Coronavirus infections are respiratory viruses that can cause a range of disorders, from mild common cold symptoms to severe acute respiratory syndrome (SARS) [1]. COVID-19 is a zoonotic illness that may be spread through encounters between animals and humans, as well as between humans themselves [2]. It has resemblance to Middle East Respiratory Syndrome (MERS-CoV) and SARS, exhibiting characteristic symptoms including fever, difficulty breathing, coughing, and abrupt respiratory failure [3]. In 2002, there were many epidemic outbreaks of Middle East Respiratory Syndrome coronavirus illness, which led to 860 fatalities [2]. Approximately 8 years following the emergence of MERS-CoV, a new virus called COVID-19 was identified in Wuhan, China, at the end of December 2019. This virus posed a substantial public health concern, endangering the lives and well-being of millions of individuals worldwide [4].

COVID-19 was officially designated as a global public health emergency by the World Health Organization on January 30, 2020 [5]. Subsequently, in the first week of March 2020, a staggering surge of novel cases was documented worldwide, leading to the official declaration of COVID-19 as a pandemic on March 12, 2020 [6].

 COVID-19 recorded more than 115.000.000 infections, 2.500.000 deaths in 223 countries worldwide a year after the declaration as a pandemic [7]. 

Most people infected with COVID-19 will have mild to moderate respiratory illness and will recover without requiring special treatment, older people and those with underlying medical problems like cardiovascular diseases, diabetes, chronic respiratory diseases and cancer are more likely to develop serious illness. The best way to prevent and slow down transmission is to be well informed about the disease and how it spreads. Protection is essential by washing hands, alcohol based hand rubs, maintaining physical distance, wearing masks and eye protection. Even in the presence of approved vaccines against COVID-19 [8]. 

 Iraq recorded more than 1700000 COVID-19 cases, 19000 of them unfortunately died until August, 2021[9]. 

Since the beginning of the pandemic many countries around the world took precautionary measures like complete lockdown, full or partial curfew, quarantine, airport and border surveillance and intensive control training for professional healthcare workers (PHWs) [10].

Knowing that those professional healthcare workers are at a higher risk of infection or spreading the virus to colleagues, family, and friends and to other patients [11]. PHWs should have awareness about the disease and awareness about the infection control measures to prevent the spread [12]. It is important to understand what PHWs know about the disease, complications and disease prevention [13].

Since PHWs are the first line healthcare providers and are in close interaction with patients infected by COVID-19, they are a critical part of disease transmission / care chain [14].

Public Health Workers (PHWs), who are responsible for directly caring for affected persons, have a vital role in containing the outbreak by adopting safety and preventative measures. Failure to do so would worsen the issue. For instance, there have been reports indicating that a range of 0.3% to 20.9% of Middle East Respiratory Syndrome-Coronavirus cases might occur among Public Health Workers (PHWs) who had direct contact with sick individuals. Another study indicated that the rise in MERS and coronavirus infections might be attributed to inadequate knowledge among public health workers (PHWs) about the disease and a deficiency in infection prevention and control strategies [16]. 

The collection of this fundamental data is essential for the organization and strategic management of healthcare services, facilitating the efficient distribution of reliable and up-to-date information, and enhancing the overall quality of health services provided by public health workers. Essential approaches for optimizing the well-being of public health workers during future emergencies [14].

3.1 Study Design

A cross -sectional study. Data collection was from December 2020 – March 2021.

3.2 Study sampling and settings 

PHWs (medical doctors, dentists and pharmacists) were included in the study aged ≥25 and working either in governmental or private sectors. Out of those respondents to the questionnaire 520 responses, 398 were included in the study.

3.3 Data Collection Technique

Data were collected using a self-administered pre-designed questionnaire derived from (the Johanniter International Assistance Perception Survey) [15] The questionnaire was reviewed by the Community–Department at Baghdad Medical College.  Due to critical situations and to achieve social distancing online data collection was used. A questionnaire link was shared with groups for PHWs on social media (Facebook and WhatsApp) or by email.

3.4 Contents of the questionnaire 

The questionnaire tool is composed of 14 questions, it takes approximately 5 minutes to complete. The questions covered demographic data of participants like (age, gender, governorate, profession, type of health facility, and source of information about COVID-19) , then awareness about COVID-19 was assessed by questions focusing on the pandemic (origin, transmission, signs and symptoms, complications [2 questions] , current treatment [ 2 questions ] and ways of disease prevention and perception of risk to overcome COVID-19 pandemic.

