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| ORIGINAL ARTICLE |
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| Year : 2021 | Volume
: 10
| Issue : 2 | Page : 95-102 |
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Assessment of the knowledge and practices of holy mosque visitors toward coronavirus disease 2019 pandemic
Hamza Assaggaf1, Radi Alsafi2, Dina Alsorrori2, Asma Almuntashri2, Sara Alzahrani2, Shahad Aladeeqi2, Omar B Ahmed3, Osama A Attala4, Majid A Bamaga5
1 Department of Laboratory Medicine, Faculty of Applied Medical Sciences, Umm Al-Qura University; Department of Environmental and Health Research, The Custodian of the Two Holy Mosques Institute for Hajj and Umrah Research, Umm Al-Qura University; Department of Environmental and Health Research, The Custodian of the Two Holy Mosques Institute for Hajj and Umrah Research at Al-Madinah Branch, Umm Al-Qura University, Makkah, Saudi Arabia
2 Department of Laboratory Medicine, Faculty of Applied Medical Sciences, Umm Al-Qura University, Makkah, Saudi Arabia
3 Department of Environmental and Health Research, The Custodian of the Two Holy Mosques Institute for Hajj and Umrah Research, Umm Al-Qura University; Department of Environmental and Health Research, The Custodian of the Two Holy Mosques Institute for Hajj and Umrah Research at Al-Madinah Branch, Umm Al-Qura University, Makkah, Saudi Arabia
4 Department of Environmental and Health Research, The Custodian of the Two Holy Mosques Institute for Hajj and Umrah Research, Umm Al-Qura University, Makkah, Saudi Arabia
5 Department of Environmental and Health Research, The Custodian of the Two Holy Mosques Institute for Hajj and Umrah Research; University Medical Center, Umm Al-Qura university, Makkah, Saudi Arabia
| Date of Submission | 10-Jan-2021 |
| Date of Decision | 09-Jul-2021 |
| Date of Acceptance | 11-Jul-2021 |
| Date of Web Publication | 16-Aug-2021 |
Correspondence Address:
Hamza Assaggaf
Department of Laboratory Medicine, Faculty of Applied Medical Sciences College, Umm Al-Qura University, Makkah 21955
Saudi Arabia
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/sjhs.sjhs_29_21
Background: Since millions of Muslims visit the Holy Mosque in Makkah, it is essential to highlight that such mass gatherings carry a risk of severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) transmission. In this study, we assessed the level of knowledge and practices among visitors to the Holy Mosque related to the coronavirus disease 2019 pandemic. Methods: A cross-sectional survey of Holy Mosque visitors was conducted in Makkah from January 19, to February 9, 2020, using a self-administered electronic questionnaire. Knowledge and practices scores were compared and multiple logistic regression analysis was used to identify the association between variables. Results: A total of 451 participants were interviewed, while 413 completed the questionnaire and were eligible for inclusion. The range of correct answer rate was 13.1%–93.5%. The mean knowledge score was 11.3 with a 64.9% correct response rate, while the mean practices score was 2.92 with a 73.2% correct response rate. The knowledge score was significantly different among nationalities and education levels (P < 0.05). A higher level of education was associated with better knowledge regarding SARS-CoV-2 (odds ratio 1.18, P = 0.028). Conclusions: Most of the visitors to the Holy Mosque had an appropriate level of knowledge and practices related to SARS-CoV-2 infection; however, there is room for improvement in some areas.
