Dobe M, Sahu M, Taklikar C, Dutta S. A Study on risk perception, cognitive awareness and

emotional responses to identify unmet training needs of frontline Health Care Workers (FLHCWs)

for COVID-19 containment In India (Original research). SEEJPH 2022, posted: 29 October

2022. DOI: 10.11576/seejph-5976

P a g e 1 | 10

ORIGINAL RESEARCH

A study on risk perception, cognitive awareness and emotional responses to

identify unmet training needs of frontline health care workers for

COVID-19 containment in India

Madhumita Dobe1, Monalisha Sahu1, Chandrashekhar Taklikar1, Shibani Dutta1

1 All India Institute of Hygiene and Public Health, Kolkata, India.

Corresponding author: Dr. Monalisha Sahu

Address: 110, Chittaranjan Avenue, Kolkata – 700073, India;

Telephone: +919873927966;

E-mail: drmonalisha@outlook.com

mailto:drvikaspsm@gmail.com

Dobe M, Sahu M, Taklikar C, Dutta S. A Study on risk perception, cognitive awareness and

emotional responses to identify unmet training needs of frontline Health Care Workers (FLHCWs)

for COVID-19 containment In India (Original research). SEEJPH 2022, posted: 29 October

2022. DOI: 10.11576/seejph-5976

P a g e 2 | 10

Abstract

Aim: Frontline Health Care Workers (FLHCWs) are the key workforce in the fight against

ongoing COVID-19 pandemic. They hail from the community and are responsible for

supporting the health system in generating awareness, implementing preventive strategies,

contact tracing and isolating potential cases. In their job responsibilities, FLHCWs thus may

perceive heightened risk of exposure to the virus, leading to overwhelming emotional response

and psychological distress. The objective of this study was to investigate risk perception,

cognitive awareness and emotional responses among FLHCWs trained to deal with Covid 19,

to identify unmet needs of this training in India.

Methods: A cross-sectional study was conducted in a total of 131 frontline workers selected

by a multistage sampling process from two states (Odisha and Himachal Pradesh) of India. The

FLHCWs were interviewed personally (when feasible) with the help of a predesigned pretested

semi-structured questionnaire.

Results: The findings suggested that majority (90%) of the FLHCWs perceived that they are

susceptible to nCoV-19 infection and 77.1% of FLHCWs felt high probability of them getting

infected with the nCoV-19. Almost 90% of them responded that it is something they think

about all the time and 41% of FLHCWs admitted that they feel helpless in the situation. About

63% of FLHCWs perceived that the nCoV-19 infection was a severe illness and 35% perceived

it to be very severe and life threatening. Although most of them had received some unstructured

and non-uniform training on preventive measures against COVID-19, yet only 38% felt that

the knowledge was adequate to protect themselves from the nCoV-19 infection. The training

sessions lacked psychological component for capacitating them with coping skills to address

their emotional and psychological responses.

Conclusion: The FLHCWs experienced heightened risk perception and symptoms of

emotional distress in significant numbers even after trainings. A more inclusive public health

policy dialogue to address the emotional and psychological coping skills is needed for

capacitation of these frontline workers to address the challenges of Pandemic response now

and in future.

Keywords: capacity building, Covid-19, emotional response, FLHCWs, pandemic, social

support.

Conflicts of interests: None declared.

Acknowledgments: We would like to thank all participants to our study, whose time is even

more precious in this difficult situation for all the country, who participated.

Dobe M, Sahu M, Taklikar C, Dutta S. A Study on risk perception, cognitive awareness and

emotional responses to identify unmet training needs of frontline Health Care Workers (FLHCWs)

for COVID-19 containment In India (Original research). SEEJPH 2022, posted: 29 October

2022. DOI: 10.11576/seejph-5976

P a g e 3 | 10

Introduction

The novel coronavirus 2019 (nCoV-19)

pandemic has caught the health systems

off-guard and countries are struggling to

control the galloping rates of transmission

(1). The role of frontline health care

workers (FLHCW) in generating awareness

and promoting preventive methods to limit

further transmission of nCoV-19 in the

communities is critical.

