A Survey of the Healthcare Workers in Afghanistan during the COVID-19 Pandemic

Abstract. Healthcare workers (HCWs) in Afghanistan faced many challenges during the COVID-19 pandemic. A cross-sectional, online survey was conducted from July 4, 2020 to July 12, 2020 to evaluate the working conditions and health situation of HCWs in Afghanistan during the pandemic. Healthcare workers from 34 provinces, who were actively working in Afghan hospitals, were invited to participate in this study; 925 HCWs completed the survey. The results showed that 85% of the HCWs participated in the study were tested positive for COVID-19. This highlights the critical need of HCWs for personal protective equipment when caring for suspected and/or confirmed cases of the COVID-19.


INTRODUCTION
COVID-19 emerged from Wuhan, China, in December 2019 and has spread to almost all countries throughout the globe, with numerous new cases/deaths being reported every day. 1 Scientific evidence shows that COVID-19 is being transmitted between people in close contact by air droplets. 2 Globally, as of July 12, 2020, there were 12,401,262 confirmed cases of COVID-19, including 559,047 deaths reported by the WHO. 3 In Afghanistan, the first positive case of COVID-19 was reported from Herat Province on February 24, 2020. It was a 35year-old man who had recently visited Qom, Iran. 4 A few days later, the highly contagious virus was found to have spread to several other locations within the country. As of July 2020, a total of 35,526 cases and 1,185 deaths due to COVID-19 have been confirmed in Afghanistan. 5 It is said that the actual figures of the infected cases and deaths could be higher than what is reported. 6 Healthcare workers (HCWs), due to the inherent nature of their profession, are at particularly high risk of catching COVID-19 infection. As of July 2020, the United Nations announced that worldwide more than 1.4 million infections of COVID-19 were accounted for in HCWs; this was 10% of all cases. 7 Afghanistan has an estimated population of 31.6 million. Among them are about 9.4 skilled HCWs and 1.9 physicians, per 10,000 inhabitants. They are unevenly distributed across the country and face many challenges. 8 Because of inadequate government support and lacking personal protective equipment (PPE), HCWs in Afghanistan got infected with COVID-19 and lost their lives in disproportionately large numbers. 9 The crosssectional survey presented here aimed at evaluating the working conditions and health situation of HCWs in Afghanistan during the COVID-19 pandemic in the month of July 2020.

MATERIALS AND METHODS
This was a cross-sectional online survey conducted among HCWs in Afghanistan. A 10-item questionnaire was developed and distributed using SurveyMonkey. Participants were recruited through social media (Facebook and WhatsApp) from an existing association of Afghan HCWs. The questionnaire was delivered in English as the targeted study participants could understand English. Those who volunteered to answer the questionnaire were allowed to complete it only once and were given the opportunity to terminate it at any time within the study period. The survey was anonymous, and the data provided by the participants were kept confidential. An introductory paragraph described the aim of the study, and an informed consent was obtained from the participants. The survey was prepared by the members of the Department of Microbiology of Kabul University of Medical Sciences. The questionnaire was developed to assess the participants' behavior regarding personal safety and their concern during the COVID-19 pandemic.
Three items of the questionnaire addressed demographic information. This included, gender (male and female), age in categories (18-24, 25-34, 35-44, 45-54, 55, or > 55 years) and occupation (medical specialist, medical trainee, dentist, nurse, midwife, anesthesiologist, laboratory technician, physiotherapist, administration staff, and other healthcare professionals). The questionnaire enquired about monthly salary of HCWs from less than 10,000 AFG/130 USD up to more than 50,000 AFG/650 USD. Other questions addressed access to PPE (disposable gloves, gowns, masks, N95 masks, facial protective shields, and safety glasses) and asked whether the respondents/HCWs provided for personal safety through their own finances, whether medical staff had sufficient knowledge about COVID-19, whether they were tested positive for COVID-19, and what clinical symptoms (fever, cough, respiratory distress, sore throat, runny nose, loss of sense of smell and taste, fatigue, headache, muscle pain, ocular pain, and others) they experienced. The questionnaire also asked about their satisfaction with their local health authorities and about other main concerns they had. Descriptive statistics, frequencies, and percentages were used to summarize the data.

DISCUSSION
To the best of our knowledge, this is the first cross-sectional survey conducted among HCWs in Afghanistan. In this online survey, 925 HCWs participated from across the country. Most respondents were medical trainees and specialists actively working in Afghan hospitals. This study indicates that more than half of the participants (68%) provided basic PPE using their own money, whereas only 14% received PPE from relevant government bodies. This could highlight the critical lack of PPE for the frontliners in the fight against COVID-19. The perception of the HCWs about limited support and supplies from public health authorities and medical institutions in regard to their personal safety suggests that improvement is needed in these areas. Moreover, 82% of the HCWs expressed that they earned less than 40,000 AFG/520 USD salary/month for a full-time employment in a government hospital. Even with such limited salary, Afghan HCWs had to purchase their PPE from their personal budget. In addition, almost one-third (31%) of the HCWs declared that their monthly salaries were not paid on time. This could further aggravate the situation, particularly in a place where most HCWs should pay for their PPE.
A notable finding of the study was that more than threequarters (85%) of the HCWs were tested positive for COVID-19. This shows an alarmingly high rate of the infection among HCWs (Figure 1) . This could possibly be because of scarcity of PPE in hospital environments for HCWs and massive exposure of people to COVID-19. This study highlights the reality and perceptions about the safety and resources available for   Participants were asked to answer very specific questions that might not cover all issues involved in the complex situation of the personal safety of HCWs. Regarding statistics, no power calculations were undertaken before the beginning of this survey. However, by definition, its purpose was descriptive only. Moreover, because of the limited number of COVID-19 test centers in Afghanistan, it was difficult to assess the accuracy of test results and infection rates.

CONCLUSION
The protection and support of HCWs are supposed to be public health priorities, particularly during a pandemic. In this survey, we report an alarmingly high rate of COVID-19 infection among HCWs and highly limited access to essential PPE during the COVID-19 pandemic in Afghanistan. It highlights that any possible resources should be made available for them urgently to protect themselves, stay healthy, and able to continue caring for patients.