Assessment and feedback of the COVID-19 pandemic’s effects on physicians’ day-to-day practices: good knowledge may not predict good behavior

ABSTRACT

The importance of doctors’ knowledge and awareness of infectious diseases was felt worldwide during the COVID-19 pandemic. With this study, we aimed to evaluate the effect of the long and dynamic pandemic process on resident physicians’ knowledge and protective behaviors for infection control in a tertiary hospital setting and protective behaviors for infection control in a tertiary hospital setting. The population of this cross-sectional study consisted of assistant physicians working at Suleyman Demirel University Faculty of Medicine Training and Research Hospital. A questionnaire evaluating information and protective practices for COVID-19 was applied to the participants through face-to-face interviews using the convenience sampling method, with an interval of one year. In the second year of the pandemic, resident physicians’ awareness of the correct use of personal protective equipment decreased (p = 0.001). Despite the continuous training, it was determined that the residents preferred masks with high protection at a lower rate when they encountered patients who received oxygen support of 5 lt/min and above (p < 0.001). To prevent the spread of COVID-19 infection in the hospital as the pandemic progresses, it has been determined that resident physicians are less prone to evaluate possible infection symptoms in patients hospitalized for non-COVID-19 reasons (p = 0.013). As a result, the data we obtained showed that despite the regular training during the pandemic and the death of many health workers, the residents’ adherence to infection control and prevention practices, which also protect them, decreased significantly in the second year of the pandemic. These valuable data showed us that good knowledge does not predict good infection control and prevention practices. Our findings show that physicians need a new education system that motivates them. In addition, psychosocial determinants, physical and mental fatigue, and institutional control factors contributing to these results and affecting individual risk perception should be recognized and prevented.

KEYWORDS:

• Infection
• prevention
• COVID-19
• physician
• knowledge and attitude

1. Introduction

In the 21st century, coronaviruses have led to epidemics throughout the world. Following SARS and MERS, the novel coronavirus SARS-CoV-2 pandemic, originating from the Hubei region of China, has made humans face the fact of how dangerous infectious diseases are [1]].

Globally, healthcare workers have been at the forefront of fighting the COVID-19 pandemic. The incremental increases in COVID-19 cases worldwide and the excessive number of patients admitted to intensive care units and hospitals have burdened healthcare professionals [2]. Physicians, especially, had to follow up-to-date data and safe practices while trying to treat, prevent and manage a previously unknown disease. In addition, healthcare workers were at a high risk of infection as they were directly exposed to suspected and confirmed coronavirus patients in healthcare facilities. Therefore, it was essential for healthcare workers to be updated on infection control and prevention information and adhere to behavior to protect themselves from infection and prevent the spread of the virus in the same hospital [3].

Today, despite the development and use of effective vaccines, infection control, and prevention practices remain of vital importance. In many countries, infection control and prevention trainings oriented toward COVID-19 have been arranged within the scope of strategic preparation and intervention plans designed to protect healthcare systems. The most important part of the training has been demonstrating the use of personal protective equipment [PPE] and implementing basic infection control measures. Controlling infectious sources and removing routes of viral infection are the primary methods to prevent the spread of the virus. Hence, healthcare professionals’ attitudes and practices regarding infectious diseases may affect disease severity, degree of transmission, and general mortality rate [4] Experience gained from the previous severe acute respiratory syndrome (SARS) outbreak in 2003 revealed that inadequate information was the biggest obstacle in controlling infections [5]. Sporting this knowledge, many international studies have found that the knowledge and attitudes of healthcare workers regarding infectious diseases remain only moderate [6–9].

The current results indicate gaps in knowledge and practice that need attention. For example, educational methods may be insufficient to increase knowledge of COVID-19, provide safe practices, and improve behavior among healthcare workers. Moreover, under extreme pressure, psychological problems such as fatigue, exhaustion, anxiety, and depression may impair their ability to adapt to infection control. Consequently, one of the most important things to remember is that awareness and adherence to preventive measures are crucial in the fight against future pandemics.

