We are currently facing a disease caused by the SARS-CoV-2 virus, known globally as coronavirus disease-2019 (COVID-19), which is considered a threat to global health due to its high contagiousness and rapid spread. ¹ According to the World Health Organization (WHO), 159,896,332 cases of this disease and more than 3,321888 deaths were reported worldwide between its emergence in late 2019, and May 12, 2021. ² Perú, like other Latin America countries, has been widely affected by the increase in confirmed cases. On May 12, 2021, the Ministry of Health (MINSA) reported 1,858,239 cases and 64,691 deaths, which makes Peru the nation with the sixth highest number of patients in the world. ³ However, there was a discrepancy between what was reported by MINSA and the figures reported by the National Death Registry Information System (Sistema Informático Nacional de Defunciones, SINADEF) since this institution reported 130,195 cases on the same date.

In Perú, health professionals are a population group at high risk of contracting COVID-19, because they are on the frontline in the fight against the disease. This disease is highly infectious; there is no specific treatment, and access to vaccination is still limited. ^{4, 5} Consequently, healthcare professionals must acquire sufficient knowledge to treat patients in an efficient and timely manner and, at the same time, protect themselves from contracting the disease.

It should be emphasized that, during the pandemic, healthcare professionals are being overworked in addition to feeling afraid of contracting the disease. ^{6- 8} This makes it more critical for any country to overcome the disease and protect healthcare professionals at the same time. ⁷

Consequently, a key element in the fight against the pandemic is to follow the guidelines established by organizations such as the World Health Organization (WHO) and MINSA. Given the challenges Perú is facing, adequate dissemination of information among health professionals is important so they can be updated with recent advances in managing the disease.

Hence, low levels of knowledge, attitudes and practices (KAP) in regard to the implementation of preventive measures against the disease ^{2- 6, 9} might cause serious public health problems, since health personnel must assume responsibility for care and control of the pandemic. ^{7- 10}

Previous studies have reported that having low levels of knowledge, risk perception attitudes and preventive practices leads to a negative impact on the behavior towards the disease in health professionals. ^{11- 16} Therefore, it is essential to know what factors are associated with KAP to face COVID-19, providing evidence that is potentially useful for healthcare facilities to improve health interventions, which will reduce occupational exposure to COVID-19 in health professionals.

Information about 302 health professionals who were providing healthcare services during the period August-December 2020 was obtained. Regarding epidemiological variables, 64.9% were female and the median age was 46 years old (IQR 42-51), with greater participation of those under 50 old (73.5%). Regarding marital status, 87.4% (n = 264) were married or cohabiting, 7.0% (n = 21) were divorced and 5.6% (n = 17) were single, 91.4% (n = 276) had children. Regarding professions, 52.9% were physicians, 35.1% were nurses and 11.92% were obstetricians. The level of education corresponded to Master’s degree (79.1%), Doctorate (11.9%) and specialty (8.9%).

Regarding the area of work, the participants worked in outpatient consultation (32.8%), internal medicine department at the hospital (28.1%), intensive care unit (15.9%), emergency (13.9%) and clinical laboratory departments (9.3%). The median number of years of service was five (IQR 3-8) and the median daily working time was eight hours (IQR 7-8).

In the case of level of knowledge, it was established that 25.2% showed scores ≥ the 75th percentile, the parameter which allowed us to establish a high level of knowledge about COVID 19. Responses with the lowest scores were those related to the severity of the disease according to age groups (42.7%), time of subsistence of the virus (50%) and the need for specialized hospitals to care for suspicion or diagnosis of infection (55.6%).

In the case of preventive practices, 31.5% (n = 95) obtained scores above the 75th percentile, indicating a high level. A low level was identified in practices such as the use of disposable gloves in the workplace (45.0%), use of disposable gowns (42.1%), use of personal protective equipment (PPE) (25.2%) and decontamination of surfaces (7.7%).

The level of risk perception attitudes towards COVID 19 was analyzed with an inverse scale, determining the frequency of low levels of manifestation of negative attitudes (fear of contagion, fear that relatives might contract the disease, fear that personal protective equipment might not work, fear of death) like confidence, fear, concern and physical and mental fatigue. A total of 37.4% (n = 113) obtained scores above the 75th percentile, with a predominance of fear of becoming infected (49.7%), returning home and infecting the family (45%) and fear of dying from COVID 19 (49.7%).

