Initial risk perception and feeling of preparedness of primary care physicians regarding the COVID-19 pandemic in Belgium, France and Spain in February 2020

doi:10.21203/rs.3.rs-371058/v1

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Initial risk perception and feeling of preparedness of primary care physicians regarding the COVID-19 pandemic in Belgium, France and Spain in February 2020

https://doi.org/10.21203/rs.3.rs-371058/v1

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published 23 Jan, 2022

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Background

The knowledge of risk perceptions in primary care could help health authorities to manage epidemics.

Methods

A European multi-center study was conducted in France, Belgium and Spain to describe the perceptions, the level of anxiety and the feeling of preparedness of primary healthcare physicians towards the COVID-19 infection at the beginning of the pandemic. The factors associated with the feeling of preparedness were studied using multivariate logistic regressions.

Results

A total of 511 physicians participated to the study. Among them, only 16.3% (n = 82) were highly anxious about the pandemic, 50.6% (n = 254) had the feeling to have a high level of information, 80.5% (n = 409) found the measures taken by the health authorities suitable to limit the spread of COVID-19, and 45.2% (n = 229) felt prepared to face the epidemic. Factors associated with feeling prepared were: being a Spanish practitioner (adjusted OR = 4.34; 95%CI [2.47; 7.80]), being a man (aOR = 2.57, 95%CI [1.69; 3.96]), finding the measures taken by authorities appropriate (aOR = 1.72, 95%CI [1.01; 3.00]) and being highly informed (aOR = 4.82, 95%CI [2.62; 9.19]).

Conclusions

Regarding the dramatic evolution of the pandemic in Europe in the weeks following the study, it appears that information available at this time and transmitted to the physicians could have given a wrong assessment of the spread and the severity of the disease. It seems essential to better integrate the primary care physicians into the information, training and protection channels. A comparison between countries could help to select the most effective measures in terms of information and communication.

General Practice

Infectious Diseases

Primary Health Care

COVID-19

Pandemic

Anxiety

Health information Management

Sentinel Surveillance

At the end of 2019, a new coronavirus (SARS-CoV-2), causing respiratory infections (COVID-19), emerged in China and further spread worldwide [1]. The number of reported cases increased steadily in Europe at the beginning of March 2020 [2], generating fears and anxiety among the general population and health care workers [3-5].

Previous health crisis due to coronaviruses (SARS in 2002/2003, MERS-CoV in 2012), or other infectious diseases (H1N1 pandemic influenza in 2009, Ebola in 2014) have shown the importance of collecting feedback of healthcare professionals [6-8]. Indeed, knowledge of primary healthcare professionals’ perceptions and behavior represents an essential tool for health authorities to implement control measures and communication campaigns [9]. Knowing perceptions and behavior at the beginning of the pandemic is particularly relevant as it enables health authorities to adapt and specifically target their actions.

Here we describe the perceptions, anxiety and feeling of preparedness of primary healthcare physicians towards the COVID-19 infection at the beginning of the pandemic in Europe, in three European countries: Belgium, France, and Spain.

A cross-sectional study was carried out in February-March 2020 among all the primary care physicians involved in European sentinel surveillance networks: “Sciensano” (Belgium), “Réseau Sentinelles” (France), and “Red Centinela Sanitaria” (Castile and León, Spain). The participants included were general practitioners (GPs) and pediatricians (only in Spain).

The questionnaire was built according to the literature [10, 11]. It addressed topics on anxiety due to the ongoing pandemic, practices’ changes, information received from health authorities, anticipated preparation measures, and feeling of preparedness. Electronic surveys were available from 14 to 27 February 2020 in France, from 19 to 28 February 2020 in Belgium and from 20 February to 2 March 2020 in Spain.

The level of anxiety was measured by a scale from 0 (no anxiety) to 10 (major anxiety), and classified into low (≤2), moderate (3 to 6) and high (≥7). The level of information about the pandemic was evaluated through a score based on the perceived knowledge about four topics: the epidemic situation in China, the risk for the local population, the case definition and the management of suspected cases. Physicians were considered as poorly (n<2 topics), moderately (n=2-3) or highly (n=4) informed.