 Practices towards COVID-19 were assessed by 6 questions 4 of them were dichotomous questions, these questions were about (receiving formal training to use personal protective equipment (PPE), contact with COVID-19 patients, caring for COVID-19 patients, contact with the environment COVID-19 patients cared in and performing any aerosol-generating procedure AGP to Confirmed COVID-19 cases. The other questions were about avoiding infection by COVID-19 while practicing their profession in general using (masks 2 selections, gloves, gowns, eye protection, hand hygiene, and PPE) and final question was about the forms of PPE used in routine care of COVID-19.

   3. Data Analysis

 Descriptive analysis was applied to calculate frequencies and proportions. The Chi-square test or Fisher Exact test was used to test the association of factors on knowledge and practices. A p-value of less than 0.5 was considered statistically significant.

  A total of 398 PHWs were included in the study. Their age was ≥25 years, giving male to female ratio 0.8:1.

 Table (1) Distribution of PHWs participated in the study

Table (2) geographical distribution of respondents

Table (3) shows type of health facility

Satisfactory knowledge among the participants is shown in table (4). The satisfactory knowledge was noticed about symptoms, origin of SARS.CoV-2, complications, supportive care (treatment) and no role for flu vaccine in prevention. Out of total doctors knowledgeable were 259 (93.5%) in symptoms, 196 (70.7%) origin of COVID-19 232(83.7%) about complications, supportive care in 265 (95.7%) and 265 (95.7%) in clear no role for flu vaccine in prevention. knowledgeable dentists in symptoms, origin, complications, supportive care and flu vaccine role in prevention against COVID-19 in 56(91.8%),52(85.2%), 53(86.9%),57 (93.8%) and 59 (96.4%) respectively. Pharmacists in 52 (86.7%), 52 (86.7%), 48(80%), 48(80%) and 56(93.3%) for items mentioned respectively. There was no significant difference in satisfactory knowledge between studied different PHWs (x² =7.6, d.f.=8 , p= 0.4 ) . (Table 4). 

Table (4) distribution of satisfactory knowledge about COVID-19 among PHWs

                                       x² =7.6 , d.f.=8 , p= 0.4

Sources for reliable information about COVID-9 used by PHWs are shown in table 5. Social media was the commonest source for medical doctors, dentists and pharmacists by 67.9%, 34.4% and 36.7%, respectively. The news media were used by 44.4%, 31.1% and 31.7% of doctors, dentists and pharmacists, respectively. Official government websites were used by 12.9 %, 13.1% and 13.3%of doctors, dentists and pharmacists, respectively. Training in health facilities was a source for knowledge in 11.5%, 11.5% and 10% by doctors, dentists and pharmacists, respectively. no significant difference in sources of reliable knowledge between studied PHWs (χ2 =5.9, d.f.=8, p=0.6).

Table 5 distribution of source of knowledge on COVID-19

                                                 χ2 =5.9, d.f.=8 , p=0.6

All studied groups of PHWs were knowledgeable about preventive measures manifested in hand hygiene (wash hands with soap and water or alcohol), avoid touching eyes nose and mouth, putting on facemask, covering nose and mouth while coughing, avoid crowdedness, frequently cleaning and disinfect surfaces, keep at least one meter distance and avoid direct contact with colleague. The details are shown in table 6. no significant differences in knowledge on preventive measures between groups of PHWs (p=0.7, 0.1, 0.9, 0.8, 0.9, 0.9 and 0.4, respectively, for items of prevention mentioned)

Table 6 knowledge on preventive measures among PHWs

Age distribution of knowledgeable PHWs about preventive measures is in table 7. All PHWs aged <40 and ≥40 years were similarly knowledgeable about washing hands in soap and water or alcohol), avoiding touching eyes, nose and mouth, avoiding crowdedness, frequently cleaning and disinfecting surfaces, keeping at least one meter distance and avoiding direct contact with colleagues. (p= 0.2, 0.1, 0.5, 0.7, 0.9, 0.9, 0.4, 0.5 respectively).

Table 7 age distribution of knowledge about preventive measures 

Male and female PHWs were similarly knowledgeable about preventive measures (about washing hands in soap and water or alcohol), avoiding touching eyes, nose and mouth, avoiding crowdedness, frequently cleaning and disinfecting surfaces, keeping at least one meter distance and avoiding direct contact with colleagues. (p= 0.4, 0.1, 0.3, 0.4, 0.09, 0.08, 0.2 and 0.6 respectively). This is shown in table 8.

