Impact of the Covid-19 Pandemic on Awareness, Risk Level, Hand Washing, and Water Consumption for Hospital Staff in Sulaimaniyah City of Iraq

Abstract


Introduction
The Coronavirus-19 disease (Covid- 19) is responsible for the global pandemic that was announced on March 11, 2020, by the World Health Organization (WHO). It is caused by the coronavirus 2 that causes severe acute respiratory syndrome (SARS-COV-2) [1]. According to Huang, on December 31, 2019, the the soap is scraped, washing hands for 15 to 20 seconds would take around two liters of water if the faucet is open or one liter if the tap is turned off [13]. If everyone washes their hands at least ten times daily to avoid Covid-19 infection, they will use about 10 to 20 liters of water daily [13]. As a result of the Covid- 19 pandemic, a family of five would require nearly 50 to 100 liters of water per day for hand washing, resulting in a 20 to 25% increase in water demand [13].
Water shortages could occur because of such rapid growth in demand; however, the increased water demand will be much more observable in hospitals among health workers due to the frequent touch with patients; evidence suggests that the frequency of hand washing enhanced throughout the co-current pandemic situation [14]. As a result, during the concurrent pandemic, people have been washing their hands more frequently. Also, in India, during this Covid-19 pandemic, due to the tap open during hand washing, the water demand has increased by 20 to 25% [15]. Additionally, water demand increased by 40% after the government ordered people to remain home as part of a nationwide curfew, claimed by an official water sector in Jordan [13]. Therefore, water poses another possible problem of water loss during hand washing because of increased water demand.
This increase in demand might put a lot of strain on already overstretched water resources as they try to fill current shortages in the system. When the water supplies dry up in the summer, the situation will become even worse. Though water loss during hand washing could be a serious issue, no previous study could evaluate water loss during hand washing globally.
Water stress affects over 2 billion people worldwide, and the number is growing daily [13]. This is especially noticeable in small and medium-sized countries around the world, which could be attributed to several factors, including 1) a limitation of water in those places, 2) water loss owing to drought or climate change, 3) water that is unfit for human use due to contamination of local water supplies, and 4) the nearest water source may be a long distance away [16]. Simultaneously, worldwide water demand is increasing at around 1% per year, and demand has been unexpectedly boosted because of the Covid-19 pandemic and is projected to worsen with time [17]. Such an unforeseen worldwide demand for water would greatly strain finite water resources, aggravating the current water supply shortage. Two solutions are raising awareness about closing taps or adopting sensor taps that turn off automatically while cleaning hands with soap. Alternatively, suppose the cost is low; alcohol-based hand sanitizer could be a viable option to avoid water loss. In that case, keeping the water supplies safe is also important during the pandemic even though. Based on current evidence, The Covid-19 virus has not been discovered in drinking water supplies since the risk to water supplies is low [18]. Many individuals leave their faucets running while lathering and cleaning their hands, wasting much water [19].
Covid-19 impacted several environmental parameters in the literature, including water consumption [20][21][22]. There are no published documents on water consumption throughout the Covid-19 pandemic in the hospitals in Sulaimaniyah City. Consequently, the authors designed a questionnaire to examine the frequency and the water loss or the demand for water throughout the Covid-19 pandemic. Also, they wanted to illustrate the anxiety and awareness of health workers in Sulaymaniyah City-Iraq. The author's hypothesis and assumption are that there will be an increase in the frequency and duration of handwashing during the pandemic and the amount of time spent washing hands before Covid-19.

Research Methodology
The authors of this study surveyed several major questions to understand more about the impact of Covid-19 on practices for personal hygiene in the Kurdish Regions of Iraq. The study site, participants, sample sizing, and other specific details about the investigation are illustrated in separate sub-sections.

Study Site
The largest Governorate in Iraqi Kurdistan is Sulaymaniyah Province, located in southern Kurdistan (northeastern Iraq) (Kurdistan Regional Government). Sulaymaniyah City, the administrative center of the Sulaymaniyah Governorate, is located at 35°33′40′′N and 45°26′14′′E, with an elevation of about 830 m above sea level. Sulaymaniyah Province covers 17,023 km2 in total [23]. The location of the study area, which includes the districts of Sulaymaniyah Province, is depicted in Figure 1. Participants had to work in the medical fields in the city's center and at least one of the hospitals as part of the exclusion criteria. Anyone who has this information is eligible to participate in this survey.