Pearson's chi-squared test and Fisher's exact test were used for estimating the p-value of qualitative variables, and Kruskal-Wallis rank sum test for quantitative ones. The factors associated with the feeling of preparedness were studied using univariate and multivariate logistic regressions. The multivariate analysis was performed using a backward elimination procedure until all variables reached statistical significance (p≤0.05). Statistical analyses were performed using the R software version 3.5.0 [12].

Perception and preparedness of primary care physicians at the beginning of the COVID-19 pandemic

The electronic survey was filled by 35.2% (511/1450) of the investigated healthcare practitioners. Participating physicians were distributed as followed: 12.1% (n=62) from Belgium, 67.1% (n=343) from France and 20.8% (n=106) from Spain. Men represented 57.4% (n=292), median age was 56 years (IQR [42; 62]), and 70.7% (n=359) were working in urban areas (Table 1).

Table 1. Characteristics of primary care physicians by country

	Total N (%) N=511	Belgium N (%) N=62	France N (%) N=343	Spain N (%) N=106	p-value
Participation
Targeted physicians	1450	98	1224	128
Respondents	511 (35.2%)	62 (63.3%)	343 (28.0%)	106 (82.8%)
Type of physicians (m.d.=0)
General Practitioners	491 (96.1%)	62 (100%)	343 (100%)	86 (81.1%)
Pediatricians	20 (3.9%)	0	0	20 (18.9%)
Sex (m.d.=2)
Female	217 (42.6%)	26 (41.9%)	131 (38.2%)	60 (57.7%)	<10^-2
Male	292 (57.4%)	36 (58.1%)	212 (61.8%)	44 (42.3%)	<10^-2
Age (years) (m.d.=9)
25-39	106 (21.1%)	3 (4.8%)	100 (29.9%)	3 (2.9%)	<10^-5
40-54	114 (22.7%)	9 (14.5%)	84 (25.1%)	21 (20%)
≥ 55	282 (56.2%)	50 (80.6%)	151 (45.1%)	81 (77.1%)
Median (IQR)	56 (42; 62)	61 (56; 65)	52 (37; 60)	60 (55; 62)	<10^-5
Practice area (m.d.=3)
Rural	149 (29.3%)	22 (35.5%)	79 (23%)	48 (46.6%)	<10^-4
Urban	359 (70.7%)	40 (64.5%)	264 (77%)	55 (53.4%)	<10^-4
Physicians’ anxiety (m.d.=7)
Low anxiety feeling	176 (34.9%)	24 (38.7%)	140 (41.3%)	12 (11.7%)	<10^-5
Moderate anxiety feeling	246 (48.8%)	28 (45.2%)	164 (48.4%)	54 (52.4%)
High anxiety feeling	82 (16.3%)	10 (16.1%)	35 (10.3%)	37 (35.9%)
Median (IQR)	4 (2; 6)	3 (2; 6)	3 (2; 5)	6 (4; 7)	<10^-5
Patients’ anxiety (m.d.=4)
Low anxiety feeling	107 (21.1%)	13 (21%)	73 (21.3%)	21 (20.4%)	0.85
Moderate anxiety feeling	286 (56.4%)	38 (61.3%)	188 (55%)	60 (58.3%)
High anxiety feeling	114 (22.5%)	11 (17.7%)	81 (23.7%)	22 (21.4%)
Median (IQR)	4 (3; 6)	5 (3; 6)	5 (3; 6)	4 (3; 6)	0.89
Risk of seeing infected patients in the next 2 weeks (m.d.=3)
Low risk	400 (78.7%)	46 (74.2%)	295 (86%)	59 (57.3%)	<10^-5
Moderate risk	97 (19.1%)	15 (24.2%)	46 (13.4%)	36 (35%)
High risk	11 (2.2%)	1 (1.6%)	2 (0.6%)	8 (7.8%)
Median (IQR)	1 (0; 2)	1 (1; 3)	1 (0; 2)	2 (1; 5)	<10^-5
Finding the measures taken by the health authorities suitable to limit the spread of COVID-19 (m.d.=3)	409 (80.5%)	51 (82.3%)	275 (80.2%)	83 (80.6%)	0.93
Changes in professional practices (m.d.=4)	207 (40.8%)	30 (48.4%)	124 (36.3%)	53 (51.5%)	<10^-2
Impact on consultations (m.d.=3)	72 (14.2%)	8 (12.9%)	39 (11.4%)	25 (24.3%)	<10^-2
Types of consequences (m.d.=5)
Questions about any links with China during consultations	44 (61.1%)	4 (50%)	19 (48.7%)	21 (84%)
Increased consultation time due to question about COVID-19	22 (30.6%)	1 (12.5%)	14 (35.9%)	7 (28%)
Specific consultations for information on COVID-19	6 (8.3%)	0	1 (2.6%)	5 (20%)
Phone calls on COVID-19	6 (8.3%)	2 (25%)	3 (7.7%)	1 (4%)
Consultations of patients who thought they had contracted COVID-19	6 (8.3%)	1 (12.5%)	4 (10.3%)	1 (4%)
Anticipation of the epidemic arrival (m.d.=3)	337 (66.3%)	40 (64.5%)	200 (58.3%)	97 (94.2%)	<10^-5
Types of anticipation measures (m.d. =32)
Search of guidelines	205 (60.8%)	33 (82.5%)	113 (56.5%)	59 (60.8%)
Purchase of protection equipment	122 (36.2%)	4 (10%)	63 (31.5%)	55 (56.7%)
Re-use of the influenza pandemic kits	106 (35.7%)	N.A.	80 (40%)	26 (26.8%)
Office reorganization to avoid patients’ influx	60 (17.8%)	9 (22.5%)	34 (17%)	17 (17.5%)
Other measures	13 (3.9%)	1 (2.5%)	9 (4.5%)	3 (3.1%)
Level of information regarding the epidemic (m.d.=9)
Low information level	80 (16.3%)	6 (9.6%)	59 (17.5%)	15 (14.6%)	0.05
Moderate information level	168 (33.5%)	14 (22.6%)	120 (35.6%)	34 (33,0%)
High information level	254 (50.6%)	42 (67.7%)	158 (46.9%)	54 (52.4%)
Feeling prepared to face the epidemic (m.d.=4)	229 (45.2%)	28 (45.2%)	139 (40.6%)	62 (60.2%)	<10^-2