With 13,36,861 confirmed Cases and

31,358 total deaths, India presently has the

third highest number of confirmed nCoV-

19 cases and the eighth highest number of

deaths due to nCoV-19 worldwide (2). The

government of India has launched a

massive operation to engage lakhs of

FLHCWs in form of Accredited Social

Health Activists (ASHAs) to contain the

spread of nCoV-19 in the rural areas of

different states of the country (3). They

serve as an important link between

community and the health facilities and are

particularly indispensable to reach out to

populations in remote and rural parts of

India for dealing the nCoV-19 pandemic.

The job responsibilities of FLHCWs

fighting nCoV-19 in India involves (4):

 Generating awareness in the
community through Inter-personal

communication about (a) Uptake of

preventive and control measures

including regular handwashing,

practicing respiratory hygiene,

maintaining social distance (b)

Addressing myths and

misconceptions;

 Supporting Auxiliary Nurse
Midwives (ANMs)/Supervisor in

house-to-house active surveillance

and contact tracing including (a)

Identification of HRG, probable

cases and their contacts;

 Mobilizing community to ensure
uptake of medical services in urban

and rural areas; and

 Reporting and providing feedback
across different phases of nCoV-19

pandemic (number of cases,

imported/sporadic cases, clusters

and community wide transmission).

In their line of duties, many FLHCWs had

to work for longer hours with Personal
Protective Equipment (PPE) on and survey

around 30 to 50 houses in a day depending on

the risk levels of the area.

Due to ‘Corona phobia’, they were often

encountering stigma and physical violence

during their home-to-home surveys (5).

There is great fear regarding personal well-

being secondary to community

transmission of the disease. This may result

in overreaction, and plethora of other

psychological manifestations like excessive

worry, fear of infection and death and

feeling of helplessness etc. Psychological

preparedness of FLHCWs, their cognitive

awareness and coping for emotional

responses in these situations, have

compelling relevance during this pandemic

(6).

Perspectives on emotional and

psychological preparedness especially the

needs of specific populations like FLHCWs

while working for nCoV-19 are sparse.

This study was conducted with the

following objectives:

 To assess the gaps in risk
perceptions, cognitive awareness

and capacity for coping with

emotional responses in their job

responsibilities during Covid 19

pandemic;

 To identify unmet needs for training
and various challenges FLHCWs

face while working in the

community for COVID-19

containment.

Methods

A cross-sectional study was carried out

from April 2020–June 2020 at selected 15

districts from the eastern state of Odisha

and Northern city of Himachal Pradesh in

India. A multistage sampling scheme was

followed. The required sample size was

calculated as 122 considering prevalence of

Dobe M, Sahu M, Taklikar C, Dutta S. A Study on risk perception, cognitive awareness and

emotional responses to identify unmet training needs of frontline Health Care Workers (FLHCWs)

for COVID-19 containment In India (Original research). SEEJPH 2022, posted: 29 October

2022. DOI: 10.11576/seejph-5976

P a g e 4 | 10

fear as 80% (as quoted from another study

conducted in India by Parikh et al) at 10%

error level and considering design effect as

2. Adjusting for non-response additional

10% sample size was added to 122 making

the total sample size as 134. However, three

of the responses were incomplete and were

omitted and finally 131 responses were

included in the study.

In the first stage purposive selection of

districts were done to select 13 districts

from Odisha (Puri, Gajapati, Keonjhar,

Kendrapara, Jagatsinghpur, Cuttack,

Angul, Bhadrak, Balasore, Mayurbhanj,

Sambalpur, Sundargarh, Sonepur) and 2

districts from Himachal Pradesh (Mandi,

Kangda). In the second stage fifteen health

centers (14 PHC and 1 CHC) from each

district were selected by using simple

random selection technique. List of

FLHCW was prepared working under these

centers. In the third stage the sample of 131

FLHCWs were randomly selected from the

list and interviewed in person (when

feasible) or over telephone, using a

predesigned pretested semi-structured

interview schedule consisting of 34 items.

