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 Table of Contents  
ORIGINAL ARTICLE
Year : 2021  |  Volume : 10  |  Issue : 2  |  Page : 88-94

Knowledge, attitudes, and practices regarding COVID-19 for health-care providers in Arab countries


1 Department of Pediatric, Faculty of Medicine, Najran University, Najran, Saudi Arabia
2 Department of Community Medicine, Faculty of Medicine, International University of Africa, Khartoum, Sudan
3 Department of Basic Medical Sciences, Faculty of Medicine and Health Sciences, University of Science and Technology, Sanaa, Yemen
4 Department of Pediatric, Faculty of Medicine and Health Sciences, University of Science and Technology, Sanaa, Yemen

Date of Submission16-Dec-2020
Date of Acceptance09-Jul-2021
Date of Web Publication16-Aug-2021

Correspondence Address:
Khaled Sadeq Al Shaibari
Faculty of Medicine, Najran University, Najran
Saudi Arabia
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/sjhs.sjhs_262_20

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  Abstract 


Context: The impact of COVID-19 on the Arab world has been particularly striking. Less well known are the knowledge, feelings, and behaviors of health care providers (HCPs) regarding COVID-19 in these countries, which has significant influence on the quality, timing, and effectiveness of the health-care response. Aims: We evaluated the knowledge, attitudes, and practice regarding COVID-19 for health-care providers in five Arab countries. Settings and Design: Using a descriptive, cross-sectional approach, knowledge concerning COVID-19 was assessed in health-care providers in Saudi Arabia, Yemen, Sudan, Egypt, and Jordan. Materials and Methods: Five hundred and one participants answered nine validated questions, and a cumulative knowledge score was tabulated for each participating HCP. Attitudes about COVID-19 were assessed with ten questions with categorical response choices “true,” “false,” and “no opinion” and were rated with cumulative scores on a scale of “strongly negative” to “strongly positive.” Clinical practices regarding COVID-19 were assessed with eight questions, with ratings of “weak,” “moderate,” and “strong” patterns of practice for COVID-19 screening and treatment. Statistical Analysis Used: SPSS software program version 26 was used for statistical analysis. Chi-square was used to study the relationship between different variables. The statistical significance level was set at P < 0.05. Results: The vast majority of respondents knew the transmission method of COVID-19, its primary symptoms, and the recommended isolation period; however, most did not know the distance recommended by the World Health Organization for physical distancing, and over a third believed that wearing multiple masks provided additional protection against viral exposure. Country of residence was predictive of COVID-19 attitudes and practices. Conclusions: Health-care providers have “fair” knowledge about COVID-19, but they are still in need for further orientation, in line with international standards for protection against COVID-19. Several demographic factors can predict attitudes and practices regarding COVID-19, which may have implications for treatment outcomes.

Keywords: Arab countries, COVID-19, health care, knowledge, attitudes, practice


How to cite this article:
Al Shaibari KS, Saghir MA, Al Hyfi HA, Al Humidi AA, Elnemr MA. Knowledge, attitudes, and practices regarding COVID-19 for health-care providers in Arab countries. Saudi J Health Sci 2021;10:88-94

How to cite this URL:
Al Shaibari KS, Saghir MA, Al Hyfi HA, Al Humidi AA, Elnemr MA. Knowledge, attitudes, and practices regarding COVID-19 for health-care providers in Arab countries. Saudi J Health Sci [serial online] 2021 [cited 2021 Dec 8];10:88-94. Available from: https://www.saudijhealthsci.org/text.asp?2021/10/2/88/323876




  Introduction Top


China was declared a global pandemic by the World Health Organization (WHO) in February 2020.[1] About 10 million worldwide documented cases of the COVID-19 and over 500,000 deaths as of July 1.[2],[3] All health-care providers (HCPs) have a role in preventing the further spread of COVID-19 in their hospitals and communities.[4] Available data suggest that relatively few providers worldwide tend to obtain their primary data about COVID-19 from multinational organizations like the WHO or national ones like the Centers for Disease Control and Prevention, but it is incumbent upon those providers to adhere to those organization's guidelines as they set the standards for treatment.[5],[6],[7] Little is known about the knowledge, attitudes, and practices (KAP) about COVID-19 in most Arab countries, and no international comparative studies have been performed in this region. This study aims to assess the current level of awareness toward COVID-19 among health-care providers in selected Arab countries and to analyze their attitudes and practices toward COVID-19, which has significant implications on the quality and effectiveness of the COVID-19 health-care response. In this study, we investigated health-care providers' KAP toward COVID-19.