Keywords: Coronavirus disease 2019, knowledge, mass-gathering, practice, Umrah
How to cite this article:
Assaggaf H, Alsafi R, Alsorrori D, Almuntashri A, Alzahrani S, Aladeeqi S, Ahmed OB, Attala OA, Bamaga MA. Assessment of the knowledge and practices of holy mosque visitors toward coronavirus disease 2019 pandemic. Saudi J Health Sci 2021;10:95-102 |
How to cite this URL:
Assaggaf H, Alsafi R, Alsorrori D, Almuntashri A, Alzahrani S, Aladeeqi S, Ahmed OB, Attala OA, Bamaga MA. Assessment of the knowledge and practices of holy mosque visitors toward coronavirus disease 2019 pandemic. Saudi J Health Sci [serial online] 2021 [cited 2023 Mar 22];10:95-102. Available from: https://www.saudijhealthsci.org/text.asp?2021/10/2/95/323878 |
| Introduction | |  |
Coronaviruses are a large group of viruses that infect both humans and animals. They belong to the Coronaviridae family.[1],[2] The Coronaviridae family comprises four genera of coronaviruses: Alphacoronavirus, Betacoronavirus, Deltacoronavirus, and Gammacoronavirus. Only seven species of these genera can cause human infections: HCoV-229E and HCoV-NL63 of the Alphacoronavirus genus and HCoV-OC43, HCoV-HKU1, Middle East respiratory syndrome coronavirus (MERS-CoV), severe acute respiratory syndrome CoV (SARS-CoV), and the newly discovered SARS-CoV-2 of the Betacoronavirus genus.[3]
The retrospectively discovered SARS-CoV-2 primarily infected 27 persons on December 31, 2019, in Wuhan City, Hubei province, China.[1] By January 2, 2020, the first reported cases in China were suffering from a fever, dry cough, dyspnea, myalgia, fatigue, normal or reduced leukocyte counts, and death was reported in severe cases.[2],[4] On January 7, 2020, researchers in China identified the causative agent of the epidemic as a novel CoV (SARS-CoV-2).[5] On January 31, 2020, the World Health Organization (WHO) declared a public health emergency of international concern regarding CoV disease 2019 (COVID-19).[4] By March 1, 2020, about 88,930 confirmed cases and 3043 deaths had been reported from 65 countries across five continents. The Ministry of Saudi Health recorded the first SARS-CoV-2 case in the Kingdom of Saudi Arabia (KSA) from a citizen who traveled from Iran to Saudi Arabia via Bahrain.[6],[7]
On March 11, 2020, the WHO announced that the new CoV infection (SARS-CoV-2) was a pandemic. Since then, many precautions have been taken by governments and public health authorities to avoid further spread of the infection. On 27 February 2020, certain countries such as KSA and gulf countries have banned large public gatherings. The Saudi government set restrictions that briefly prohibited Umrah pilgrims from visiting the two holy mosques in Makkah and Al-Madinah.
The novel CoV (SARS-CoV-2) is thought to have originated from an animal source but now seems to be spreading between people.[8] Person-to-person transmission of SARS-CoV-2 has been confirmed in several countries.[9],[10] The SARS-CoV-2 infection can transmit from symptomatic patients to other people by close contact (about 6 feet/2 m), either directly or indirectly through SARS-CoV-2 contaminated surfaces.[11] Kampf et al. found that SARS-CoV-2 can be stable for 72 Hours (h) on plastic, 48 h on stainless steel, 24 h on cardboard, and 4 h on copper.[12] Moreover, a study in Germany confirmed that the infection can be spread to others during the incubation period, which ranges from 2 to 14 days (median 4–5 days).[13],[14] Apart from respiratory secretions, other body fluids, including blood, vomit, and urine, have not yet been confirmed to transmit the SARS-CoV-2 infection. However, several studies stated that the SARS-CoV-2 could be transmitted through the fecal-oral route, as anal swabs tested positive for SARS-CoV-2 from infected patients.[15],[16],[17]
The SARS-CoV-2 genome is closely associated with two bat-derived SARS-like coronaviruses (88% similarity); bat-SL-CoVZC45 and bat-SL-CoVZXC21 appeared in 2018 in Zhoushan, eastern China. The genome similarity of SARS-CoV-2 to SARS-CoV and MERS-CoV is about 79% and 50%, respectively.[18] Currently, reverse transcription-polymerase chain reaction (RT-PCR) is the commonest laboratory diagnostic assay used for SARS-CoV-2. It targets the RNA-dependent RNA polymerase (RdRp) envelope (E) and nucleocapsid (N) genes. The RdRp assay has the top analytical sensitivity (3.8 RNA copies/reaction at 95% detection probability).[15] Tang et al. did another study that agreed with the findings of Chan et al. about the preferred RT-PCR testing method.[19]
Around 9 million Muslims visit the Holy Mosque in Makkah for prayer and Umrah. This mass gathering could lead to an increase in the rate of transmission of respiratory viruses such as SARS-CoV-2. Since the mass gathering of the 2020 Umrah season reached 2,595,830 visitors, it is essential to highlight that such mass gatherings represent a suitable environment for SARS-CoV-2 transmission.[20] To our knowledge, no other studies have been conducted in Makkah or Saudi Arabia to assess the knowledge of visitors to the Holy Mosque regarding the transmission of SARS-CoV-2. Thus, we aimed to assess the knowledge and practices of visitors to the Holy Mosque related to transmission modes of SARS-CoV-2. Assessing the knowledge of visitors would help the Saudi government determine knowledge gaps, which could then be used to tailor awareness programs and educational activities targeting the general population, as well as visitors coming from different countries around the world.