Table

KEY POINTS

Despite effective vaccines, infection control, and prevention practices remain vital. Healthcare professionals’ attitudes and practices regarding infectious diseases may affect disease severity, degree of transmission, and general mortality rate. The pandemic process can mediate determining health workers’ deficiencies in acquiring professional knowledge. To produce policies that increase the knowledge of healthcare professionals and improve their awareness and commitment.

Based on these data, we wanted to evaluate the results of our intensive training efforts. Therefore, we decided to determine the compliance of resident doctors with infection control and prevention during the pandemic period and the sustainability of this compliance in our study. Residency physicians were included in the study because they are at the center of managing the disease and are subject to a longer training process. In addition, we aimed to determine the effect of the pandemic process on attitudes, behaviors, and knowledge changes regarding infection control, despite continuous education and training. Hence, we planned to compare residents’ knowledge, preventive and protective practices between the first and second years of the COVID-19 pandemic in our study.

As a side gain, the pandemic process can mediate determining health workers’ deficiencies in acquiring professional knowledge. The findings of our study may contribute to developing procedures or guidelines (such as developing new training modules, establishing policies, instrumental and psychological support) to prevent and mitigate these adverse effects.

2. Methodology

2.1. Study design, setting and population

This cross-sectional study was designed to evaluate the residents’ knowledge and preventive practices during the first year of the COVID-19 pandemic [November – December 2020] compared to those of the second year [November – December 2021]. The research population was comprised of residents working in Suleyman Demirel University’s Faculty of Medicine Research and Training Hospital. The university hospital was preferred due to the fact that training on infection control and prevention are given regularly and it is an academic environment where residents are trained.

2.2. Ethical approval

Before the study, received its approval from Suleyman Demirel University’s Clinical Research Ethics Board [No: 2020–216]. Only residents who gave informed consent to participate in the study were included. The names of participants weren’t identified in survey, so that the results could be objectively evaluated. Research maintained privacy and confidentiality by using unique codes to identify participants. Participation was voluntary, and no incentives were given to participants.

2.3. Sample size and sampling technique

Convenience sampling method was used, and 126 residents who agreed to participate in the study were interviewed face-to-face during the first year of the pandemic [November – December 2020]; 98 residents who agreed to participate in the study were interviewed face-to-face during the second year of the pandemic [November – December 2021].

2.4. Data collection tool

This study used a survey comprised of three parts as a data collection tool. The same survey form was applied twice at a one-year interval.

Previous studies were used as a basis for the questions that included the descriptive characteristics (general socio-demographic information) of the residents participating in the research [10,11]. The researchers prepared a question pool regarding knowledge – attitude awareness regarding COVID-19. For the preparation of the survey questions, the World Health Organization [WHO] and the Ministry of Health of the Republic of Turkey published recommendations were used [12,13]. The correct answers to the questions in the knowledge section were derived after consensus from guiding information and reports periodically published by international healthcare authorities [14]. Questions about general information about COVID-19 were determined by literature review [15,16]. The survey questions prepared by the researchers were evaluated with the opinions of five experts [three infectious diseases specialists, a Turkish language specialist, and a public health specialist]. As a result of the experts’ evaluation, four questions were removed from the survey. A pilot study was conducted with ten residents face-to-face after expert opinions were sought to measure whether the survey questions were correctly understood. Following the pilot study, no further questions were removed.

The first part of the survey included questions about age, sex, marital status, the clinic at which they were working [surgical/internal], duration of professional experience, and whether they had worked in the COVID-19 clinic [a total of 6 questions]. The second part comprised ten questions aimed at infection control and prevention awareness regarding COVID-19. Finally, the third part of the survey included two questions regarding general information on COVID-19.

