**4. Discussion**

The present study examines the perceptions, attitudes, and practices of healthcare workers related to the COVID-19 pandemic in four major COVID-19 hospitals in Greece. The study reveals some misconceptions and knowledge gaps in everyday practice that allow for further improvement, especially in terms of hand hygiene and antimicrobial use in COVID-19 patients.

In the fight against infectious diseases, knowledge, attitudes, and practices towards these diseases can be very important, since they can affect the extent of their spread, the severity of the disease, as well as, the overall mortality rates [11–13]. Thus, it is important to evaluate the knowledge, perceptions, and practices of HCWs during a pandemic, in order to recognize early any misconceptions in HCWs and elaborate targeted educational initiatives and preventive interventions [14].

Female participants were twice as male participants in this study sample, while, most participants were nurses, followed by physicians. The majority of the participants had chosen scientific websites and medical journals as their main source of information regarding COVID-19, with media being the second most prevalent source. Knowledge regarding the causal pathogen, transmissibility, and COVID-19 symptoms was adequate, with most participants replying correctly to the questions. Compared to other studies evaluating the knowledge and perceptions of HCWs on COVID-19 that were performed earlier during the pandemic, our study shows superior overall knowledge of COVID-19 transmissibility and symptoms [11,15]. Similarly to our results, a recent study that was performed in Turkey, showed adequate knowledge and correct perceptions among HCWs on COVID-19 matters in the hospital setting [16].

Interestingly, a significant proportion of HCWs doubts about the preparedness of their hospital to face COVID-19 second wave, while another significant proportion is afraid about the possibility of contracting the virus and spreading the disease to their family. This is a very important finding, since anxiety and fear of acquiring COVID-19 may affect the level of provided healthcare and contribute to reduced willingness of HCWs to accept new admissions, even though their fear was associated with appropriate infection prevention practices [17]. Furthermore, fear and anxiety, in conjunction to long working hours due to increasing demands during the COVID-19 pandemic may lead to the development of mental disorders in HCWs, such as depression, suggesting that psychosocial interventions could be developed in order to support the staff [18]. We found significant compliance to infection control measures, especially in terms of hand hygiene after contact with patients, irrespective of their COVID-19 status. On the other hand, hand hygiene was not adequately performed after a contact with the patient's surrounding environment. Misconceptions regarding the proper use of antiseptic solutions and indications for hand washing were observed in a small proportion of HCWs. This could serve as alarming issue and guide

the Hospital Infection Control Committees of the participating hospitals to enhanced educational programs during the pandemic. The knowledge of HCWs regarding the hospital aeration was adequate.

Knowledge regarding isolation after exposure to a COVID-19 patient was inadequate and diverged between HCWs of the same hospital and between the participating hospitals. Interestingly, the expressed willingness for COVID-19 vaccination was around 71%, in accordance with other European studies [19,20], but was higher compared to other studies performed in healthcare professionals, that show a willingness for vaccination of about 50% [21].

Physicians, even though aware of criteria for antimicrobial prescription in COVID-19 patients, overestimated the percentage of COVID-19 patients with bacterial co-infection. As previously shown, only a minority of physicians recognized that co-infections at the time of COVID-19 diagnosis are evident in less than 10% of patients [22,23]. This could help initiate educational efforts towards antimicrobial stewardship in the pandemic era. Additionally, physicians provided diverse responses regarding the isolation guidance for patients tested positive for COVID-19, either with or without symptoms, which represents a need for focused actions towards better education, based on the local guidelines by the National Public Health Organization.

There were slight differences in the responses of male and female HCWs, with female HCWs more often stating that they know and always apply the five steps of hand hygiene, slightly more often responding that oropharyngeal RT-PCR is the most reliable means of COVID-19 diagnosis, and by supporting in a higher proportion that isolation period for HCWs exposed to SARS-CoV-2 is 14 days, or that they would consult the hospital infection control group or the Greek National Public Health Organization in the case of such exposure. This is partially in line with the literature, where female gender is associated with better hand-washing practices during the COVID-19 pandemic [24–26].

Responses from HCWs from different hospitals differed slightly, with the most obvious difference being the significantly, less fear noted in HCWs working in the University Hospital of Heraklion and the General Hospital Papageorgiou, Thessaloniki regarding the possibility of suffering from COVID-19, or contracting it to their relatives. This, suggests that, in general, there are no important specific local factors affecting knowledge and perceptions regarding COVID-19 infection, as most responses did not differ significantly. However, different levels of preparedness of different hospitals, factors regarding epidemiology and geographic distribution of COVID-19 cases in Greece or other factors may have influenced the perceived fear by HCWs of being infected by SARS-CoV-2. Thus, in areas with higher burden of COVID-19 cases, and lower preparedness due to financial or political reasons, perceived fear of exposure to SARS-CoV-2 may be higher. This suggests that targeted interventions to hospitals with higher burden of COVID-19 could positively affect the psychology and perceptions of HCWs, leading to improvement of their well-being, and, as a consequence, to an improvement in the healthcare provided. To that end, this study shows that centrally controlled initiatives (for example, directed from the Ministry of Health or the Greek National Public Health Organization) involving questionnaires like the one used in the present study, or audits, could help identify gaps in knowledge and practice of HCWs during the pandemic both in general, as well as more specific gaps that have to do with specific areas and hospitals. This more individualized approach could allow for interventions, such as educational activities towards the groups that require them the most, in order to improve infection control practices and increase knowledge regarding COVID-19. Interestingly, the less fear of being infected by SARS-CoV-2 in the hospitals of Heraklion and Thessaloniki does not correlate to the local trends of the pandemic, since, the second wave of the pandemic (during which, this study was performed), involved the northern part of Greece, including Thessaloniki [27–29].

Physicians were found in this study to be more knowledgeable regarding COVID-19, disinfection and hand-washing practices. On the other hand, they were less satisfied with the protective equipment provided by their hospital, but were also less afraid of being

infected by the virus. This shows that not all HCWs share the same beliefs, or knowledge regarding COVID-19, as their education regarding healthcare in general, and COVID-19 in particular, differs. This also underlies the need for an individualized approach towards targeted interventions in order to increase awareness regarding COVID-19 and infection control practices (such as hand hygiene and disinfection). Furthermore, the increased willingness of physicians to be vaccinated suggests, as probably expected, that approval of vaccination will vary depending on the social status, the profession and other factors. This suggests that, in order to increase the approval of vaccination, HCWs and the society in general should be approached also in a structured and individualized manner, through political decisions regarding educational interventions in the workplace, media coverage, and maybe societal benefits for vaccinated individuals [30–32].

This study has limitations that should be mentioned. First, the exact number of persons asked to participate in the study could not have been recorded due to the nature of the questionnaire (paper-based), even though, it is estimated that the response rate was about 50% which is close to the rate noted in other studies [33,34]. Second, this is a study conducted in four tertiary COVID-19 hospitals, and the results cannot be generalized until additional data are collected from multiple hospital settings in other countries. Finally, the questionnaire reflects the perceptions, attitudes, and knowledge at the specific time period the study was conducted, as such, one cannot predict what the perceptions and attitudes of the HCWs would be in other instances, for example in times of COVID-19 vaccination generalization or in countries not experiencing a pandemic wave as the one we were experiencing in Greece at the time the study was performed.
