Abstract
BACKGROUND:
COVID-19 has affected millions of people around the world since its first case in 2019. In this pandemic, health professionals have been among the most vulnerable groups to contracting the virus or spreading it to others; therefore, their appropriate response in line with health and safety is crucial and needs to be addressed.
OBJECTIVE:
This study evaluated health professionals’ behaviors and attitudes toward COVID-19. This includes testing, vaccination, history of infection, and fear of infection.
METHODS:
A cross-sectional study was conducted among health professionals practicing in Sindh, Pakistan. A sample size of 400 was considered for the present study, including dentists and medical doctors practicing in Sindh’s healthcare setups.
RESULTS:
According to the results, the response rate was 95.50%. 73.04% of participating health professionals reported a history of COVID-19 infection. The highest levels of fear and anxiety of getting infected with new COVID-19 variants were derived among junior medical professionals (RMOs). 98.69% of health professionals were reported to be vaccinated against SARS-CoV-2 virus. 3% of participating health professionals revealed that they do not believe in testing.
CONCLUSIONS:
Although fear and anxiety towards new emerging COVID-19 variants were largely prevalent, negligible reluctance toward vaccination among health professionals of Sindh was reported in the study. More studies are required from other parts of Pakistan to address health professionals’ response to the COVID-19 pandemic, to aid health policymakers in establishing precise SOPs for health professionals, and to manage COVID-19-related negative psychological and corporal effects on them.
Introduction
COVID-19, caused by the SARS-CoV-2 virus, manifests as a severe acute respiratory syndrome. It was declared a pandemic by the World Health Organization (WHO) on 11th March 2020 [1, 2]. Since its first outbreak in Wuhan, China, in December 2019 [3], it has affected approximately 212 countries, including populous countries like India and the U.S.A, leading to a global death toll of more than 6 million [4]. Pakistan, the 5th most populous country in the world, has identified its first COVID-19 case in Karachi on 26th February 2020 [5]. Since then, the number of reported cases has risen to around 1.6 million in the country [6]. The Asian region was affected largely by COVID-19, impacting the global population, as it is home to about 60% of the world’s population [7]. According to WHO’s situational reports, Japan, the Russian Federation, and Singapore have seen an increase in COVID-19 cases and related hospitalizations in 2023, meanwhile, India has reported the highest number of COVID-19 related deaths [8, 9]. Hence, highlighting the continued threat of the virus to Asian regions. Other than the pandemic’s impact on the world population, COVID-19 has severely strained healthcare systems worldwide; meanwhile, appropriate behavioral responses of health professionals remained momentous.
Healthcare workers are the most vulnerable group as they are at high risk of occupational exposure to the virus, besides carrying a similar risk of transmitting it to patients, colleagues, and family members [10]. Thus, a risk-based approach was essential for managing COVID-19 for all health professionals, using the WHO’s recommended tools, including COVID-19 testing, vaccination, strengthened health system capacity, and targeted response [11]. Despite the declaration of the vaccine’s crucial role in pandemic control, regrettably, delays in COVID-19 vaccine acceptance from healthcare workers were reported from Asian countries. [12–14]. Moreover, anti-vaccine movements and protests were reported worldwide in which healthcare professionals’ notable participation was observed [15].
In May 2021, Pakistan’s health authorities initiated their vaccination campaign, prioritizing high-risk groups such as health professionals and the elderly [16]. However, by 2021, a mere 57% of the healthcare workforce in Pakistan received the vaccine shots against COVID-19 [17]. Although vaccination does decrease the risk of infection, the efficacy of vaccines against the evolving coronavirus’s new variants remains uncertain. This ambiguity might have fueled the fear and anxiety among frontline health professionals. Thus, it was essential to gauge the attitudes and behaviors of health professionals towards COVID-19, encompassing their testing and vaccination preferences as well as their levels of fear and anxiety concerning emerging variants.