Through a bivariate analysis, it was possible to establish that being married was a risk factor for having low levels of knowledge (OR = 7.01; CI: 1.64-29.85). The study showed, in addition, some preventive factors: having a Master’s degree (OR = 0.496; CI 0.27-0.90); working more than nine hours a day (OR = 0.36 CI: 0.16-0.75) and having relatives with diagnosed COVID-19 (OR = 0.47; CI 0.24-0.92).

Regarding preventive practices, it was shown that the use of public transport (OR = 1.68; CI 1.03-2.77), working in the hospital’s internal medicine department (OR = 2.11 CI 1.25-3.56) are risk factors for having a low level of preventive practices. However, we found some preventive factors such as being older than 50 (OR = 0.45; CI 0.24-0.83), experiencing comorbid conditions like hypertension (OR = 0.27; CI 0.08-0.94) and obesity (OR = 0.34; CI 0.14-0.79).

Regarding risk perception attitudes, the findings revealed risk factors such as having relatives with suspected COVID-19 (OR = 1.50; CI 1.08-2.64), having had contact with patients diagnosed with COVID-19 (OR = 1.92; CI 1.05-3.08) and having asthma as a comorbid condition (OR = 2.29; CI 1.17-4.50) ( Tables 1 and 2).

Our study revealed that healthcare professionals in Perú have insufficient knowledge about COVID-19 (more than 70% did not have a high level of knowledge), in contrast to a study in Nigeria, ²² where fewer than 20% of health professionals showed insufficient knowledge. Although frontline healthcare staff are expected to have a high level of knowledge of SARS-CoV-2, our study found a large knowledge gap regarding the severity of the disease according to age group and duration of virus persistence. Knowledge of the severity of the disease according to age group represents a weak link in clinical management, since therapeutic management is prioritized according to the risk of contracting a disease or its complications. ²³ Regarding the persistence of the SARS-CoV-2 virus, it is important to highlight it can survive at least 72 hours on plastic surfaces and stainless steel. ²⁴ This is fundamental in the prevention of person-to-person or patient-to-healthcare worker transmission during clinical care.

The present study revealed that being married represents a higher probability of having a low level of knowledge. Authors such as Naser et al., ²⁵ and Rani et al., ²⁶ have shown associations between marital status and low levels of knowledge of COVID-19 in health professionals in Saudi Arabia, where low levels of knowledge were found in single health professionals, as opposed to married health professionals, which can be explained by cultural aspects of Eastern countries such as believing that children and young adults are at a lower risk of contracting the disease, attending crowded places such as markets and mosques, in addition to their low acceptance of the use of masks. ^{25, 26} These results are different from what we found in our study, where a low level of knowledge in married health professional was shown, which can be explained by the fact that the proportion of single population was low (12.6%).

In addition, regarding the methodological aspects of the present study, one factor that may affect the results is the low participation of single people under 40 to the study, which corresponds to the age at which continuous or post-graduate training processes are carried out.

However, this association was not observed in the level of practices and attitudes. This could be due to social reasons, as married people might have less time to do COVID-19 training courses, unlike single people who might have more free time to acquire such knowledge. However, the level of practices and attitudes would not change, which could be due to the experience acquired in healthcare.

It was found that some factors such as having a Master’s degree, working more than nine hours and having relatives diagnosed with COVID-19 were preventive factors against having a low level of knowledge. This could be happening because self-learning, such as that employed when studying for a Master’s program, plays a key role in the process of acquiring COVID-19 knowledge. Similar studies in physicians found that younger physicians and those who had not worked with patients for a long time had lower COVID-19 knowledge scores. ²⁷ Presenting with comorbidity conditions was associated with good levels of knowledge, attitudes and practices towards COVID-19, which may be due to the fact that being part of a population at risk demands a greater level of care and attention to this disease compared to other groups that are not at risk. ²⁸ The presence of comorbidity conditions contributes to the inclusion of self-care behaviors by health professionals, based on their personal and professional experience and, thus, they can minimize the risk of contagion in their workplace.

Studies conducted in some Asian countries found that health professionals had a high level of knowledge of COVID 19, but had low levels of preventive practices, which allows them to affirm that knowledge is not a determining factor in developing preventive practices and attitudes, and that other measures should be implemented, such as improvement of the work environment and access to adequate PPE. ^{28, 30- 32} In our research, it became evident that 75% had low levels of knowledge and preventive practices, despite the fact that about six months had passed since the notification of the first case of COVID 19 in Perú. The explanation for this situation could be related to the fact that much of the information on the pandemic circulating in the academic media came from the opinion of “experts”, social networks or the media, which lacked scientific rigor.