The answer ‘Yes’ was scored as ‘1,’ and the answer ‘No’ was scored as ‘0’ for the responses given to ten questions that aimed to assess infection control and prevention awareness regarding COVID-19 (in terms of the intersection of knowledge and attitudes). The total score was obtained by adding the scores from the ten items. A score between 0 and 10 can be obtained using the scale. No cut-off points were used. The averages, over the total scores, were compared. Likert scale was used to assess the attitudes about drug efficiency, and for each drug, ‘1’ was considered as ‘Not efficient at all’ and ‘5’ as ‘Extremely efficient.’ The study’s dependent variables were knowledge-attitude scores about COVID-19, and the independent variables were gender, department, age, professional work experience, working in a COVID-19 clinic, and marital status. Internal consistency of the knowledge scale and attitudes was determined using Cronbach’s alpha. This score was 0.76, indicating that the data were internally consistent.

2.5. Study variables

The primary outcome was to measure the adherence of resident physicians working in a tertiary hospital to infection control and prevention practices for COVID-19. The secondary result; was to evaluate the impact of the long and dynamic pandemic process on the commitment and adherence to infection prevention and control measures.

2.6. Statistical analysis

Data obtained from the study was evaluated using the SPSS 22.0 program. General descriptive characteristics of the physicians and distributions of descriptive information were calculated in terms of frequency and percentage. The measurable data from the study is shown in terms of mean and standard deviation. The Independent Samples t Test was applied in parametric conditions, and the chi-square [post-hoc Bonferroni] and Mann – Whitney U test were applied in non-parametric conditions. The statistical significance was set at p < 0.05.

3. Results

3.1. Descriptive characteristics of residents participating in the study during the first year and second years of the pandemic

The results were evaluated in two groups depending on when the survey was conducted. Table 1 shows the demographics and descriptive characteristics of 126 residents [Group 1] who participated in the study during the first year of the pandemic and 96 residents [Group 2] who participated during the second year of the pandemic. The mean age of the participants was 28.94 [±4.49] and 28.91 [±5.25] years, respectively. In both groups, the majority of the participants were male [50.8–57.1%] and residents working in internal clinics [56.3–52%]. When the participants’ status of having worked in a COVID-19 clinic was assessed, we found that compared to the second year of the pandemic, more residents worked in such clinics during the first year [p = 0.005]. The professional working experience of the residents was 3.98 [±4.58] in the first group and 3.81 [±5.43] years in the second group.

Table 1. Descriptive characteristics of residents participating in the study during the first year [Group 1] and second year [Group 2] of the pandemic.

	Group 1		Group 2
	n	%	n	%	p
Sex
Male	62	49.2	42	42.9	.345
Female	64	50.8	56	57.1
Department
Surgical	55	43.7	47	48.0	.521
Internal	71	56.3	51	52.0
Working in COVID-19 clinic
Yes	102	81.0	63	64.3	.005
No	24	19.0	35	35.7
Age
Mean	28.94		28.91
[SD] [min – max]	[4.49] [17-]54]		[5.25] [17–]60]
24–26 years	31	24.6	23	23.5
27, 28 years	40	31.7	33	33.7	.276
29, 30 years	33	26.2	33	33.7
>30 years	22	17.5	9	9.2
Professional working experience as a resident
	3.98		3.81
Mean	[4.58] [1–16,,24,25–31]		[5.43] [1–16,,24,25–36]
[SD] [min – max]		18.3	19	19.4
1 year	23	23.0	23	23.5
2 years	29	19.0	18	18.4	.448
3 years	24	11.9	19	19.4
4 years	15	27.8	19	19.4
5+ years	35
Marital status
Married	57	45.2	43	43.9	.839
Single	69	54.8	55	56.1
Total	126	100	98	100

3.2. Evaluation of the adherence of resident physicians to infection control and prevention of COVID-19 by comparing the first and second years of the pandemic

Table 2 presents knowledge – attitude answers related to the awareness of residents regarding infection control of and prevention against COVID-19. Remembering the correct order of the removal of personal protective equipment [PPE] [gloves, goggles, scrubs, mask] [p = 0.001], to evaluate possible infection symptoms in patients hospitalized for non-COVID-19 reasons [p = 0.013], and behaving by the short-term isolation measures recommended by the authorities for all patients [p = 0.02] decreased during the second year of the pandemic compared to the first year, and the differences between the groups were found statistically significant [Table 2]. During the first year of the pandemic [Group 1], the residents reported using highly protective masks together with surgical masks, but during the second year [Group 2], use of surgical masks alone increased [p = 0.015]. Furthermore, difficulty procuring PPE was more frequent during the second year of the pandemic [p = 0.046].