The current study aimed to provide various facets of health professionals’ behaviors and attitudes towards COVID-19. This includes vaccination, history of infection, fear of infection, concerns about transmission, treatment apprehensions, interactions with patients and colleagues, and reactions to news on variants. The authors posit that the insights derived from this investigation will furnish invaluable data for health policymakers, equipping healthcare professionals to respond to forthcoming variants of COVID-19 rightly, readiness for future possible pandemics, and mitigate the adverse psychological effects these new variants might engender.
Materials and methods
A cross-sectional study was conducted among health professionals practicing in urban cities in the Sindh province of Pakistan. The cities included in the study were Karachi, Hyderabad, and Jamshoro. Data collection from health professionals was carried out between December 2021 and February 2022. The convenience sampling method was used to approach study population. The sample size of 266 was derived using a 77.8% prevalence of COVID-19 vaccine acceptance [18] among health professionals. The study ultimately included 400 participants, comprising dentists and doctors from the Sindh province, who fulfilled the criteria of practicing in their respective fields during data collection. The study received approval from the Ethical Review Committee of Jinnah Medical and Dental College, Karachi, with the ERC Number 000159/21. Informed consent was obtained from all participants included in the survey, and the study was carried out in compliance with the Helsinki Declaration.
The data collection tool was divided into two parts. Part 1 contains the cover letter explaining the project purpose, assuring them of the confidentiality of their responses, the procedure of answering the questions, and consent to participate in the survey. Part 2 contains a self-constructed questionnaire comprised of three sections. Section 1 has opening questions about demographic background followed by three questions about COVID-19 history and six descriptive questions regarding healthcare professionals’ attitudes towards COVID testing and vaccination. 6th question in section 1 is about reasons for refusal of COVID-19 testing. Section 2 has two descriptive questions about fear related to new COVID-19 variants. Section 3 consists of four questions that gauge levels of fear and anxiety related to COVID-19 and its new variants, using a Likert scale ranging from 0 (No fear) to 4 (High).
A pilot test of the questionnaire, including questions from Section 3, was performed on 25% of the projected sample size. The internal consistency of questions in Section 3 was evaluated using Cronbach’s alpha, resulting in a value of 0.81. Construct validity for the fear-related questions was ascertained by computing the Pearson’s correlation coefficient (r) of individual responses against their total scores. With two degrees of freedom, correlation scores exceeding 0.22 were deemed valid. The scores for the fear questions varied between 0.720 and 0.874. The content and face validity of the questionnaire were assessed by an expert health professional, leading to the creation of the final version based on pilot data.
For the study’s context, health professionals were categorized based on their academic and clinical ranking in Pakistan [19]. The designations included Junior-most level: Fresh graduates serving as medical or dental House Officers (HOs). Junior level: Graduates employed as Resident Medical Officers (RMOs) or Lecturers. Mid-level: Postgraduate trainees in both medical and dental specialties. Senior level: Medical and dental specialists with postgraduate qualifications, holding senior faculty positions such as Assistant/Associate Professors and Professors. General Dentists (GD) and General Practitioners (GPs) were individually categorized as clinicians.
Researchers distributed hard copies of data collection sheets to participants in person, while soft copies were sent via email and WhatsApp application. The questionnaires were completed anonymously and the filled forms were returned to the authors via the same respective sources for distribution.
SPSS 21 was used to analyze the data. The frequencies of all responses to the COVID-19-related questions were derived using descriptive analysis. The mean score of the fear and anxiety between each group was compared using Repeated measure analysis of variance (ANOVA). The level of significance was set at <0.05.
Results
Out of 400, 382 health professionals completed and submitted the questionnaires, establishing a response rate of 95.50%. Among the sample of 382, 208 (54.45%) dentists and 174 (45.54%) medical doctors participated. Table 1 shows the demographic characteristics of all participants in the study.