| Methods | | |
Study design and population
We conducted a cross-sectional study in Makkah, Saudi Arabia from January 19 to February 9 2020 in the central area of the Holy Mosque among Umrah visitors and residents. We performed the survey ahead of expected safety measures being implemented by the Saudi government, which were eventually announced later in March 2020. Interviewers used electronic devices with questionnaires translated into three languages (Arabic, English, and Ordo) to cover the majority of visitors. Noneducated participants were helped with translation to ensure questions were understood. All participants were included in the study except nonvisitors (e.g. Holy Mosque employees) and those younger than 9-year-old. The sample size was calculated based on a 2.5% margin of error of 2.5% and 95% confidence intervals (CIs), and the total population visiting the Holy Mosque periodically.
Questionnaire and scoring
The questionnaire consisted of three parts to collect demographic data, and data related to visitors' knowledge and practices relating to SARS-CoV-2 transmission. Demographic variables included age, gender, nationality, identity (residency), level of education, and travel history to China in the last 2 months. The authors developed 17 general knowledge questions about SARS-CoV-2 infection, modes of transmission, vaccination, and prevention measures; and four questions related to practices [Table 1]. The questionnaire was validated to confirm that all questions were comprehensive, clearly understood, and presented simply. The questions were reviewed by two experts in the field to confirm the acceptability and efficacy of the questions. A pilot study including 24 visitors was also conducted. Each individual took about 5–10 min to complete the questionnaire. | Table 1: Questionnaire of knowledge and practice towards severe acute respiratory syndrome-coronavirus-2 infection and correct answer percentage
Click here to view |
The participants were informed to respond to the questions based on their knowledge of the subject. The questions were answered on a yes/no basis with an additional “I do not know” option. A correct answer was scored one and an incorrect answer was scored zero. The total knowledge score ranged from 0 to 17, with a high score reflecting more knowledge. The total practices score ranged from 0 to 4, with a high score reflecting better practices relating to SARS-CoV-2.
Statistical analysis
Frequencies of correct answers were described with different options for each question. Comparisons of knowledge and practices scores were compared among participants grouped by demographic variables using independent samples t-test or one-way analysis of variance as appropriate. The knowledge and practices scores ± standard deviation (SD) and P value are reported. Multiple logistic regression analysis was used to identify variables associated with all demographic variables and knowledge scores. Odds ratios (ORs), CIs, and P values are reported. Data analysis was conducted with IBM Corp. Released 2017. IBM SPSS Statistics for Windows, Version 25.0. Armonk, NY: IBM Corp. The statistical significance level was set at P < 0.05 (two-sided).
| Results | | |
Demographics and characteristics of the study population
A total of 451 visitors were interviewed and were asked if they are willing to participate in filling the questionnaire, while 413 completed the questionnaire and were eligible for inclusion. Thirty-eight people were excluded as they either refused participation, did not complete the questionnaire, were younger than 10-year-old, and/or missing values were reported. The rate of correct responses to knowledge and practices questions is reported in [Table 1]. The range of correct answer rates was 13.1%–93.5%. The baseline characteristics of the participants are presented in [Table 2]. Most participants were 30–49 years old (48.4%), with 24.5% and 14.3% of participants aged 20–29 and 50–59 years old, respectively. The majority of participants were female (56.9%). The respondents included 137 (33.2%) people from Egypt, 63 (15.3%) from Saudi Arabia, 29 (7%) from Sudan, 24 (5.8%) from Pakistan, and 23 (5.6%) from Jordan.