Participants and Sample Size Technique
According to estimates made in 2020, the population of Sulaimaniyah City was approximately 1.893 million individuals, constituting a portion of the overall population of Iraq [26]. In this case, the following formula for calculating the necessary sample size for this study will be sufficient [27,28]: Where n = required sample size, N= population size, and d= margin of error (considered d= 0.05) [28]. This cross-sectional and quantitative research was performed from Nov 01, 2021, to Dec 01, 2021.
The questionnaire was designed to get specific data like (age, gender, profession, days, hours spent at work, exposition to covid patients). The questionnaire was created, and later it was checked by experts.
Furthermore, some opinion questions were asked to familiarize the person's anxiety and awareness. At last, some comparative questions were asked about the frequency of washing hands before and during covid.
The result of the questionary was fascinating and was worth sharing.

Questionnaire Design and Data Collection
The current study aimed to learn more about the medical staff's opinion regarding the impact of the Covid-19 pandemic on hand washing, water consumption, awareness, and risk level for hospital staff in Sulaymaniyah City. It also shows how the results have unintended consequences. Primary data were collected using the standardized questionnaires created after a review of the literature [27]. The authors benefited from the field interview and snowballing methods via a web-based tool (i.e., google form) to gather the data from several local and private hospitals in Sulaymaniyah City. This survey consisted of 19 questions with a suggested filling time of 3-5 minutes. The authors used snowball sampling to distribute the

Statistical Analysis Instrument
After collecting the data, the authors analyzed the results via Microsoft Excel tool, and with the help of this tool, the data could be analyzed scientifically [29]. First, to analyze the results sufficiently and easily, the authors encoded the data into reliable numbers [30]. Then, via using the Microsoft Excel function tools, some statistics about the ratio of gender, age, profession, awareness degree, water consumption, and many other parameters were analyzed. Therefore, some figures were produced from the result sheet. The analytical method of having a percentage of 100% is considered while analyzing the data. For instance, in the question "Barriers for not washing hands frequently, " the following barriers were commonly noticed: Equipment fear, far away bathroom, forgotten, no sanitizer, no time, cold water, no equipment, and water quality. Participants could tick the right answer regarding their opinion. For analyzing it, it has been encoded as 0 and 1.
Then, the percentage of awareness level can be easily extracted by using the following formula: [( Average of Opnion 5 ) + ( Sum of avoinding Barriers 8 )]

(4)
Here is the formula, if a person strongly agrees to all four questions and has no barriers. Consequently, the result would be 1, which is 100%. The total percentage of awareness risk in Table 1 is determined using the following equation. Here the authors wanted to measure a ratio between the risk that an employee has and his/her awareness by using this simple formula: Total percentage of awareness − risk = Awareness% − Risk% (5) Here the answer is rational, meaning that: 0 is a neutral point (the person has a balance between awareness and risk), (+) is a good sign (the person is at low risk with high awareness), (-) is a bad sign (the person is at high risk with low awareness)

Demography Data
In this part, the general demography of the participants is discussed, such as the number of participants, gender, age, and profession, Table 1. A total of 404 contributors from different hospitals and private clinics in Sulaymaniyah City participated in the questionnaire. Among them, 51.23% were female, and 48.77% were male, as shown in Figure 2.   The participants' profession is categorized as Doctors, Dentists, Microbiologists, and Health workers.
While the maximum and minimum rates of about 31.4% and 18% consisted of healthcare and dentists, respectively, only data from those professions were collected (i.e., patients were not contributed to the current work) as shown in Figure 4.