It is known that healthcare professionals who have received instructions on donning and discarding PPE could cause a decrease in the risk of making errors, as along with professionals who have had active training with spoken instructions and computer simulation on correct PPE removal. ³³ A study in Jordan found that there was an association between biosafety at work and good biosafety practice at home, with a biosafety score at work of 73% (considered low by the researchers). ³¹ The only way to control new potentially deadly epidemics such as the one we are experiencing, and from an early stage, is to educate the population and especially healthcare personnel to adopt optimal behavior of biosafety practices and maximum PPE protection. ^{34, 35}

In relation to preventive practices, we could identify an association with epidemiological variables such as age, i.e. being older than 50. This suggests that an increase in knowledge may lead to better attitudes and practices. In this case, it is known that COVID-19 affects people of any age, but people over 60 are more severely affected, ³⁶ which may imply that older healthcare professionals, knowing that they are a population at a higher risk of contracting this disease, may follow better recommendations regarding preventive practices against COVID-19. Similarly, with respect to occupational factors, an association with being part of the hospital personnel was identified; a possible explanation may be that due to the serious clinical conditions of patients with COVID-19 in hospitals, the involved physicians and health personnel made greater efforts to have preventive practices against contagion.

In the present study, we found that certain groups of medical professionals have little knowledge about COVID-19, which is why the importance of ensuring the delivery of knowledgeable information to medical professionals should be emphasized. These low levels of knowledge would explain why Perú has one of the highest rates of medical professionals infected with COVID-19. This should be taken into account by front line care teams, physician managers and, in general, all health professionals in order to eliminate knowledge gaps and improve COVID-19 knowledge scores, attitudes and practices.

Knowledge allows the establishment of prevention strategies to avoid the spread of the virus, and also facilitates the development of positive attitudes towards the acquisition of self-care habits at work as well as respect for the rights of patients diagnosed with COVID-19, and the recognition of the effectiveness of the treatment plan and coping behaviors. ³⁷ In addition, exposure to the virus in the workplace implies a mental burden and could have a negative impact on control measures, ^{38, 39} which increases the risk of infection. In the present study, among the risk perception attitudes, fear of becoming infected predominated, which coincides with the findings of Zhang et al., Abdel et al., and Maleki et al., ^{39, 41} who found that between 85% and 92% of healthcare workers expressed fear of transmitting the disease to their family members. Therefore, it can be concluded that the perception of risk is a determining factor for the modification of attitudes in the work environment and the restructuring of healthy and safe behaviors during the working day, ^{38, 39} which impacts on family and social relations.

These results contrast with the findings of Abdelhafiz et al., ⁴³ who stated that stigma associated with the disease is based on fear associated with mortality and its transmission capacity. This could explain the association between the level of negative attitudes in those with relatives with suspected COVID-19, and having had contact with patients diagnosed with COVID-19. Although it may seem irrelevant, stigma is important because it can lead to public reluctance to seek medical care and the underreporting of cases, which can influence the increase in confirmed cases in a scenario characterized by community transmission. Thus, to combat stigma, it is necessary to develop appropriate education strategies framed in health policies and launching de-stigmatization programs in hospitals. ⁴³

The main limitation of this study was that the attitudes and practices of health professionals may be overestimated, as they may answer interview questions in a way that they believe is socially acceptable rather than completely accurate, because of “social desirability”. ^{44, 45} However, we believe that this could not have affected the measurement of knowledge. Another limitation was the low percentage of surveyed health professionals working at the hospital and in the Intensive Care Unit; in addition, we could not survey another group of health professionals who were working in more complex health institutions. Therefore, we cannot infer their level of KAP.

In conclusion, being married, having a Master’s degree, and working more than nine hours a day were associated with a low level of knowledge of COVID-19 in health professionals. Being older than 50, and working at the hospital, were associated with preventive practices. Physical contact with patients with COVID-19 was associated with the report of negative attitudes towards COVID-19. We recommend that universities and health institutions incorporate comprehensive training programs that seek to improve knowledge and promote preventive measures against COVID-19.