Participants knowledge related to coronavirus disease 2019 pandemic
The mean knowledge score was 11.3 (SD 2.47, range 2–16), with an overall correct response rate of 64.9%. The knowledge questions with the highest proportion of correct answers were K5 (Do you think the new CoV could transmit from person to person?), K6 (Do you think that sneeze is considered as a way to transmit the new CoV infection?), and K7 (Do you think that cough is considered as a way to transmit the new CoV infection?), with 93.5%, 89.3%, and 87.4% of respondents answering correctly, respectively. The questions with the lowest proportion of correct answers were K3 (When you experience the following symptoms: Fever, cough, shorten of breathing will you go to the hospital immediately?), K8 (Do you think that the new CoV could be transmitted by Mosquito bite?), and K10 (Do you think that the new CoV can transmit from place to another by air?), with 13.1%, 40.7%, and 44.8% of answers correct, respectively [Table 1]. The knowledge score differed significantly among nationalities and education (P < 0.05). However, there were no significant differences in the knowledge score based on age, gender, or identity [Table 3]. Multiple logistic regression analysis revealed that a higher level of education was associated with better knowledge about SARS-CoV-2 (OR 1.18, P = 0.028). However, there was no association between age, gender, nationality, or identity with better knowledge about SARS-CoV-2 [Table 4]. | Table 3: Demographic characteristics of participants and knowledge score
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 | Table 4: Multiple logistic regression analysis of the association between demographic variables and knowledge scores related to severe acute respiratory syndrome-coronavirus-2
Click here to view |
Participant practices related to severe acute respiratory syndrome coronavirus-2 infection
The mean practices score was 2.92 (SD 0.71, range 0–4), with an overall correct response rate of 73.2%. For the questions related to practices, the highest correct response rate was for P2 (Do you think washing your hands by water and soap can reduce transmission of the new CoV?), with 92.7% of respondents answering correctly, while the lowest correct response rate was for P3 (If you have a package from China in the next 2 days, are you going to receive it?), with 20.1% of respondents answering correctly. The practices score differed significantly among nationalities (P < 0.05). Respondents from most nationalities responded correctly in saying that wearing masks and washing hands by water and soap can reduce the transmission rate of SARS-CoV-2. Interestingly, most people responded “No” when asked if they would take a package received from China during the outbreak. There were no significant differences was reported with age, gender, education, or identity [Table 5].
| Discussion | | |
Acute viral respiratory tract infection is the most common respiratory infection worldwide.[21] Even though most viral respiratory infections are self-limiting and have a low mortality rate, there were around 50 million deaths as a result of Spanish flu reported worldwide in 1918.[22] Raising awareness of transmission modes of viral respiratory infections is considered one of the most important ways to help reduce the incidence and prevalence of infection.
Globally, several studies have assessed the knowledge and practices related to SARS-CoV-2.[23],[24],[25],[26],[27] However, in Saudi Arabia, particularly Makkah city, no studies have been conducted to assess the Saudi population or Umrah visitors regarding their knowledge and practices related to SARS-CoV-2.
This study began in the early stages of the COVID-19 outbreak at the beginning of January 2020, before any case of the disease had been reported in Saudi Arabia. The first SARS-CoV-2 case in Saudi Arabia was reported on March 2, 2020. At that time, the information provided by decision-makers to the public about this new infection was not sufficient, which is why in this study we found that the majority of participants' responses were not correct for some questions related to knowledge and practices. Later on, government authorities started to encourage people with suspected symptoms (such as fever and dry cough) to stay home, not go to the emergency room and seek help through the MOH hotlines. Only 13.1% of the study population responded correctly on how to react when experiencing any suspected symptoms of SARS-CoV-2 infection.