  Materials and Methods Top


The sample consisted of a spectrum of HCPs who responded to a request from researchers to complete a web-based survey. The researchers were based in Saudi Arabia, Yemen, and Sudan. The study was reviewed by the Institutional Review Board at the Najran University, which was also responsible for its approval. The survey was written and offered in English, and was advertised over social media platforms such as Facebook, WhatsApp, and Twitter. Responses from five Arab countries were selected for survey analysis: Saudi Arabia, Yemen, Egypt, Sudan, and Jordan.

For the purpose of this cross-sectional survey of HCPs, the term “health-care provider” included physicians, nurses, pharmacists, dentists, hospital management, and public health employees. Inclusion criteria consisted of professional practice in one of these areas, a willingness to participate in the study, and a residence in one of the five selected countries.

To ensure that the survey sample size was sufficient given the unknown number of health providers in these countries, a target sample size of 384 providers was derived from known standard formulations. This target sample size was exceeded by 117 providers.

The survey was administered via the social media platforms – Facebook, WhatsApp, and Twitter, where it was open for responses for 10 days beginning May 1, 2020. By clicking on a provided uniform resource locator link, the participants could view the questions and answer them by selecting radio buttons. The cover page of the questionnaire included a short introduction regarding the objectives, procedures, the voluntary nature of participation, and declarations of confidentiality and anonymity.

Survey respondents agreed to submit demographic and professional information, including age, gender, nationality, country of residence, educational level, specialty, and years of experience. These factors were used as independent variables in data analysis. The survey questions consisted of 27 items about COVID-19.

Nine questions were devoted to assessment of HCP knowledge, asking about the characteristics of the disease, appropriate sources of information, symptoms of the disease, and prevention and control measures. Tabulated responses were followed by the calculation of a total cumulative knowledge score for each participant. Questions were given 1 point for each correct response and 0 point for an incorrect or “I don't know” answer. The maximum score was 9, and the minimum was 0. A score of under 6, 6–7, and above 7 was classified as poor, fair, and good knowledge regarding COVID-19, respectively.

Ten questions assessed provider attitudes about COVID 19 health care practices. The answering and scoring systems were (true = 3, false = 1, and no opinion = 2). The total attitude score ranged from 10 to 30. Similar to the assessment of knowledge, scores of under 18, 19-24, and above 24 were classified as pessimistic, moderate, and optimistic attitudes toward COVID-19, respectively.

Eight questions measured practice and approach of HCPs regarding COVID-19, with a similar scoring system as the knowledge assessment (correct = 1, incorrect = 0, and no opinion = 0). Total scores ranged from 0 to 8. A score of under 5, 5–6, and above 6 was classified as weak, moderate, and strong practices toward COVID-19, respectively.

The goal of the study was to find associated qualities for good KAP regarding COVID-19. Collected data were analyzed using the SPSS software program, version 26 (Armonk, New York, USA). All information gathered via questionnaire was coded into variables. Normality of data was tested using the KolmogorovSmirnov test. To showcase results, the team generated descriptive and inferential statistics using Chi-squared tests, MannWhitney U-test, Kruskal–Wallis H-test, and binary regression when statistically appropriate. Spearman correlation tests were applied to find any correlation between knowledge, attitude, and practice sections. P < 0.05 was considered statistically significant in all tests.[8] The Cronbach's alpha coefficient of the questionnaire was 0.79 in our sample, indicating acceptable internal consistency of questions.


  Results Top


[Table 1] displays a summary of respondent demographics. A total of 501 practitioners completed the survey. There were 289 male respondents and 212 female respondents. The most well-represented age range in the participant group was 31–40 years old, followed by 20–30 and 41–50. Practitioners over age 50 comprised just 7.4% of the respondent total.
Table 1: Demographic characteristics of respondents

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Regarding nationality, just over half of the participants were from Yemen. The next largest national origin representations in the survey were Saudi Arabia, Egypt, Sudan, and Jordan. No other nation represented more than 3% of the respondent population. Of these five countries, most respondents lived in either Saudi Arabia or Yemen. Nearly 11% of respondents lived in Egypt, and over 10% lived in Sudan, with about 4% living in Jordan.