Demographic characteristics of all the participants among the sample of health professionals in Sindh (n = 382)
Demographic characteristics of all the participants among the sample of health professionals in Sindh (n = 382)
∼AP = Assistant Professor or Associate Professor.
Table 2 shows the frequency of responses from a sample of 382 health professionals on the history of COVID-19 infection. A total of 279 (73.4%) health professionals, including 147 (52.69%) medical professionals and 132 (47.31%) dental professionals, reported a history of COVID-19 infection in the last two years. Among all health professionals with a positive COVID-19 history, 56.63% were infected once only, followed by 34.05% and 9.32% who were infected twice and more than twice, respectively. 377 (98.69%) health professionals were reported to be vaccinated against COVID-19.
The responses from a sample of 382 health professionals in Pakistan regarding COVID-19 history
Table 3 shows the responses regarding their attitude toward COVID-19 testing, vaccination, and providing treatment. Among all participants, 86.91% of health professionals confirmed to be tested for COVID-19 in the last two years, 62.65% went for testing more than twice, 12.35% went for testing twice, and 25% went for a test once only. 379 (99.21) health professionals recommend the vaccine to their patients, followed by family 380 (99.48%), as shown in Table 3. 91.66% of participating health professionals agreed to provide treatment to the patients infected with COVID-19, 8.64% of health professionals denied providing treatment, of which 75.86% were reported to be female dentists.
The responses from the health professionals in Pakistan related to their attitude regarding COVID-19 testing, vaccination and providing treatment. (n = 382)
Figure 1 demonstrated reasons for refusal of COVID-19 testing among health professionals of Sindh (n = 50), among which the most common reason (67%) that appeared was “No COVID or seasonal flu specific symptoms.” 3% of health professionals who refused COVID-19 testing mentioned that they “Did not believe in testing at all”.
Reasons for refusal of COVID-19 testing among health professionals of Sindh, n = 50.
Table 4 shows the frequency of responses regarding fear of new COVID-19 cases. 90.84% of health professionals feared being infected with new variants of COVID-19. 46.59% and 31.94% of health professionals reported that they feared getting infected by patients and coworkers, respectively.
The responses from a sample of 382 health professionals in Pakistan regarding fear from new COVID 19 cases
Table 5 shows the rate of fear and anxiety among health professionals toward the new variants of COVID-19. The RMOs (3.43±0.63) appeared to be the most feared group, among others, of getting infected with new variants of COVID-19. Upon rating fear related to news about new emerging variants of COVID-19, GD showed a high level of fear (3.45±0.72). Assistant/Associate professors rated more anxiety when talking to patients in close vicinity (3.56±0.61). When assessing fear of carrying infection from practice back to home, high fear was reported among RMOs (3.70±0.46) and APs (3.67±0.59).
Comparison of mean rate of fear and anxiety towards COVID-19’s new variants among sample of health professionals of Sindh (n = 382)
ANOVA. HO: House Officer, RMO: Resident Medical Officer, AP: Assistant Professor: GP: General Practitioner, GD: General Dentist, *Significant p value less than 0.05.
Despite the termination of COVID-19 as a Public Health of International Concern (PHEIC), declared by WHO on 5 May 2023, many governments still consider it a health threat due to the continued global emergence of new variants and related deaths. Thus, WHO continues to track SARS-CoV-2 variants, including six variants under monitoring (VUMs) [9]. The COVID-19 pandemic’s detrimental effects on human development outcomes have engorged the burden on Pakistan’s healthcare system, which is already grappling with economic instability and other socioeconomic adversities. [20, 21]. Consequently, health professionals in Pakistan were forced to work under these difficult circumstances; hence, their attitude and psychological persistence remained pivotal, particularly in response to COVID-19 and its new emerging variants. The current study, therefore, aimed to dissect behavioral responses to COVID-19 and its emerging variants from health professionals, in addition to gauging the pandemic’s psychological toll, emphasizing the importance of their mental well-being in these tumultuous times and readiness for future possible pandemics.