Table 2. Residents’ knowledge and attitudes regarding infection control and prevention of COVID-19 during the first year [Group 1] and second year [Group 2] of the pandemic.

	Group 1		Group 2		p
	n	%^a	n	%
(1) Remembering the correct order of wearing PPE^b [scrubs, mask, goggles, gloves]	77	61.1	59	60.2	.890
(2) Remembering the correct order of removing PPE [gloves, goggles, scrubs, mask]	76	60.3	36	36.7	.001
(3) Questioning symptoms and exposure to COVID-19 in hospitalized patients	103	81.7	66	67.3	.013
(4) Thinking that he/she had asked about all symptoms during symptom questioning	80	63.5	62	63.3	.972
(5) Daily repetition of symptom questioning until the end of hospitalization	32	25.4	36	36.7	.067
(6) Patients being admitted into single rooms in the clinic at which the resident works	48	38.1	23	23.5	.02
(7) Watching the videos found on the hospital website regarding the order of wearing and removing PPE	69	54.8	44	44.9	.143
(8) Difficulty procuring PPE	23	18.3	29	29.6	.046
(9) Reliably finding PPE provided by the hospital	77	61.1	61	62.2	.863
(10) Mask used in the polyclinic
Surgical mask only	44	34.9	47	48.0
Two surgical masks only	40	31.7	29	29.6	.015^c
Mask with high protection only	13	10.3	14	14.3
Surgical mask + mask with high protection	29	23.0	8	8.2
Total	126	100.0	98	100.0

Note: ^a PPE: Personal protective equipment.

^aNumber and percentage for only the answer ‘Yes’ were given.

^bFactor providing significance as a result of post-hoc Bonferroni test; mask with high protective + surgical mask use increased in Group 1 and surgical mask use increased in Group 2.

3.3. Examination of participants’ general information about COVID-19 management - “treatment” and “mask selection”

Residents were questioned regarding general information on COVID-19 according to two headings [Table 3]. Under the first heading, the opinions of the participants on the efficiency of the drugs used in treating COVID-19 were evaluated on a scale of 1 to 5. Among the treatment options, favipiravir [p < 0.001], remdesivir [p < 0.001], chloroquine [p < 0.002], and plasma application were found to be more effective by the participants of Group 1, and the difference was statistically significant. Under the second heading, residents were questioned regarding indications to use highly protective masks. Compared to the first year of the pandemic [Group 1], the rate of residents indicating that highly protective masks should be worn during patient examination [p < 0.041] and in the event of contact with cases receiving 5 L/min oxygen [p = 0.001] was statistically higher during the second year of the pandemic [Group 2].

Table 3. Evaluation of residents’ opinions on general information regarding COVID-19.

	Group 1		Group 2		p
	M	SD	M	SD
Drugs are effective
Favipiravir	3.92	1.24	2.43	1.71	<.001
Remdesivir	3.12	1.50	1.83	1.46	<.001
Immunomodulator	3.19	1.59	3.11	1.80	.731
Plasma	3.40	1.52	2.12	1.56	<.001
Steroid	3.99	1.26	4.29	1.26	.085
Chloroquine	1.83	1.24	1.36	0.98	.002
	Group 1		Group 2
	n	%^a	n	%^a	p
Indications to use highly protective masks
During patient examination	27	21.4	32	32.7	.041
Intubation	99	78.6	79	80.6	.741
Bronchoscopy	102	81.0	78	79.6	.799
Endoscopy	93	73.8	73 [	74.5	.908
Respiratory function test	81	64.3	81	64.3	.522
Cases receiving 5 L/min oxygen	32	25.4	48	49.0	<.001
Aspiration	96	76.2	76	77.6	.811
Taking samples for COVID	96	76.2	63	64.3	.055
Every time in the hospital	29	23	31	31.6	.172

Note: ^aMore than one option was selected.