Written informed consent was taken prior

to the interviews. Confidentiality and

anonymity of the respondents was

maintained throughout the study. Data was

analysed using Microsoft Excel and SPSS

Ver. 20. Appropriate statistical tests of

significance were applied as necessary. The

data were analysed using descriptive and

inferential statistics.

Results

Sociodemographic profile of FLHCWs

Nearly half (52%) of the FLHCWs were

between the age group of 21-40 years old.

Majority of them (70%) were educated up

to matric or higher level. Most of them were

trained for covid-19 (Table 1).

Table 1. Distribution of the FLHCWs according to the socio- demographic profile

and training status (N=131)

Socio-demographic characteristics Number Percent

Age (in yrs.)

21 – 30 07 5.34

31 – 40 61 46.56

41 – 50 58 44.28

51 – 60 05 3.82

Educational Qualification

Primary 1 0.77

Upper Primary 39 29.78

Matric 56 42.74

Higher Secondary 22 16.79

Graduation 13 9.92

Training

Trained 125 95.5

Untrained 6 4.5

Perception of risk: Majority (90%) of the

FLHCWs felt that they are susceptible to

nCoV-19 infection. 58% of them expressed

that despite having knowledge about

preventive measures it is difficult for them

to avoid acquiring the infection. Most of the

Dobe M, Sahu M, Taklikar C, Dutta S. A Study on risk perception, cognitive awareness and

emotional responses to identify unmet training needs of frontline Health Care Workers (FLHCWs)

for COVID-19 containment In India (Original research). SEEJPH 2022, posted: 29 October

2022. DOI: 10.11576/seejph-5976

P a g e 5 | 10

FLHCWs (77.1%) felt that probability of

them getting infected with the nCoV-19 is

likely or extremely likely.

Perception of severity: 63% of them

feared that nCoV-19 infection causes

severe illness and 35% perceived it to be

very severe and life threatening.

Table 2. Distribution of FLHCWs according to their knowledge and risk

perception (N=131)

Knowledge and risk perception No. FLHCWs %

Knowledge of protective measures against nCoV-19

Not at all 0 0.0

Inadequate/some 80 61.1

Adequate 51 38.9

Perception regarding possibility of avoiding nCoV

infection

Extremely difficult 3 2.3

Difficult 74 56.5

Easy 43 32.8

Extremely easy 11 8.4

Total 131 100

Perception of Susceptibility to nCoV-19 infection

Not at all susceptible 14 10.7

Susceptible 67 51.1

Very susceptible 50 38.2

Perception regarding possibility of getting

themselves infected with the nCoV-19

Extremely unlikely 1 0.8

Unlikely 29 22.1

Likely

83 63.4

Extremely likely

18 13.7

Perception about severity of nCoV-19 infection

Not Severe 2 1.5

Severe 84 63.1

6 Very Severe and life threatening 47 35.3

Cognitive awareness regarding

effectiveness of various preventive

measures and the ease of practicing them

[Figure 1]:

Cognitive awareness is the most important

part of decision making and practicing a

particular behaviour. When asked about

their perceptions regarding the protective

measures against nCoV-19 infection, most

of the FLHCWs (61.1%) reported that they

have some knowledge about how to protect

themselves from nCoV-19 but only 38%

Dobe M, Sahu M, Taklikar C, Dutta S. A Study on risk perception, cognitive awareness and

emotional responses to identify unmet training needs of frontline Health Care Workers (FLHCWs)

for COVID-19 containment In India (Original research). SEEJPH 2022, posted: 29 October

2022. DOI: 10.11576/seejph-5976

P a g e 6 | 10

believed that the knowledge was adequate

to protect themselves from the nCoV-19

infection.

When asked to rank the preventive

measures based on their effectivity,

majority (74.8%) of the FLHCWs

responded that washing hands frequently

with soap and water was the most effective

way to avoid infection followed by social

distancing. Very few of them mentioned

measures like staying at home, registering

names in Govt. portals like ‘Arogya Setu’,

using gloves and not spitting in public place

as preventive measures that are important in

preventing spread of nCoV-19. (Table 3).

