1. INTRODUCTION

Increasing globalization, population and intrusion of man into new places has led to exposure of humans to unknown pathogen which results in new diseases called emerging diseases. Emerging and re-emerging diseases have always posed threat to human health. Recent emerging diseases were Sever Acute Respiratory Syndrome (SARS), Middle Ease Respiratory Syndrome (MERS), Ebola, Chikungunya, Avian flu, Swine flu and Zika. The latest among emerging diseases was discovered in Wuhan city, Hubei province of China in late December 2019 which is known as Corona Virus Diseases 2019 (COVID-19).

On December 31st 2019, World Health Organization (WHO) was informed about cases of pneumonia of unknown etiology [1]. Later the number of cases rose very rapidly and also the number of affected countries increased drastically. On January 31st 2020, WHO declared this outbreak as Public Health Emergency of international concern and later on 11th March 2020 as pandemic [2]. As of April 30th 2020, more than 3.2 million cases and 234,005 deaths have been reported globally [3].

Droplet precautions are recommended by WHO for prevention of COVID-19 as there is possibility of air born transmission in aerosol generating settings [4]. Given global extent of problem and high potential of transmission, Health Care Workers (HCWs) are at higher risk of contracting COVID-19 at their work settings. A report of Chinese center for disease control and prevention (11 February 2020) indicated 1716 HCWs contracted the COVID-19 and majority, 63% of these HCWs belonged to Wuhan where outbreak started [5].

Health care workers are the backbone of health systems. A healthy and skilled workforce is the basic requirement to ensure healthy community and this is even more important during crisis such as COVID-19 pandemic. It is also important that HCWs should have good knowledge about the disease and practice preventive measures to protect themselves and community at large. Studies from China have reported high level of knowledge among HCWs and majority of them had received training about COVID-19 [6,7]. This level of knowledge of HCWs about the disease could be one of the contributory factors behind China’s exemplary control of the disease [8]. An understanding of status of knowledge, attitude and practices of HCWs and differences between physicians and non-physicians is an important step towards outbreak control. This would help prepare the health care workforce with targeted approaches for a better response to the pandemic.

Saudi Arabia is the Muslim pilgrimage country with millions of people across the globe visiting holy places of Makkah and Al-Madinah. Additionally there are about 10 million expatriates in the country. Saudi Arabia is no exception from the COVID-19 infection. As of April 30th 2020, a total of 24,097 cases and 169 deaths have been reported from Saudi Arabia [3]. Saudi Arabia is currently implementing a multi-sectoral national level response according to WHO operational planning guidelines [9]. To the best of our knowledge, no study has been published on assessment of knowledge of HCWs about COVID-19 in The Kingdom of Saudi Arabia. This study aimed to assess the knowledge, attitude and practices of HCWs related to COVID-19 and to compare the knowledge, attitude and practices of physicians and non-physicians in Saudi Arabia.

2. MATERIALS AND METHODS

3. RESULTS

A total of 398 participants completed the questionnaire and included in the analysis. Mean age of the participants was 35.6 (±9.7) years. Fifty nine percent of the participants were male. A little more than half 57% were Saudis and majority of the participants were from Qassim region (67%). Near half (52%) were physicians and working in Primary Health Care (PHC) centers (49.7%) (Table 1).

Table 2 presents the knowledge, attitude and practices of HCWs about COVID-19. Only 45.5% of the participants knew about the causative agent. Almost all (97.5%) of the respondents were aware that close contact with infected person is the most important risk factor. More than 90% of the respondents could identify common symptoms and modes of transmission. Only 63% of the respondents were aware that antibiotics have no role in treatment of COVID-19, however surprisingly, 25% were not sure about it. About role of flu vaccine in prevention of COVID-19, 20% were not sure. Regarding use of mask during routine practice, about one-third (32%) thought that surgical mask is not suitable or were unsure about it. About use of mask, (74%) agreed that HCWs should wear mask all the time at work. Most common sources of knowledge were MoH (97.4%), WHO (73.1%) and Saudi Center for Disease Prevention and Control (CDC) (64%). Only 24% and 35% of the participants had attended an in-class and online session respectively on COVID-19.

