F-HCWs to prepare for the worst during this grim and challenging situation. Despite having a fear of COVID-19, still, F-HCWs displayed appropriate practice. Hand hygiene practice is exceptionally essential. It is quite useful for infection prevention, and even the governments and many other stakeholders are promoting adequate hand hygiene practice. Saqlain et al.reported that hand-washing to be one of the efficient barriers for disease transmission. In this survey, we asked the participants if they believed that hand-washing with soap and water was sufficient for infection prevention; 91.2% of the F-HCWs chose strongly agreed and agreed. Upon further asking if they are following 5 moments of hand hygiene with 7 steps, 88.4% of the participants reported often or always, but the remaining participants reported sometimes, rarely, and never. These results mean that our participants have appropriate hand hygiene practices. However, we still believe that hand hygiene is practically the most neglected procedure, and usually, F-HCWs do not follow all the moments and steps. Furthermore, multiple studies supported our findings of having appropriate practice[13, 29].
Unfortunately, the shortage of PPEs, such as facemask, face shield, gloves, goggles, and gown, during this COVID-19 crisis are the major problems faced by not only the developing countries like Nepal, but also the developed world like the USA, UK, and Italy. Being a developing country, an adequate supply of PPEs is a tremendous challenge in Nepal. Even if the government or local bodies supplied PPEs, especially the facemask and gown, the quality could not be assessed as most of them are prepared by local factories in an emergency situation. In this survey, only 56.4% of the participants were using PPEs. Most of them were using facemask, gown, and gloves. A negligible amount of N95 respirators were available for the F-HCWs. Albarrak et al.reported that only 24.2% were wearing a facemask. It is essential to wear PPE throughout taking care of the patients, especially when performing aerosol-generating procedures such as; intubation, bagging, cardio-pulmonary resuscitation, and nebulization. . At the initial stage of the disease outbreak in Wuhan, many local F-HCWs were infected. Upon the arrival of the rescue team from different provinces, the infection to the F-HCWs went down to zero. They mentioned for the infection transmission to the F-HCWs at the inial stage was carelessness, inadequate knowledge, insufficient PPEs, and even improper practice. So, the WHO has also given a particular focus on the correct use of PPEs, including masks, goggles, gloves, and gown. Additionally, those F-HCWs who have used PPEs have comparatively fewer infection rates.
It is the fact that F-HCWs are highly susceptible to the infection, while their constant exposure makes them vectors for the disease transmission . Even though the F-HCWs have significant roles for infection prevention and disease transmission, it is necessary to follow strict rules of the PPE use, hand-hygiene, and isolation of the patients as per the CDC and WHO guidelines. The government and stakeholders have the responsibility of providing public awareness, regular updates of the infection prevention protocol, and provide adequate IPC training during this pandemic, and adequate logistic supply. Moreover, responsible bodies, including the government and hospitals, must focus on motivational factors, including the availability of the resources and provision of salary and incentives to the F-HCWs.
It is a cross-sectional survey, so we could not assess the changes. A web-based survey was conducted to identify the KAP of the F-HCWs working at different hospitals of the nation where they have full access to the internet service. We could not reach out to the place where this facility was not available. Despite these limitations, it is a national survey on the KAP regarding the COVID-19 among F-HCWs in Nepal. This survey would probably be responsible for providing up-to-date information and improve clinical practice among F-HCWs.