3.4. Analysis of awareness of infection control and prevention measures against COVID-19 by descriptive variables

When sexes were compared across both groups, awareness regarding infection control and prevention measures against COVID-19 decreased significantly in female residents during the second year of the pandemic [Table 4]. According to the clinics at which the residents worked, the residents working at internal clinics had a higher level of awareness regarding infection control and prevention measures against COVID-19 during the first year of the pandemic [Group 1] [p = 0.05]; however, when the first and second years of the pandemic were compared, this awareness decreased in the second year [Group 2] [p = 0.013]. When age distribution was taken into consideration, we found that awareness regarding infection control and prevention measures against COVID-19 was similar among age groups; however, when Group 1 [first year] was compared to Group 2 [second year], the awareness decreased in residents aged 28 years and over in the second year of the pandemic [p = 0.029]. Being experienced in the profession did not cause a change in the awareness regarding infection control and prevention measures against COVID-19. Nonetheless, the awareness of residents with more than two years of professional experience decreased in the second year [Group 2] of the pandemic [p = 0.002]. The awareness regarding infection control and prevention measures against COVID-19 of those who had not worked in a COVID-19 clinic decreased significantly in the second year [Group 2] of the pandemic [p = 0.003]. Again, when residents who had not worked in a COVID-19 clinic were compared, their awareness was found to be lower in the second year [Group 2] of the pandemic compared to the first [Group 1] [p = 0.001].

Table 4. Gap analysis according to the descriptive variables of residents’ awareness regarding infection control and prevention measures against COVID-19 in the first [Group 1] and second [Group 2] years of the pandemic.

	Group 1 Infection Control and Prevention Awareness Score		Group 2 Infection Control and Prevention Awareness Score		p
	M	SD	M	SD
Sex
Female	5.97	2.42	5.05	2.07	.037
Male	5.89	2.11	5.27	1.77	.106
p	.849		.580
Department
Surgical	5.29	2.13	4.89	1.88	.324
Internal	6.42	2.24	5.43	1.97	.013
p	.005		.171
Age
28 years and under	6.03	2.24	5.18	2.03	.029
28 years and over	5.80	2.29	5.17	1.83	.145
p	.576		.976
Professional working
experience
2 years and less	5.48	2.24	5.19	2.20	.530
2 years and more	6.24	1.73	5.16	1.73	.002
p	.062		.940
Working in COVID clinic
Yes	5.80	2.13	5.60	1.79	.534
No	6.46	2.72	4.40	1.97	.001
p	.202		.003
Marital status
Married	5.63	2.24	5.09	2.00	.216
Single	6.17	2.26	5.24	1.90	.015
p	.180		.718
Total	5.93	2.26	5.17	1.94	.009

Marital status was not found affect awareness regarding infection control and prevention measures against COVID-19. However, awareness decreased in the second year of the pandemic [Group 2] in the unmarried resident group [p = 0.015].

4. Discussion

Physicians struggled to execute proper patient management and prevent within a rapidly developing COVID-19 pandemic context while trying to align needed practices to constantly changing and updating information. Our study aimed to evaluate the effects of the long and dynamic pandemic process on physicians’ knowledge levels, awareness, and compliance with protective, infection control, and prevention measures.

This study’s findings suggest that residents’ conformity to infection control and prevention measures mainly decreased in the second year of the pandemic. Despite continuing education during the pandemic and increased experience working in COVID-19 clinics, it was found that our assistants lacked general knowledge about COVID-19. It is known that conformity to infection control and prevention measures in the management of all infectious diseases is fundamental. Within this scope, we periodically compared and analyzed the responses of residents.