In terms of general knowledge about the SARS-CoV-2 infection, it was found that around 70% of the participants knew the common clinical symptoms of the infection, while Zhong et al. found that about 96% of the Hubei Province study population was familiar with the disease symptoms.[24] This good level of knowledge among the participants could be explained by the fact that COVID-19 is a respiratory infection, and the information about these respiratory diseases is widely available and accessible for the general population, especially given the effect of social media and online search engines. Since COVID-19 is a new emerging infection, around half of this study population knew that there is no curative treatment or approved vaccine to date. However, in a study by Rugarabamu et al., the majority (96%) of the study population was knowledgeable about this information.[25],[28]
It is important to mention that during the onset of the COVID-19 pandemic, information about the source of SARS-CoV-2 was connected to the Wuhan animal market.[28] Thus, one of the study questions was about “the origin of SARS-CoV-2.” It was found that about 66% of the participants were aware that SARS-CoV-2 originated from animals, versus 91% of Hubei Province residents who participated in the Zhong study.[24] The high level of knowledge among Hubei Province residents could be explained by the fact that the outbreak was first discovered in Wuhan, China, and due to intensive exposure to COVID-19 news from the media and the Chinese government.[29] Regarding the question about the transmission possibility of SARS-CoV-2 through eating raw meat (e.g. beef, chicken, and seafood), around 51% of respondents answered correctly. By contrast, only 22% of the participants in the Rugarabamu et al. study knew that eating or contacting wild animals could cause SARS-CoV-2 infection.[25]
As SARS-CoV-2 is known to affect the respiratory system and can be transmitted from person to person through respiratory droplets,[28] it was found that the study participants were aware that SARS-CoV-2 is transmitted through sneezing and coughing, with around 89% and 87% answering correctly, respectively. Similar results were observed by Zhong et al. and Rugarabamu et al., where they found 98% and 97% of their participants knew that SARS-CoV-2 spreads via respiratory droplets, respectively.[24],[25]
Crowded places are considered one of the risk factors that may increase the susceptibility of SARS-CoV-2 transmission,[30] and it was found that 94% of the study population were aware of this. Almost the same results (99%) were reported by Zhong et al. and Rugarabamu et al.[24],[25] It is interesting to note that the majority (90%) of the respondents knew the importance of SARS-CoV-2-infected patients being isolated from others. This might be due to the visitors of the Holy Mosque having a high education level, with 48.3% of people having a University/Bachelor's degree.
It is well known that personal protective equipment is mandatory for medical staff who are dealing with COVID-19 patients.[5] The Saudi MOH did not give any recommendations for the general population to wear masks and/or gloves while being outside their residence, as opposed to Malaysia and Vietnam, where citizens were encouraged to wear masks at all times.[31] Even with Saudi MOH recommendations, it was found that the majority (91%) of participants exhibited good practices regarding wearing masks within crowded places. The participants in studies by Kamate et al. and Giao et al. also believed that wearing masks could prevent SARS-CoV-2 transmission, with 99.8% and 98% reporting this, respectively.[26],[32]
There were some misconceptions about the transmission pathways of the virus. Our study revealed that approximately 41% of the participants thought that SARS-CoV-2 could be transmitted through mosquito bites. In addition, around 45% of the respondents thought that SARS-CoV-2 could be transmitted from one place to another through aerosols. These misconceptions among the general population could be explained by the high transmission rate of SARS-CoV-2 that has been observed between individuals.
The new era of modern trade has seen a shift toward online merchandise. Obviously, China is considered the primary industry of global trading, and many people from worldwide purchase goods online from China.[28] Due to the restriction of access between countries as a result of the SARS-CoV-2 outbreak,[33] the express shipping sector was profoundly affected because of some misconceptions in the general population. Our study confirmed this misconception, with 20% of participants reporting that they would not receive packages from China throughout the COVID-19 outbreak.
| Conclusions | | |
We conducted the first study of visitors to the Holy Mosque to assess their knowledge and practices related to the SARS-CoV-2 infection. Since this study was performed at a very early stage of the outbreak, it was not predicted that we would find a high rate of correct responses among study participants. In general, most of the visitors had an appropriate level of knowledge regarding SARS-CoV-2 and its transmission modes, although there is still room for improvement in certain areas such as health education, awareness of protection, and practices toward SARS-CoV-2 infections. Our suggestion for future work is to continue the assessment of visitors to the Holy Mosque throughout the year (different seasons), to cover as many nationalities and age groups. The ultimate goal is to create a proper and safe environment for Holy Mosque visitors to educate and protect them throughout the COVID-19 outbreak and any other future outbreak. Since regulations updates from the Saudi government institutes, including the Ministry of Health, are frequent, hopefully, our study results will help the decision-makers to plan future restriction/gradual re-open orders at such mass gathering events.
Acknowledgments
We would like to thank the Custodian of the Two Holy Mosques Institute for Hajj and Umrah Research, Umm Al-Qura Universiy for their support throughout the study. This study would not have been possible without the institute's support to collect the study data.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]
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