[Table 2] represents the professional identities of the survey participants. Nearly all respondents had at least a bachelor's degree. About half had either a bachelor's or master's degree. A little less than half had a doctorate degree or higher, with about one-third of the total population having either board certification or fellowship training.
Table 2: Professional specialties of respondents

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By far, the largest number of respondents worked in primary care, with pediatrics, general practice, and internal medicine comprising the largest groups. Also well represented were the fields of surgery, pharmacy, and nursing. Level of experience was spread out, with 25.5% of respondents having <3 years of experience, 15.8% having 3–5 years, 23.2% having 6–10 years, and 35.5% having 10 years of experience or more.

A plurality of respondents (43.3%) stated that their primary source of information about COVID-19 was from research articles and journals. However, 31.1% noted that their primary information source was social media on software programs such as Facebook, WhatsApp, and Twitter.

[Figure 1] demonstrates the relative availability of common personal protective equipment (PPE) items. With multiple responses available, an equal number of respondents (81.8%) stated that they had access to disposable gloves and alcohol-based hand sanitizer. Nearly 3 in 4 (74.3%) had access to surgical masks. Long-sleeved cuffed gowns, face shields, and N95 respirators (so called because they are designed to filter 95% of incoming particles) were each available to approximately 40% of the survey population. One of the more sophisticated articles of PPE, powered air-purifying respirators, called PAPR for short, was available to 13% of respondents.
Figure 1: Bar graph of personal protective equipment availability

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As measured by the questionnaire, respondents showed good knowledge about the relationship of COVID-19 to lung impairment due to smoking, droplet transmission, transmissibility with mild cases, and the proper post-COVID-19 exposure isolation time, with at least 90% of the survey population answering questions about them correctly. Participants had less knowledge about who were at the greatest risk for COVID-19 and the WHO-recommended social distancing length, with less than half answering these questions correctly. A “good knowledge” score was achieved by 22% of respondents, a “fair knowledge” score by 60.9%, and a “poor knowledge” score by 17.2%. The mean knowledge score was 6.6 out of 10.

More than 85% of respondents felt it was possible to get COVID-19 infections in their area, felt worried that they or one of their family members would acquire COVID-19 infection, and were ready to isolate themselves if necessary and take community anti-epidemic measures. Participants were less confident about the origin of COVID-19, their ability to protect themselves from infection, and the prospects for getting COVID-19 under control. However, the majority (73.7%) expressed an optimistic or positive attitude about treating COVID-19.

Nearly all participants knew that multiple PPE items are recommended when treated known or suspected COVID-19. The vast majority (89.2%) knew that COVID-19 is treated supportively, and that there is no specific treatment for it. There was a similar level of knowledge in this population (88.2%) that handwashing is recommended before and after PPE administration and before and after contact with a patient, fluids, or a patient's surroundings. About two-thirds of respondents stated that they had attended an online learning activity about COVID-19. On the other hand, only 34.3% of participants correctly answered that droplet precautions were the recommended protective measures against COVID-19. The mean composite practice score was 5.71. A plurality of respondents (47.1%) earned a moderate strength practice score, while 33.1% earned a strong practice score.

Scores for knowledge and attitudes about COVID-19 were highly correlated with each other (P = 0.001), as were scores for attitude and practice strength (P < 0.001). However, these correlations were not transitive; knowledge scores were not correlated with practice scores (P = 0.201).

[Table 3] describes the relationships between demographic and professional characteristics of respondents with KAP about COVID-19. Male sex was highly correlated with higher scores on attitude and practice strength, but not correlated with knowledge scores. Older age was highly correlated with higher scores for knowledge and practice strength, but not attitude. There was no statistical difference in knowledge and attitudes by nationality, but there was a major difference in practice strength; for example, Saudi practitioners had a 60 point higher than their Yemeni et al. Similar disparities existed for attitude and practice scores between HCPs who live in Saudi Arabia and those who live in other nations.
Table 3: Correlates of demographic and professional specialties with COVID-19 knowledge, attitude, and practices

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Both degree type and level of experience were highly correlated with practice strength score, though not with knowledge or attitude scores. Type of specialty was correlated with knowledge and practice scores; general practitioners had high knowledge scores on average, and public health and community medicine professionals had high practice strength scores.