Our study found no difference between the groups in descriptive characteristics such as age, sex, marital status, professional experience, and the department where they worked [internal/surgical]. However, the rate of having been assigned to a COVID-19 clinic among the residents was found to be higher in the early period of the pandemic compared to the second year. We believe that this is related to the development and widespread use of vaccines, which provided a decrease in the number of COVID-19 cases, and as a result of the normalization process, the residents returned to non – COVID-19 clinics [18]. It is important for physicians to thoroughly understand possible infection routes and protection methods. In our hospital, we provided trainings oriented toward infection control and prevention measures within the scope of preparations before the COVID-19 pandemic and in line with the guidelines updated during the pandemic. Despite regular and continuous trainings, we detected that the rate of removing PPE in the correct order decreased in the second year of the pandemic compared to the first year. In a study conducted in a university hospital in Germany that tracked PPE conformity, it was reported that there were shortcomings in PPE use [correctly wearing and removing PPE] despite high awareness regarding the dangers of SARS-CoV-2 [19]. Similar to our study, Phan et al. also determined that 52% of healthcare workers remove PPE in the wrong order [20]. In many studies investigating PPE performance, the low conformity rate of healthcare workers with different professional roles including physicians is notable [21–23]. Research has reported that factors such as negligence, lack of knowledge, doubting the quality and effectiveness of PPE, disbelief in using PPE, and personal traits are associated with PPE unconformity [22–24]. Gurses et al. concluded that the safe removal of PPE includes the order and technique of removal as well as the necessary knowledge, skills, and attitudes [17]. PPE conformity in our study was found to be low despite continuous training and education. Particularly in the second year of the pandemic, correctly remembering the order of removing PPE dropped to 36.7%. This data points to the fact that the reasons for decreasing PPE conformity should be identified. Again, our findings suggest that trainings to develop the skills and attitudes to motivate healthcare workers to use PPE in the right order and with the correct techniques that are more comprehensive than those used today are needed. These results also support that the traditional medical education process is insufficient and that problem-based teaching should be developed with mechanisms such as continuing education and board certification. In both studies conducted in China and Greece, a low level of knowledge among healthcare professionals was identified as a significant risk factor for failure to follow infection control measures [25,26].

One of the most important methods to prevent the transmission of SARS-CoV-2 is the continuous reevaluation and monitoring for epidemiological (such as close contacts and being in the affected area) and clinical criteria (signs and symptoms of infection) for a COVID-19 [13]. In our study, residents’ rate of questioning COVID-19 exposure and symptoms in hospitalized patients for non-COVID-19 reasons were low. In a study by Bucakcı et al., the nonadherence of individuals to personal protective behavior was found to be associated with personal psychosocial attributes that lead to the weakening of risk perceptions [27]. We are of the opinion that the main reason for this is desensitization, which emerges as a marker of mental and physical exhaustion due to the prolonged COVID-19 pandemic [28,29]. In a study by Kılıç et al. evaluating only physicians, the desensitization scores of physicians, particularly those directly serving COVID-19 patients, were found to be significantly higher during the pandemic compared to the pre-pandemic period [30]. Again, a study has reported that differences between healthcare workers also result from the qualities of personal behaviors oriented toward infection risk [31]. In conclusion, adequate knowledge does not always predict effective infection control and prevention practices.

The guidelines Republic of Turkey Ministry of Health recommend that patient rooms are rearranged to be single rooms to decrease infection risk in non – COVID-19 wards [13,18]. However, the rate of implementing this recommendation by residents decreased significantly in the second year of the pandemic compared to the first year. Various studies have determined factors decreasing conformity to be inappropriate physical conditions of hospitals, deficiency in supervisory hierarchies, and the inability to evaluate the potential risk of the transmission [32,33]. In our hospital, the physical conditions and the increase in the number of patients after the beginning of the normalization process may have had negative effects on assuring and maintaining recommended organizational changes. Another instance where institutional policy has been reflected in the pandemic process is in the difficulty procuring personal protective equipment. Other studies support that this difficulty is related to the strategy for the limited use of resources due to the uncertainty and insecurity brought about by the protracted pandemic process [34,35]. Although this strategy sounds meaningful when there is a limited number of PPE, we believe that hospitals need to be more prepared for epidemic and pandemic conditions.