Table 8 sex distribution of knowledge about preventive measures

  PHW were asked, (how to avoid the risk of catching COVID-19 while screening and assessing the patients, the answers were the following: (220) 79.4%of doctors, (53) 86.6%of dentists and (53) 88% of pharmacists are wearing surgical masks, (220) 79.4% of doctors, (51) 83.6%of dentists and (39) 65% of pharmacists are wearing gloves. (222) Also 80% of doctors, (53) 86.6% of dentists and (50) 83.3% of pharmacists are wearing eye protection glasses. (163) 58.8% of doctors, (19) 33% of dentists and (21) 35% of pharmacists are wearing PPE during assessment of patients.

Table (9) distribution of PHW using PPE

Of the question (Have you received formal training in the use of the recommended PPE (Personal protective equipment) for airborne transmitted infections at your institution?) (75) 27% of doctors answered (yes), (17) 27.8 % of dentists and (20) 33% of pharmacists answered (yes) about this question. 

Table (10) distribution of training among PHW

 The question: What forms of PPE do you use in the ROUTINE CARE of confirmed COVID-19 patients? (247) 89% of doctors, (53) 86.8% of dentists and (53) 88.3% of pharmacists are using Surgical mask or equivalent face mask, while (115) 41.5% of doctors, (24) 39% of dentists, (18) 30% of pharmacists are using full body waterproof suit.

Table (11) distribution of PHW using PPE during care for COVID-19 patients

Table (12) PPE type used by PHW to examine confirmed COVID _19 cases 

The question (Did you provide direct care to a confirmed COVID19 patient?) (205) 74% of doctors, (27) 44% of dentists and (36) 60% of pharmacists answered (yes) about providing direct care to COVID 19 patients.

Regarding the question (Did you have face-to-face contact (within 1 meter) with a confirmed COVID-19 patient in a healthcare facility?) (237) 85.5% of doctors, (37) 60.6% of dentists and (45) 75% of pharmacists answered (yes) about contacting patients.

The question (Did you have direct contact with the environment where the confirmed COVID-19 patient was cared for? bed, linen, medical equipment, bathroom. (246) 88.8% of doctors, (42) 68.8% of dentists, (41) 68.3% of pharmacists answered (yes) about this question. 

Table (13) distribution of items of contact among PHW

PHWs should have awareness about the disease and awareness about the infection control measures to prevent the spread. It’s important to understand what PHWs know about the disease and their knowledge of pandemic complications and disease prevention [14]. In Iraq, the published data on COVID-19 is scarce [16].

PHWs are the frontline caregivers dealing with infected individuals, play a crucial role in limiting the outbreak by implementing safety and prevention practices [17].

The study included 398 participants of PHWs 277 (69.6%) doctors, 61 (15.3%) dentists, 60 (15%) pharmacists, and male to female ratio of 0.8 :1. The data was collected online. This study revealed a prominent source of knowledge was social media among PHWs. It is in contrast to that published in UAE [18], GCC [19], Malaysia [20]. The difference might be attributed to the professional nature of governmental websites. Another explanation is that the working PHWs in Iraq are juniors which in turn were interested in social media.

Satisfactory knowledge was demonstrated on symptoms, origin, transmission, complications, supportive care and no role for flu vaccine in prevention. PHWs were knowledgeable on symptoms. There were no significant differences in knowledge between different PHWs (p=0.4). It is in the line of that in UAE [18] China [21].

No significant differences on preventive measures were noticed between different PHWs. Preventive measures were hand hygiene, avoiding touch and avoiding direct contact with colleagues (p=0.7, 0.1, 0.9, 0.8, 0.9, 0.9 and 0.4, respectively). This finding is similar to that reported in UAE [18]. Being a pandemic crisis might lead to fear among PHWs which in turn encourage them to look for knowledge.

It was noticed that low figures of PHWs use full body suits (PPE). It disagrees with that reported in UAE ^[18]. In UAE high figures were trained to use PPE (96.7%), However, in this 27% of medical doctors were trained. It is a matter of a deteriorated health system by conflicts.

This study reveals that high figures of PHWs were using masks. It is not the situation in UAE ^[18]. It is a defect in the managerial process that lacks supervision and monitoring in health institutes (hospitals and PHCCs). It is the conflicts that weakened the administration in health institutes might be behind this low figures in Iraq. Toleration of risks of danger might be the character of youth in Iraq.

Direct contact, face to face contact and environmental contact did not significantly differ between doctors, dentists and pharmacists (p=0.8). It is in contrast with that reported in GCC [19]. All PHWs in Iraq participated in care (Triage, or taking swab, or dealing with patients, which is different from that in GCC, because PHWs were foreigners.

Knowledge about COVID-19 among PHWs was satisfactory, especially about preventive measures. Social media was the main source of information for PHWs. Official websites attract a smaller number of PHWs.

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