Vaccination
Since the COVID-19 vaccine substantiated as a fundamental tool in controlling COVID-19, benefiting high-risk populations like healthcare workers, vaccine acceptance and administration remained the most crucial attitude in response to the pandemic for all health professionals. From the onset of the pandemic in February 2020, the Ministry of National Health Services, Regulations and Coordination (MoNHSRC) in Pakistan responded critically to the COVID-19 emergency with the support of UNICEF. As a result, in one year, nearly 7 million people had received two doses of COVID-19 vaccine in Pakistan, including healthcare workers [22].
A 2020 study carrying a global survey reported that only 26% of health professionals had been vaccinated, with Pakistan’s health workers constituting 19% of the figure [15]. On the other hand, our study illustrated an increased trend in vaccination among health professionals whilst demonstrating that an overwhelming majority (99%) of study participants were vaccinated. Such high vaccine acceptance echoes previous findings of South Asian studies, including India and Pakistan, noting the similar responses from healthcare professionals [15, 23]. Our study observed a disparity as all medical professionals were vaccinated, nonetheless a small percentage of Sindh’s dentists remained unvaccinated. This divergence mirrors global trends where vaccination among medical professionals outpaces their dental counterparts [24]. Reinforcing the positive attitude towards vaccination, nearly all participants of the current study advocated COVID-19 vaccine endorsement to their families and peers, aligning with the sentiments of UAE’s health professionals, as stated in a former study [25].
History of infection and testing
Most previous surveys from different countries confirmed the self-reported cases of COVID-19 among health professionals that ranged between 40% and 70% [15, 27]. Similarly, our data reveals that 73.04% of participating health professionals had contracted COVID-19 within the last two years, claiming it to be confirmed by test. Within our sample, gender did not appear as an interrelated factor for COVID-19 history, as male medical professionals exhibited a higher infection rate than their female counterparts, in contrast to dental professionals, where female dentists reported more infections than maledentists.
COVID-19 testing for all health professionals remained the central attitude in response to the pandemic, particularly until the innovation of the COVID-19 vaccine. It is still key to continue testing for COVID-19 to track the evolution of the epidemic and the virus itself. According to the current study, most (87%) Pakistani health professionals proactively sought COVID-19 testing in the past two years, reflecting a responsible approach. Although COVID-19 testing remained significant for surveillance, a small portion of health professionals in our study rejected the vaccination and expressed nil belief in testing. This belief among highly educated and professional individuals is a threat to the healthcare system, which may limit the successful implication of pandemic control.
Currently, a decline in testing and delays in reporting new cases in many countries have been observed [9]. Nevertheless, WHO recommends maintaining and strengthening COVID-19 surveillance through testing to monitor changes in epidemiological patterns, including the burden of disease on healthcare workers and the evolution and circulation of new variants [28].
Fear and anxiety among health professionals in response to COVID-19
Since COVID-19 was a stressful pandemic, healthcare professionals’ behavioral responses naturally adapted in the form of unpredictable and uncertain stress. Thus, addressing COVID-19-related mental health issues among health professionals is significant for appropriate occupational health management. According to W Rana et al. 2020, the continued outbreak of new variants is causing further mental health complications among Pakistan’s healthcare professionals, which is not only affecting their decision-making ability moreover, it may potentially lead to a sense of frustration, helplessness, and adjustment challenges for them [29].
The prevalence of fear among medical and dental professionals concerning COVID-19 differs considerably, with varying degrees reported in previous global studies [15, 30–32]. A significant portion of our respondents expressed apprehension about the newer virus variants. Such findings parallel a previous Pakistani study, highlighting a prevalent fear of infection among health professionals [33]. However, this contrasts with the sentiments of health professionals from higher-income Asian countries like the UAE and Saudi Arabia, where a lesser fraction reported such fears [18, 34].