Despite being underlined many times in trainings, mask selection in the polyclinic was found to have contradicted the recommendations on appropriate mask use. While residents preferred using highly protective masks and surgical mask togethers during the first year of the pandemic, surgical masks alone were preferred more in the second year of the pandemic. Studies on this subject indicate that mask preference is associated with social, cultural, political, ethical, and and personal health and non-health related concerns [36]. Nevertheless, the uncertainty regarding COVID-19, the rise in the number of cases, and the fact that there was no efficient vaccine during the early pandemic period may have caused the residents to wear highly protective masks and surgical masks together. Moreover, COVID-19 can trigger anxiety disorder and negatively affect knowledge, attitudes, and practices regarding health habits [,37].

The opinions of the residents regarding general information on COVID-19 were questioned under two headings, the first being the efficiency of the drugs used in treating COVID-19 and the second being the indications to use highly protective masks. Participants found favipiravir, remdesivir, plasma, and chloroquine treatments to be less effective in the second year of the pandemic. In a study by [38] it was reported that therapeutic choices differ throughout time due to comparative clinical outcomes that have emerged during the pandemic. Treatment decisions must be based on the best possible evidence; however, several drugs were used in the first year of the pandemic despite weak or no evidence regarding their clinical efficacy [39,40]. In this unprecedented emergency situation, therapeutic attitudes have been polarized as rational and emotional. While some physicians have shown a tendency towards applying various treatments, underpinned by ‘to do something’ principles, others have adopted a more skeptical attitudes and approaches, while advocating for a more evidence-based approach. Martinez et al, established that physicians’ specialties, quality of COVID-19 publications, sex, geographical origin, and participation in medical research affected their therapeutic choices [41]. Similar to previous studies, our results can be associated with the information storm that the medical community faced during the pandemic [42].

The key component of infection control and prevention strategy is the adequate use of PPE (such as maska) when COVID-19 is suspected or verified [12]. The use of highly protective masks, especially during aerosol-producing procedures is recommended [43]. Knowing the difference of protective equipment related to their role in protection against aerosols allows for healthcare workers to select the correct protection type needed [44]. In our study, residents in both groups believed that highly protective masks should be used during aerosol-producing procedures. However, using highly protective masks in the event of contact with patients who require oxygen support was found to be low during the first year of the pandemic and under 50% during both pandemic periods of the present study. Again, residents were unlikely to agree that using highly protective masks during routine patient examinations was indicated; however, this belief was higher in the late period of the pandemic [32%]. Despite trainings continuing throughout the pandemic and the increased experience while working in COVID-19 clinics, the general knowledge of our residents regarding COVID-19 was found to be lacking. Similar to a study in Bangladesh, these findings point to the need for appropriate educational programs and preventive actions to help medical professionals gain confidence in adequately treating their patients [3]. Our results showed that more effort is needed to train and support healthcare workers in the optimal use of PPE and sufficient management of aerosol-producing procedures.

In the last part of our study, we investigated the effect of the descriptive characteristics of the residents on the infection control of and prevention scores regarding COVID-19 during the first and second years of the pandemic. Infection control and prevention scores dropped in female residents, those under the age of 28 years, those with more than two years of professional experience, those not working in COVID-19 clinics, and those who were not married. When examining the relevant literature, we found no similar study. However, in studies conducted without considering the first or second year of the pandemic, a positive correlation was reported between control and prevention scores for COVID-19 and female sex, age, professional experience, and having worked in a COVID-19 clinic [10,44,45]. Nonetheless, our study showed that the prolonged pandemic process has changed the positive correlation previously detected and even decreased it.