On applying chi-square test those who were

educated up to higher secondary and above

had significantly better knowledge of

protective measures against nCoV-19

(Chi=79.56 p<0.01). Their perception

regarding possibility of getting themselves

infected with the nCoV-19 was that chances

of getting infected was low if preventive

measures were practised properly

(Chi=6.64 p<0.05).

Figure 1. Distribution of ASHAs according to their cognitive awareness of preventive

measures to limit spread of COVID-19 infection

On questioning about their ease to practice

preventive measures like washing hands

and wearing masks, few (1.5%) of the

FLHCWs said that wearing mask always

was very inconvenient. 46% of them

reported feeling uneasy and suffocated

while wearing mask all the time. Some

FLHCWs (22.1%) felt inconvenient to

maintain social distancing while others

(10%) found washing hands frequently

with soap and water very inconvenient.

Capacity for coping with emotional

responses in Covid 19 pandemic work

When asked about their emotional response

to nCoV-19 infection, almost all of them

(99%) answered that they feel worried

about the possibility of acquiring nCoV-19

Dobe M, Sahu M, Taklikar C, Dutta S. A Study on risk perception, cognitive awareness and

emotional responses to identify unmet training needs of frontline Health Care Workers (FLHCWs)

for COVID-19 containment In India (Original research). SEEJPH 2022, posted: 29 October

2022. DOI: 10.11576/seejph-5976

P a g e 7 | 10

infection. 94% of them said that nCoV-19

is causing a lot of fear amongst them. 90%

of them also responded that it is something

they think about all the time and 41% of

FLHCWs admitted that they feel helpless

because of nCoV-19. 22% of FLHCWs

admitted that they search for information

about nCoV-19 more than 10 times a day.

Most of them (64% reported checking

COVID related information more than 10

times a day due to worry.

42% of the respondents said that getting

infected due to their job responsibilities,

was a major concern to them; some others

(5.3%) reported non availability of

sufficient PPE kits as a major concern.

However, 59% of FLHCWs felt that nCoV-

19 infection could be combatted through

their own practices.

Figure 2. Perceptions of FLHCWs about nCoV-19 infection and emotional response

towards it (N=131)

On probing about other challenges faced

while doing active surveillance in the

community, more than half of the FLHCWs

reported that the stigma against the virus has
also set off a chain of harassment against

them, further demolishing their morale.

Anxieties of their family members over their

possibility of getting infected and

transmitting it to others in the household also

affected their attitude towards work. Some of

them also reported feeling lonely and

depressed when they stayed isolated at

home due to the compulsion of maintaining

physical distancing from their friends,

relatives and family members.

Identified unmet needs for training of

FLHCWs for effectively addressing these

gaps:

For performing COVID-19 related work,

almost 96.2% of the FLHCWs had received

some training regarding COVID-19.

However, most of them said that the

training sessions were unstructured and not

uniform. Also, the training session lacked

psychological component for capacitating

them with coping skills to address the

psychological responses.

Discussion

In a similar study for Risk perception

assessment of COVID-19 among

Portuguese Healthcare Professionals

(HCPs) it was found that 54.9% of HCPs

believed there was a high probability of

becoming infected. Regarding the

likelihood of family and friends becoming

infected, about 60% of them felt there was

Dobe M, Sahu M, Taklikar C, Dutta S. A Study on risk perception, cognitive awareness and

emotional responses to identify unmet training needs of frontline Health Care Workers (FLHCWs)

for COVID-19 containment In India (Original research). SEEJPH 2022, posted: 29 October

2022. DOI: 10.11576/seejph-5976

P a g e 8 | 10

a “moderate” probability. Regarding the

perceived effectiveness of the quarantine

measures, more than 70% believing it to be

“very effective”. Most participants (60.0%)

had the opinion that communication from

the Health Authorities was “moderately

adequate”. When asked about health

services' preparations to manage this

pandemic, 63.5% of the HCPs responded to

be “poorly prepared” (7).

In another study conducted in Italy it was

found that health workers reported higher

risk perception, level of worry, and

knowledge as related to COVID-19

infection compared to general population.

Psychological state, gender, and living area

were found to be important predictors of

these factors. Instead, judgments about

behaviours and containment rules were