The present study found that health professionals reported a moderate to high level of fear and anxiety about contracting the new variant of the virus or becoming infected. Similar trends were found earlier in Arab, South Asian, and African countries, where health professionals suffered moderate to high fear and anxiety due to COVID-19 [15, 35–37]. Our data underscores the pervasive fear among health professionals regarding transmitting the virus to family and friends. Junior medical professionals, particularly RMOs, exhibited the highest levels of this anxiety. This aligns with the findings from studies conducted in a provisional region of Punjab in Pakistan [23, 31].
Fear and anxiety in healthcare setup
A substantial 97.70% of medical professionals and 86.06% of dental professionals in the study articulated anxiety when attending to potentially infected patients, alongside carrying a perception of unease when conversing with patients in close proximity. Both concerns mirror the sentiments voiced by health professionals in previous studies from South Asian regions. [31, 38]. Moreover, most of our respondents feared getting infected at the workplace by either patients or colleagues, echoing concerns from medical professionals in Wuhan [38, 39]. However, this diverges from the sentiments of Saudi health professionals, where only a minority echoed similar apprehensions [27].
Moderate to high levels of fear and anxiety in our study reveals COVID-19 related stressful mental health conditions among Pakistani health professionals. Health workers with mental health conditions have the same rights to treatment and access to care as the general population. Thus, a detailed psychological crisis intervention plan should be developed in addition to health workforce policy and management guide in the context of the COVID-19 response. Evidence shows that dentists in Pakistan had a good perception and positive attitude towards infection control practices against COVID-19, which should have been the same for medical professionals instead of being afraid of the virus.[40] Realistically, health policymakers in Pakistan are suggested to establish a complete COVID-19 response guide to protect and empower health workers at all levels, particularly building basic psychosocial skills among them while responding to epidemics. WHO 2020 guide [41] is a prime example of administrating COVID-19, which also consolidates COVID-19 guidance for human resources for health managers and policymakers at national, sub-national, and facility levels.
Limitations
The study focuses on health professionals in the Sindh province of Pakistan. Thus, findings may limit the readers or policymakers who want to use the study results to make broader generalizations or decisions at the national level. The manuscript places a significant emphasis on descriptive data, which provides a snapshot of attitudes and behaviors at a specific time. Thus, the study might not capture underlying causes, patterns, or trends that could provide more profound insights into the behaviors and attitudes of health professionals.
Strengths of the study
The study achieved a robust response rate of 95.50%. This enhances the reliability and representativeness of the findings. Including dentists and doctors from urban cities in the Sindh province, the study offers a varied perspective, capturing the sentiments of different health professional groups. Conducted between December 2021 and February 2022, the study captures the attitudes and behaviors of health professionals during a crucial phase of the pandemic, marked by the emergence of new variants; hence, results may remain valid for readiness for future possible health emergencies.
Conclusions
The present study demonstrated moderate to high fear and anxiety levels due to emerging variants of COVID-19 among health professionals in Sindh, Pakistan. Certainly, nil reluctance to COVID-19 vaccination has appeared among them. Although COVID-19 testing remained significant for surveillance, some health professionals in the study did not believe in testing. The findings are poised to guide health policymakers in Pakistan and formulate strategies that address health professionals’ concerns, behaviors, and needs related to COVID-19 and its new variants. Further studies from other parts of Pakistan are required to comprehend the response of health professionals to COVID-19 to help health policymakers establish precise SOPs to manage the adverse psychological and corporal effects of the pandemic on health professionals.
Ethical approval
The study received approval from the Ethical Review Committee of Jinnah Medical and Dental College, Karachi, with the ERC Number 000159/21.
Informed consent
Informed consent was obtained from all participants included in the survey, and the study was carried out in compliance with the Helsinki Declaration.
Conflict of interests
The authors declare that they have no competing interests.
Funding
The authors received no financial support for the research, authorship, and/or publication of this article.
Footnotes
Acknowledgments
The authors would like to thank the participants who helped in the data collection by filling up and spreading the web-based online survey.