Almost all of the participants were worried about COVID-19 pandemic; most common worries were risks of contracting the infection or transmitting it to friends and family members. About one-third reported that they found it difficult to obtain personal protective equipment (PPEs).

Majority (87%) always cleaned their hands with soap or alcohol based rub and washing hands was quite common practice. Near two-third (64%) reported that they advised all people to seek care if there are symptoms of flu.

We also compared physicians and non-physicians with respect to their knowledge, attitude and practices (Table 3). Compared with non-physicians, physicians generally showed better knowledge in most of the studied items. The differences in identifying the causative agent, role of antibiotics, flu vaccine, fear of getting disease at work place and carrying infection to home were statistically significant, while there was no significant differences for other items such as; identifying main modes of transmission, factors that increases the severity of the disease, worriedness about COVID-19 and hand washing and wearing mask practices. About effectiveness of antibiotics, correct answer was given by 81% physicians and 44% non-physicians (p-value <0.001). There was no significant difference between the two groups with respect to worriedness about COVID-19. However, fear of getting disease at work place and carrying infection to home were higher among physicians, 79% and 95% respectively compared to non-physicians, 67% and 88% respectively. With respect to practices, we did not find significant difference between physicians and non-physicians. Around 8% of the physicians and 35% of non-physicians never or occasionally used mask during their work. These respondents were mainly working in administrative and non-patient care areas.

4. DISCUSSION

This study, to the best of our knowledge is the first of its kind from Saudi Arabia to assess knowledge, attitude and practices of HCWs in the Kingdom.

Correct knowledge about a disease is an important factor in prevention and control of disease [14] this is even more important during pandemics where a large section of population is susceptible. In our study, knowledge about agent was low 45%. This is lower than studies from China [7] and Pakistan [15] where 99% and 100% respondents were correct. However, in these studies researchers inquired only if this was a viral disease, whereas in our study we inquired about the name of the specific virus. Knowledge about close contact as most important risk factor was higher in our study (97%) compared to HCWs in China (67%) [7]. Knowledge about incubation period was slightly lower 92% than reported from Pakistan 96% [15]. Our study found that correct knowledge about role of antibiotics was 63% which is higher than reported from China 58% [7] but lower than Pakistan 82% [15]. Having more than one third of participants with incorrect knowledge about the antibiotics use for COVID-19 indicates a poor state of basic understanding of infectious diseases. This has important implications on patients as well as health care system in terms of health consequences such as antimicrobial resistance and costs of care.

Previous studies from Saudi Arabia and Greece also reported a higher proportion of HCWs being worried about their families during MERS-CoV and H1N1 epidemics respectively [11,13] Risk to friends and family members was most frequent reason in our study, a finding similar to earlier report from China during this pandemic [7,16]. Majority (75%) of the HCWs believed that their institution was not prepared for COVID-19 pandemic. Similar findings were reported previously from Saudi Arabia during MERS-CoV outbreak [10]. This is also reflected as fear among 92% of the respondents about carrying infection to their homes. This is important finding as one’s beliefs about preparedness of his/her institution has effects on feelings of safety, motivation and morale during work [17]. Proper risk communication with HCWs and their training is essential in this regard along with upgrading and maintaining health care facilities to face the challenge of emerging diseases such as COVID-19.

Without adequate practices, knowledge and attitude do not provide the desired outcome for prevention and control of diseases. In our study we found that a large proportion frequently cleaned their hands. This finding is similar to a study from Pakistan [15] while a lower proportion 82% of HCWs reported cleaning their hands often or always following MERS-CoV outbreak in Saudi Arabia [10]. This may indicate improvement in hygiene practice which has resulted from previous experience of an outbreak. For a respiratory disease, wearing mask during practice is an effective measure for prevention of infection among HCWs. Our study found that about 30% often and 41% always used surgical mask at work. This finding is similar to previous study from Saudi Arabia where 24% and 43% of HCWs used mask often and always respectively [10]. We assume that even small proportion of workers who do not practice can pose risk to other colleagues and patients.