m.d.: missing data; IQR: interquartile range; N.A.: not available

Only 16.3% of physicians (n=82) were highly worried about the COVID-19 pandemic, 80.5% (n=409) found the measures taken by the health authorities appropriate to control its spread, and 40.8% (n=207) had made changes in their professional practices (Table 1). The most frequent changes were “increased oral information given to patients about COVID-19” (60.4%, n=125), “increased handwashing or hand sanitizing” (49.8%, n=103), and “increased frequency of disinfection” (23.7%, n=49) (Figure 1). Physicians reported impacts on their consultations (like an increase in time) for 14.2% of them (n=72), and 66.3% (n=337) had started anticipating the epidemic arrival. The main anticipation measures were the research of action guidelines (60.8%, n=205) and the purchase of protection equipment (36.2%, n=122).

Half of the physicians (50.6%, n=254) felt they received clear information from health authorities overall. For 90.6% (n=454), the main source of information consisted of emails sent by health authorities (Figure 2).

Factors associated with preparedness

Less than half of primary care physicians (45.2%, n=229) felt prepared for the epidemic arrival, ranging from 40.6% (139/342) in France to 60.2% (62/103) in Spain. Factors positively associated with feeling prepared were: being a Spanish practitioner (adjusted odds ratio (aOR)=4.34; 95% confidence interval (CI) [2.47; 7.80]), being a man (aOR=2.57, 95%CI [1.69; 3.96]), finding the measures taken by authorities appropriate (aOR=1.72, 95%CI [1.01; 3.00]) and being highly informed (aOR=4.82, 95%CI [2.62; 9.19]). Factors negatively associated were: being moderately (aOR=0.34; 95%CI [0.21; 0.53]) or highly worried (aOR=0.27; 95%CI [0.14; 0.52]) (Table 2).