To the best of our knowledge, this is the first study to investigate the effect of the prolonged pandemic process on physicians’ knowledge, attitudes, and related measures by comparing them with a one-year interval. Many studies conducted during the pandemic have shown that health workers’ good knowledge was positively associated with attitudes and practices [46,47]. However, our analysis revealed that, unlike other studies, residents’ commitment to infection control and prevention practices decreased during the pandemic despite continuing education efforts. Thus, we have determined that good knowledge does not predict good infection control and prevention practices.

So, what could have been the reasons for this result? Two factors in particular, the ineffectiveness of education and psychological reasons, may have led to these results. We want to draw attention to the fact that the results of our study, unlike other studies, point to essential deficiencies in professional development. In addition to going through a lengthy medical education process, the negative relationship between the knowledge and practices of resident doctors exposed to intensive and regular in-service training may be related to inadequate in-service training.

Anxiety disorders such as burnout or anxiety that occur with the prolongation of the pandemic process can negatively affect the performance of healthcare professionals. Ironically, psychological resilience highlights the beneficial link between stress and adaptation [28]. In general, we think that in coping with COVID-19, optimal pressure may be stimulating, but maximum exposure may have detrimental effects on the adaptation mechanisms of modern society.

As a result, physicians’ knowledge, attitudes, and practices about infectious diseases can affect the severity, the extent of their spread, and the overall mortality rate. Education is the most critical mechanism that changes and develops knowledge, attitudes, and practices. For example, in the 2003 SARS epidemic, lower anxiety levels were associated with higher knowledge and positive attitudes towards infectious disease transmission. Effective education can overcome psychological barriers [48]. In addition, effective training can contribute to developing conceptual frameworks and increase individuals’ ability to work without being influenced by their feelings and thoughts. Besides educational suggestions, assistants should also be supported socially. The work schedule and the continuity of a comfortable environment should not be ignored, which will prevent the emergence of burnout.

Due to the changing nature of infectious agents and society, it is vital and urgent to prioritize studies to increase the adoption and adherence to infection control and prevention measures.

5. Strengths and limitations

The study’s strength is the application of the survey instrument over a two-time period. This method has shown us that good knowledge is not enough. Another strength of the study is the subject of the research because adherence to infection control and precautions is a current and vital issue and is not limited to the COVID-19 pandemic.

Our study has some limitations due to pandemic conditions. The first is the low number of participants. Assistants working in clinics and polyclinics actively participated in the study. In the first period, 60.8% of 207 residents and 49.7% of 197 residents in the second period participated in the study. The busy work pace and different timelines may have contributed to this situation. Another limitation of the study is that it is not known whether there is an overlap between the participants in Group 1 and Group 2.

To prevent the social tendency to give the desired answer, name and surname information is not taken, participation is optional, and the number of actively working assistants varies (taking leave due to illness, etc.) are significant limitations in the design of the groups. Due to this limitation, the probability of the same residents participating in the study is unknown.

6. Conclusions

Analyzes revealed that residents’ commitment to infection control and prevention practices decreased during the pandemic despite continuing education efforts. The knowledge, attitudes, and practices of physicians about infectious diseases can affect the severity of the disease, the extent of its spread, and the overall mortality rate. Implications for clinical practice or policy,

• Identifying and preventing the factors contributing to this predicament should be the goal (For example, psychosocial that affect risk perception, physical and mental exhaustion, and institutional structure and processes).

• It shows a need for a new education system that motivates the use of knowledge and develops skills and attitudes during the routine clinical practice of doctors.

• Infection prevention, and control are the most basic methods of limiting the spread of infections which might become of even greater concern in the near future (due to the changing nature of infectious agents as well as the society). For this reason, it is vital and urgent to prioritize studies to increase adoption and adherence of all health professionals with infection control and prevention measures. Having in mind the complexity of the relationship between knowledge, attitudes and behavior, such efforts should ultimately seek to align personal with professional selves, that is, aim to foster a development of a proper kind of physicians’ identity [49].

Disclosure statement

No potential conflict of interest was reported by the authors.

Additional information

Funding

The author(s) reported there is no funding associated with the work featured in this article.