Risk and Awareness Levels
The average risk and awareness levels for the hospital employees are shown in Table 1. This section included age, working days, working hours, and exposure to Covid-19 patients.
In Table 1, the authors illustrated the average level of potential risks of getting the Covid-19 pandemic. At the same time, according to the participants' answers, the level of awareness regarding covid and sanitary issues was analyzed. The last column is a ratio between risk and awareness levels. The table shows the percentage level of risk, awareness, and cross-tabulation ratio according to gender, age, and profession [30,31].
According to the results shown in Table 1, it can be realized that there is a total of -39% ratio gap between risk and awareness, meaning that despite that the risk level is 64%, the awareness level is three times less than the risk level. This is a big threat that the employees at the hospital should be warned and awareness level with only 22%, and the total aware-risk level ratio percentage is -54%. The male age group of more than 55 years also has the most risk, but their awareness level is somehow more than females in the same age group, with a percentage of 26%, and the total aware-risk level ratio percentage is -45%. It is worth mentioning that the employees aged 20-25 are the most aware group regarding other aged employees. In the case of female employees aged between 20-25, the awareness-risk ratio percentage is -23%, but the males of the same age group are -29%.

Hand Washing
Information regarding hand washing, cleaners, and reasons for hand washing are given in Table 2.
This part is sub-divided into the following sections:

Hand Washing Before and During Covid -19
After finding the demographical information from the participants, the authors took information about (washing their hands, frequency, and tools of cleaning hands) before and during the pandemic.

The Change of Hand Cleaner Equipment
Here the authors wanted to know the equipment the employees used to clean their hands before and during the pandemic. The options were alcohol, hand sanitizer, soap, and only water.

The total Change Percentage of Reasons to Wash Hands
In this section, the authors wanted to find out why an employee would think he/she should wash his/her hands before and during the Covid-19 pandemic. The authors put seven reasons for this section, and the participants answered accordingly. The options were washing time, touching equipment, contacting the patient before and after a meal, coughing/sneezing, and others. Several studies assessed using hygiene equipment in hospitals to prevent spreading infectious diseases like the Covid-19 virus [33].

Grand Total Change in Washing Hand Analysis
Here the researchers needed to analyze all factors affecting washing hands before and during the Covid-19 pandemic by taking the average of the previously calculated parameters of hand wash change, hand cleaner, and reasons to wash hands.
According to the results shown in Table 2 highest among other age groups. The female doctors aged between 46-55 were the group in which their washing hands percentage decreased to negative -20% during pandemic, and the materials used for washing their hands were not changed nor increased by 0%. They had a total grand change percentage of -1%.  Figure 5 elaborates clearly on the change in washing hand ratio before and during the pandemic. It can be seen that the washing hand ratio increased mostly by doctors, following them are dentists.
Microbiologists are the least changed ratio range before and during the pandemic. Their hand-washing ratio range was between 23-63% [34].

Figure 5.
Washing hand ratio before/after the pandemic according to professions

Water Consumption Level
The effect of Covid-19 on hospital employees' water consumption rate has been examined in this section. The parameters for total water consumption were because not all employees work daily.   According to the results in Table 4, doctors were at the top of the list, with an increase of 213% in water usage. This may be because they are more in contact with patients, and it gives them the anxiety to wash their hands more, eventually increasing water consumption. On the other hand, health workers had the least increase in water usage compared to other groups, with an increase of 110%. It's also worth mentioning that the ranking of water usage may be based on the employees' contact with Covid-19 patients.
Studies also show that the pandemic has a negative impact from the perspective of increasing consumption levels by healthcare staff [36].  eventually, they will also get Covid-19. Therefore, the range changes in that manner.

Conclusions
This investigation has focused on the effect of Covid-19 on awareness, risk level, and hand cleaning by hospital staff in Sulaimaniyah City hospitals. The level of awareness has been upgraded by the hospital staff in Sulaimaniyah City during the Covid-19 pandemic. Employees over 55 years were more under threat because of their age, but at the same time, females over 55 years had the most risk. The rate of washing hands increased by 38%, and 46% of materials were used more while washing hands compared to the era before the Covid-19 pandemic. The average total change percentage was 41% which is a high rate. Water consumption increased by 135% in the Sulaimaniyah Hospitals during Covid-19. This can lead to a problem of water supply shortage during drought times. Less working hours in the hospitals resulted in a high-water consumption ratio among the employees. More specific studies can be held with the hospital staff to measure their continuity of awareness level after the pandemic ends.

Declaration of Competing Interest
The authors declare that they have no known competing of interest.