Table 2. Factors associated with the feeling of preparedness among primary care physicians (univariate and multivariate analyses)

		n	Feeling prepared	OR [95% CI] Univariate analysis	p-value	OR [95% CI] Multivariate analysis	p-value
Age	25-39	105	43 (41.0%)	Ref.	0.01
	40-54	114	39 (34.2%)	0.76 [0.44;1.32]
	≥ 55	278	142 (51.1%)	1.53 [0.97;2.42]
Country	France	342	139 (40.6%)	Ref.	0.01	Ref.	<10^-5
	Belgium	62	28 (45.2%)	1.2 [0.69;2.07]		0.94 [0.5;1.75]
	Spain	103	62 (60.2%)	2.21 [1.41;3.48]		4.34 [2.47;7.8]
Sex	Female	216	78 (36.1%)	Ref.	0.001	Ref.	<10^-4
	Male	291	151 (51.9%)	1.91 [1.33;2.74]		2.57 [1.69;3.96]
Type of practice area	Rural	149	69 (46.3%)	Ref.	0.74
	Urban	358	160 (44.7%)	0.94 [0.64;1.38]	0.74
Physicians’ anxiety	Low	176	104 (59.1%)	Ref.	<10^-4	Ref.	<10^-5
	Moderate	245	93 (38.0%)	0.42 [0.28;0.63]		0.34 [0.21;0.53]
	High	82	31 (37.8%)	0.42 [0.24;0.72]		0.27 [0.14;0.52]
Patients’ anxiety	Low	107	54 (50.5%)	Ref.	0.46
	Moderate	285	126 (44.2%)	0.78 [0.5;1.21]
	High	114	49 (43.0%)	0.74 [0.43;1.26]
Risk of seeing infected patients in the next 2 weeks	Low	399	186 (46.6%)	Ref.	0.03
	Moderate	97	35 (36.1%)	0.65 [0.41;1.02]
	High	11	8 (72.7%)	3.05 [0.87;14.1]
Practice changes	No	300	131 (43.7%)	Ref.	0.39
	Yes	206	98 (47.6%)	1.17 [0.82;1.67]	0.39
Impact on consultations	No	435	191 (43.9%)	Ref.	0.16
	Yes	72	38 (52.8%)	1.43 [0.87;2.36]	0.16
Feeling response measures appropriate	No	99	32 (32.3%)	Ref.	0.01	Ref.	0.05
Feeling response measures appropriate	Yes	408	197 (48.3%)	1.95 [1.24;3.14]	0.01	1.72 [1.01;3]	0.05
Level of information	Low	80	21 (26.2%)	Ref.	< 10^-5	Ref.	< 10^-5
	Moderate	167	46 (27.5%)	1.07 [0.59;1.98]		1.02 [0.54;2]
	High	254	161 (63.4%)	4.86 [2.82;8.67]		4.82 [2.62;9.19]
Anticipation	No	171	84 (49.1%)	Ref.	0.20
	Yes	336	145 (43.2%)	0.79 [0.54;1.14]	0.20

This study enabled to identify the initial risk perceptions and the feeling of preparedness among primary care physicians from Belgium, France, and Spain when COVID-19 pandemic emerged in Europe and when only isolated cases were observed in those three countries.

At the beginning of the COVID-19 pandemic, between mid-February and the beginning of March 2020, the majority of primary care physicians investigated were little to moderately worried about the disease. As suggested by the results of the study, this could be explained by a low perceived risk of handling infected patients, the feeling to be well-informed and the trust in health authorities’ ability to implement appropriate measures to limit the spread of the disease. These results could appear to be contradictory with the predominant feeling of being insufficiently prepared to face the COVID-19 pandemic, as the physicians were not directly involved in the management of this growing epidemic. Regarding the dramatic evolution of the pandemic in Europe in the weeks following the study, it appears that the scientific data available at this time and transmitted to the physicians could have given a wrong assessment of the spread and the severity of the disease [13, 14]. A previous study had highlighted that making available an internal information channel to ensure factual, accurate, and reliable information while preventing information overload represents a key measure in increasing infectious disease preparedness [15]. With the current hindsight on the pandemic, it seems essential to better integrate the primary care physicians into the information, training and protection channels for this kind of health risk, which may be lacking at this level, unlike the hospital level, and this is could be managed by the health authorities [16].

