In this study, the PubMed, Web of Science, and Scopus databases were searched for peer-reviewed literature published from January 2008 to January 2023. All database searches included combinations of the following keywords (in the Title/Abstract): “bioterrorism,” “disaster,” “accident,” “event,” “healthcare workers,” “health professionals,” “knowledge,” “attitude,” “practice,” and “preparedness.” The systematic search strategy is shown in Table 1.

The inclusion and exclusion criteria used in this study are shown in Table 2.

The searched article titles were imported into EndNote, which was used to remove duplicate titles. The authors also manually removed duplicate titles by sorting them alphabetically to avoid omissions in software deletion. The article titles and abstracts were screened by two independent reviewers, and disagreements were resolved through negotiation until an agreement was reached. The other two reviewers screened and evaluated full-text articles in the same manner, and promptly recorded the reasons for article exclusion. All reviewers read articles that met the criteria, excerpted scale questions and interview outlines from the articles, and categorized knowledge, attitudes, and practices by brainstorming. The reviewers have been engaged in research investigating health emergency management for a long time, especially research exploring biosafety management.

This study used Mixed Methods Appraisal Tool (MMAT) version 2018 (25) for quality assessment. The method does not propose that a total score be calculated from the rating of each criterion but rather that a judgment of whether each criterion is met be made. The articles included in this study were independently assessed by two reviewers based on the evaluation checklist and interpretation of the criteria.

In this study, a total of 16 studies addressed the knowledge dimension of bioterrorism. The authors analyzed and combined these 16 studies, and divided the knowledge dimension into three main aspects, namely, basic knowledge, protection knowledge, and process specification, each of which includes corresponding subaspects. Table 4 shows the main research components of the knowledge dimension.

In this study, a total of 14 studies addressed the attitude dimension of bioterrorism. The authors analyzed and combined these 14 studies, and divided the attitude dimension into three main aspects of cognition, emotion, and behavioral tendency, each of which included corresponding subaspects. Table 5 shows the main research components of the attitude dimension.

In this study, a total of 7 studies addressed the bioterrorism practices. The authors analyzed and combined these seven articles, and divided the practice dimension into two main aspects, namely, internal performance and external performance, each of which included corresponding subaspects. Table 6 shows the main research components of the practice dimension.

Knowledge of bioterrorism can increase the level of response and confidence of health workers (51). This study showed that researchers currently focus on hospital professionals but should also focus on collaboration with first responders from other institutions (52). In addition, current studies mostly focus on groups, and attention should also be paid to the study of individuals in different departments. Insights and roles in bioterrorism work vary between departments; for example, respiratory and dermatology may perform early identification and diagnosis, and neurology may provide treatment decisions (53–55). Finally, Finally, based on past emergency experience, the lack of public understanding of disaster response capabilities makes the medical response system vulnerable to collapse. The public, a non-professional, can be an important complementary force in the necessary moments of disaster response. Public participation should be predicated on raising public awareness of disaster response. Thus, knowledge of the concepts, modes of transmission, and epidemiological characteristics of bioterrorism should be enhanced among public groups to raise public awareness of bioterrorism. It has been argued that the public is important for effective knowledge dissemination, but their understanding of and attitudes toward bioterrorism lack widespread attention (56). A study also pointed out that in addition to national military training, it is important to ensure that a country’s citizens are equipped to effectively respond to bioterrorism (57).

This study found that current research is more focused on bioterrorism agents, early identification, while research on bioterrorism detection is still relatively limited. First, potential bioterrorism agents are internationally classified as A, B, and C (5). Existing studies have focused on category A agents. Although Category A bioterrorism agents have the highest priority, other categories of agents should also receive attention. For example, it was proposed that Category B toxins are readily available and fast-acting, and they are a potential choice for terrorist use in acts of bioterrorism (58). Second, early identification capabilities are crucial to reducing casualties, initiating appropriate treatment, and protecting resources (55). Current research on early identification focuses on the symptoms and signs caused by the disease, and there is a lack of research on epidemiological patterns. For instance, a previous study pointed out that identifying epidemiological patterns, including unusual age distributions of disease, unusual aggregations, and rapidly increasing incidence, is an important task in distinguishing naturally occurring epidemics from terrorist attacks (55). In addition, bioterrorism detection can effectively support clinical diagnosis, surveillance, and epidemiological analysis (42). However, the current research in this area is still relatively sparse, focusing only on the most basic areas of knowledge, and there should also be further research on the operation and application of detection equipment.

Bioterrorism is relatively unique and rare compared to other emergencies, which has led to few opportunities for healthcare workers to learn about bioterrorism. This study found that knowledge does not necessarily contribute to attitudes due to the specificity of bioterrorism. It has been found that there is a positive relationship between the level of knowledge of health workers and their willingness to respond (32, 59). However, other studies have suggested the opposite, namely, that healthcare workers with higher levels of knowledge are less likely to respond positively during bioterrorism (28). Nonetheless, according to the KAP model, knowledge about disease influences health and preventive behaviors (60). Institutions should strengthen bioterrorism training and education to improve the knowledge of health workers.

Current research on bioterrorism attitudes has focused on willingness to respond, perceived professional responsibility. Willingness to respond is important in improving hospital surge capacity and maintaining appropriate disaster management. It has been reported that willingness to respond depends on the type of disaster, with healthcare workers more likely to be willing to respond to a natural disaster and substantially less willing to respond to an infectious disease outbreak or bioterrorist event (61). It has also been pointed out that common barriers to the willingness to respond include family and personal response plans, family responsibilities, pet care responsibilities, transportation issues, the need for personal protective equipment. (62).

Surprisingly, perceived professional responsibility plays an important role in bioterrorism preparedness. Healthcare workers are more likely to demonstrate a positive attitude in emergency response due to perceived professional responsibility. It has been reported that physicians who perceive professional responsibility are more than four times more likely to report willingness to respond during outbreaks involving unknown levels of initial risk (63). However, healthcare workers often lack disaster awareness, are unclear about their roles and functions at disaster work sites and are reluctant to respond actively in disaster or relief efforts (64). Thus, healthcare workers’ education on professional responsibility should be strengthened, the number of lectures and trainings should be increased, and appropriate incentive mechanisms should be developed to continuously enhance healthcare workers’ awareness of responsibility, the division of functions, and positive response.

This study showed that participation in continuing education was the focus of attention for the practice dimension of bioterrorism. Response plan development was also of concern, but to a lesser extent.

The emergency response capacity of health workers can be improved through continuing medical education, which also improves the quality of care and increases the effectiveness of teamwork among nurses (64). It has been pointed out that the modalities of continuing medical education include conferences, lectures, seminars, self-study papers, online training scenario simulations. (30). It has also been reported that scenario-based simulations are more effective in enhancing knowledge, preparedness, disaster management, communication, and other areas than traditional education methods such as workshops (51).

Bioterrorism response plans are extremely valuable and relevant as an important safeguard against bioterrorist attacks. It has been reported that healthcare workers in all countries have a responsibility to develop response plans to meet their specific needs and to understand their roles and responsibilities in workplace disaster planning (7). However, current research on response plans is still not thorough enough, and attention should be given to the development of office, community, and patient response plans in addition to research on individual and family response plans.

The present study also has some limitations. First, there is relatively little research on bioterrorism and even less focus on bioterrorism knowledge, attitudes, and practices, resulting in a small number of included studies and findings that cannot be generalized to all health workers. In addition, only studies published in English were selected for this study, while potentially relevant studies published in other languages were not selected.