We also compared knowledge, attitudes and practices between physicians and non-physicians. The findings are similar to previous study from Saudi Arabia where physicians were found to have better knowledge about MERS-CoV than other HCWs [10]. Generally, it was observed that knowledge about agent, roles of antibiotics and antivirals and use of masks were better among physicians compared to non-physicians. However there was no significant difference in knowledge between the two groups with respect to common signs and symptoms, modes of transmission, factors affecting severity of the disease and concerned authority for reporting a case.

There was no significant difference between physicians and non-physicians in terms of worriedness. However, fear of getting disease during work and carrying infection to home was higher among physicians. There were no significant differences in the practices of both types of HCWs except for educating patients about prevention and control of COVID-19, which was higher among physicians. These differences could be due to the fact that in our sample non-physicians also included technicians, health inspectors and those working in administration and they are not in direct contact with the patient. This may have led to perception of lower risk of getting infected and different opportunities for educating patients. We also did exploratory analysis (results not shown) by excluding technicians and health inspectors and compared physician with nurses. This exercise however did not show any major changes in the results.

Poor knowledge about causative agent, role of antibiotics and antiviral medications and wide spread fears need to be addressed. Policy makers and administrators should arrange workshops and training sessions for the staff. Health care workers need to avoid information from unauthentic sources and refer to only official communications from their ministry and/or other recognized international organizations such as CDC and WHO. Social media is known source of misinformation and may lead to myths and malpractices [18]. Therefore HCWs should not give any heed to such information. Psychological assessment and counselling are also required to protect the mental health of frontline workers.

In this study we comprehensively assessed the knowledge, attitude and practices of a diverse group of HCWs. However there are certain limitations which should be considered while interpreting findings of this study. First, given the COVID-19 pandemic and lockdown across the country, face-to-face interviews were not possible, therefore we designed this study as online survey in which it is possible that some of the respondents might have not understood the question properly and may not answer accurately. This however, we assume to be affecting our results minimally because we developed questionnaire based on previous studies specifically from Saudi Arabia and we also translated questionnaire to Arabic language for better understanding by some respondents. Second, in our sample there was over representation of participants from Qassim region. This, we assume be a minor limitation as there is unified response at the country level for the prevention and control of COVID-19. There are standardized protocols and guidelines from MoH and Saudi CDC which are implemented across the country uniformly. Third, this was an open online survey where response rate cannot be ascertained. It is also possible that those responded might be different from those who did not respond despite receiving the survey link. This may limit the generalizability of our study. We did not do a priori sample size calculation given the open nature of survey and defined time period of data collection (3 weeks). However, we are able to reach a sample size which would give us absolute precision ranging from 1.5% to 5.0%. Additionally, composition of our sample with respect to gender and nationality among physicians and non-physicians was comparable to national health workforce statistics [19]. Finally, as the epidemic continues, more disease facts are evolving and staff knowledge and practices are changing.

5. CONCLUSION

We found the knowledge about the agent of the disease and role of antibiotics was poor among HCWs in Saudi Arabia which needs attention of policy makers. However, knowledge about the other aspects of disease such as modes of transmission and prevention was better. Worriedness and fears were present among majority of the HCWs which may affect their level of motivation. Infection control practices such as cleaning hands, wearing mask and educating people about the disease were also high. These findings call for targeted interventions such as timely orientation about emerging diseases, training on disease management and counseling services for worries and fears. Ensuring adequate infection control supplies and constructive supervision of staff practices can augment the overall performance.

CONFLICTS OF INTEREST

The authors declare they have no conflicts of interest.

AUTHORS’ CONTRIBUTION

UR conceived the research idea and developed the proposal. Both UR and AMAS developed the study tool. UR analyzed the data and AMAS reviewed the results with UR. UR wrote the first draft and both edited the draft for final submission. Both the authors approved final version for publication.

FUNDING

No financial support was provided.