Differences between countries concerning the level of anxiety and the feeling of preparedness were observed, with Spanish physicians feeling more anxious but more prepared. Such variations have been previously studied across countries, with Asian countries feeling more prepared than European or Northern American countries to face emerging diseases [10, 17]. However, no comparison between European countries has been undertaken. The national epidemic context was rather similar over the study period in the three countries involved in the study: 6 COVID-19 cases and 2 related-deaths were reported in France; 134 cases and no deaths in Spain; no cases or deaths in Belgium [2]. The main difference is that the study started in Spain later than in France, and was ended up one week later than in Belgium and France. The anxiety of the Spanish GPs could have been higher, as the European situation was complicated at that time (i.e. Italian situation). Also, communication regarding the epidemiological context could have been emphasized in Spain, as well as the preparation of the health services, which could contribute to the feeling of preparedness of the Spanish GPs compared with France or Belgium. A comparison could be of interest in adapting one country’s most effective public health measures in terms of information and communication to the other countries [17-19].

This study has some limitations. Physicians included are part of sentinel surveillance networks, which generate inherent biases (these professionals are more interested in research, well-informed and specially concerned with advances in clinical practice), making the results not representative of the primary care physicians in these countries. In France, the réseau Sentinelles representativeness has been previously studied, showing no particular differences regarding age and professional activities [20]. In Spain, Red Centinela Sanitaria evaluates representativeness yearly using cluster analysis and principal components analysis to ensure a good representation [21]. Finally, this cross-sectional study lacks a follow-up during this COVID-19 pandemic, which could have been particularly interesting to evaluate and adapt the guidelines and information campaigns. Repeating this study through the course of the COVID-19 pandemic, under different conditions of the epidemic and of awareness, could help identify critical aspects to be further improved.

The present study could help health authorities to define preparedness planning for primary care physicians against an emerging epidemic, and identify areas of improvement in terms of information and actions.

GPs: general practitioners

aOR: adjusted odds ratio

CI: confidence interval

Acknowledgements: We thank all the physicians participating in this study.
Funding: This study was supported by REACTing, a collaborative network of major French research institutions coordinated by Inserm. The funder had no role in study design, data collection, data analysis, data interpretation, writing of the report, or in the decision to submit this article for publication. All researchers’ decisions have been entirely independent from funders.
Conflicts of interest: The authors have no relevant financial or non-financial interests to disclose.
Ethics approval: The protocol was approved by the French Data Protection Agency (CNIL#471393) and the French ethical research committee.
Consent to participate: Consent was obtained from all individual participants included in the study. An email was sent to the physicians of the sentinel networks, with information and a link to accept or decline their participation. This procedure has been approved by the institutional review boards of the sentinel networks.
Consent for publication: Consent for publication was obtained.
Availability of data and material: Data could be requested to the authors
Code availability: not applicable
Authors’ contributions: All authors contributed to the study conception and design. Data collection and analysis were performed by Caroline Guerrisi, Bérenger Thomas, Ana-Maria Vilcu, Tomàs Vega Alonso, Ana Ordax Diez, Jose Eugenio Lozano Alonzo, Dieter van Cauteren and Sarah Moreels. The first draft of the manuscript was written by Caroline Guerrisi, Bérenger Thomas and Thierry Blanchon and all authors commented on previous versions of the manuscript. All authors read and approved the final manuscript.

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Initial risk perception and feeling of preparedness of primary care physicians regarding the COVID-19 pandemic in Belgium, France and Spain in February 2020

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