  Discussion Top


This article reports on the KAP of health-care professionals regarding COVID-19 in the countries of Saudi Arabia, Yemen, Egypt, Sudan, and Jordan. The results demonstrate moderately sound knowledge, high optimism, and medium strength practices in this population, as measured by the questionnaire tool. To the authors' understanding, this represents the first multinational survey in Arab countries on KAP regarding COVID-19.

The unprecedented speed at which new information and studies are generated about COVID-19 makes this study's data particularly relevant. Moreover, there is increasing evidence in multiple countries for a resurgence in cases after initial success with isolative measures and a subsequent reopening of businesses and other economic generators.[2],[9] The strength of KAP in the affected countries is likely to have a significant impact on the health-care response to this resurgence for months and possibly years.

Findings in this study reveal some substantial knowledge and practice gaps in professional practice that may be amenable to short-term, high-value training. A lack of awareness that the elderly at most risk for severe disease, for example, may have widespread implications for everyday logistics of treatment: Procedure scheduling, testing resource allocation, patient flow through clinics, and the like. A lack of awareness about the efficacy of droplet precautions (as was displayed in the study population) can have a major impact on the distribution and usage patterns for PPE in many populations, including health care.[10],[11]

The correlation between knowledge and experience was quite apparent in the analysis of knowledge by specialty. Areas of practice with less patient exposure (hospital management and radiology, for example) tended to have lower knowledge scores, while practice areas with high patient flow such as general practice and obstetrics/gynecology tended to have better knowledge scores. However, both groups fared relatively well in practice scores.

The disparity between male and female providers on attitude and practice scores may have been confounded by other factors, such as experience and specialty, as it did not appear to be a function of a difference in knowledge. In addition, one striking characteristic of the respondent demographic was that it was relatively young (over two-thirds of the respondents were aged 40 and under) but also relatively experienced (over half of the respondents had 6 or more years of experience in their field).

Although most respondents noted that they had access to disposable gloves and alcohol-based hand sanitizer, it was remarkable that nearly one in five respondents stated that they did not. Similarly, one in four respondents did not have access to surgical masks. Lack of access to these basic necessities will severely hinder a health-care system's ability to enact preventive and treatment measures against COVID-19 and could contribute to further spread.[12],[13]

The study should be viewed in light of its assets and liabilities. The mode of primary advertisement was over social media platforms; however, older people in general useless social media.[14] This recruitment approach was thus likely responsible for the younger skew in the age range of respondents. That approach could limit the generalizability of the study's findings. Furthermore, a large percentage of respondents stated that social media was their primary outlet for COVID-19 information, but correlations between source of information and KAP were not measured.

One area for future study, as mentioned, will be understanding the correlation - should there be one - between KAP about COVID-19 and the respondents' main source of information about the pandemic, as an increasing number of health providers obtain medical information through social media, following public trends. We put this as suggestion for further studies, as we noted correlation between national income in countries and KAP. Finally, longitudinal assessments of KAP as the pandemic continues would likely be useful, especially to gauge the character of response for the next pandemic. As COVID-19 appears likely to continue infecting at high rates even with isolation measures until immunization or effective therapeutics are available, measuring awareness and sentiment about it has clear value.


  Conclusions Top


As the world continues to wrestle with the difficulties presented by the COVID-19 pandemic, new knowledge about its management is likely to present HCPs with particular challenges about disease management, resource allocation, and policy implementation. This study showed that KAP tended to be of high-moderate quality in health-care professionals in several Arab countries. Ensuring that the current population of HCPs is knowledgeable about COVID-19 will be of paramount importance, and understanding their attitudes about treatment is likely to affect treatment quality and the efficiency of treatment delivery.

Acknowledgments

The authors would like to thank Dr. Moneer Ali Abdullah and Dr. Murwan Eissa Osman from the Community Medicine Department, Faculty of Medicine of the International University of Africa, for their help and advice.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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