Assessment of knowledge and attitude of allied healthcare professionals about COVID-19 across Saudi Arabia

1.Introduction

Since the inception of the coronavirus disease (COVID-19) in December 2019 [1], healthcare workers (HCWs) are constantly providing services to the diseased individuals. For a system to function effici-ently, it needs support of people who are working at the background or providing assistance to the he-alth care professionals (HCPs) [2, 3]. For any nation, the allied health care professionals (AHPs) are an indispensable component in the Health care delivery system. They continued to act as a backbone in the present pandemic situation by providing constant support to the frontline HCPs. AHPs play role in disease identification, evaluating the parameters wh-ich assist in obtaining a diagnosis and providing rehabilitation services [4, 5]. Broadly speaking they are non-nurse, non-physician health care providers, including physical therapists, occupational therapi-sts, nutritionists, dieticians, speech pathologists, dental technicians, dental assistants, diagnostic medical personnel, imaging specialists, physician assistants, and many more [4]. Any disparity in coordination while following the protocols and recommendations between the HCPs and AHPs can result in severe consequences [6]. With the constant rise in COVID-19 cases, the AHPs are stressed and show signs of burnout, because of the overload and fear of the unknown [7]. In this difficult time, they have to provide care to the patients by keeping themselves safe.

COVID-19 has been declared a pandemic on 11 march 2020 by the World Health Organization (WHO) [8]. It is believed to be caused by severe acute respiratory syndrome corona virus-2 (SARS COV-2) [9]. The disease can be asymptomatic in its initial phase to symptoms ranging from fever, dry cough, shortness of breath, headache, diarrhoea and vomiting [9, 10]. Furthermore, an alteration or loss in taste sensation and perception of smell has been recognized as a common clinical presentation [11]. COVID-19 has the potential of being transmitted from one person to another through direct or contact transmission [10]. The other routes of transmission can be fecal-oral, saliva and aerosol. In case of indirect transmission, it occurs via airborne and fomite [12, 13]. It is believed to be transmitted via inanimate objects as the virus can stay alive on these objects from hours to days [14]. Although the case fatality rate is 3.4%, which is comparatively less than past epidemics such as the severe acute respiratory syndrome coronavirus (SARS-CoV) and Middle East respiratory syndrome coronavirus (MERS-CoV), it has claimed more lives all around the world [15].

Saudi Arabia (KSA) had witnessed an epidemic of MERS-CoV in 2012 and subsequently government had made policies and procedure to combat the dis-ease [16]. Similarly, in the early days of COVID-19, advisories and guidelines were issued to counteract this pandemic situation [17–19]. Globally, AHPs such as diagnostic personal at screening or imaging specialist who are processing the radiographs and dental technicians are working at the same pace with the HCPs or dental health care professionals (DHCPs). Nonetheless, the role of other AHPs such as nutritionists and dieticians during and post COVID-19 in providing counselling to the diseased indi-viduals are noteworthy [20]. In the present COVID-19 era, it is important to assess the knowledge and attitude of the health services provided by the allied healthcare professionals (AHPs) as they play a pivotal role against COVID-19 along with other healthcare workers. To the best of our knowledge, none of the research papers have exclusively assessed the knowledge and attitude of AHPs about COVID-19. Thus, the aim of the study was to assess the knowledge and attitude of AHPs towards COVID-19 across KSA.

2.Materials and methods

3.Results

A total of 195 respondents participated in the study, of which 68.7% were male and 31.3% were female. About half (50.3%) of the respondents were in the age group of 31–40 years. The maximum responses for the survey were gathered from the northern region (34.9%) whereas the eastern region of KSA (5.1%) contributed the least. The majority of our responde-nts had a bachelor’s degree (47.2%) and AHPs with more than 10 years of experience constituted maximum (35.4 %) in the sample. AHPs working in the governmental sector represented in high number (84.6%) compared to their private contemporaries. Considering the nature of work set-up, AHPs engaged in regional hospitals (52.8%) outscored their counterparts by participating in large numbers. On com-paring the preferred source of information, the Ministry of Health (MOH) website was found to be trending compared to the other sources (Table 1).

The assessment of knowledge domain was done with 15 questions. More than half of the respondents (52.8%) displayed a moderate level of knowledge, whereas about 32.8% showed good knowledge. Majority of respondents gave an incorrect response for two questions which dealt with nomenclature (63.07%) and regulation regarding hand hygiene (91.8%). For the remaining questions, they responded well with outstanding response for question related to disease transmission (97.4%) and presenting symptoms (99%) (Table 2).

For evaluating the attitude domain, 14 questions were asked from the AHPs. The majority (80%) sh-owed good attitude whereas only 2.1% had poor attitude. A large part of the questions were answered correctly and a phenomenal response were observed for question referring to the identification of precipitating factors (Strongly agree –82.6%) and PPEs (Strongly agree –81.5%). The negatively worded que-stions were answered incorrectly (Table 3).

With regards to the knowledge domain, except so-urce of information (P < 0.001), no other independent factors were found to have significant association. For the sake of better statistical interpretation, the moderate and poor levels of attitude scores were combined resulting in overall attitude score into dichotomous variable. AHPs working in governmental organization were found to have significantly (P < 0.05) higher than then their contemporary working in a private setup (Table 4).

Significant results of univariate analysis for attitude domain were subjected to multivariate logistic regression. The AHPs working in private organiza-tion displayed a 2.8 times hgher risk of having moderate/poor attitude in reference to employees of a governmental organization (Table 5).

4.Discussion

Presently, the cases of COVID-19 are tremendously increasing across the globe. It is noteworthy that collective efforts of public, government, HCPs along with AHPs can taper the condition [24]. Until now, none of the studies have exclusively focused AHPs’ knowledge and attitude about COVID-19. Only few studies have assessed the knowledge and attitude regarding COVID 19 of DHCPs, and HCPs along with AHPs [3, 25–29]. Thus, a direct comparison cannot be made. Although, relevant questions and segment of previous studies dealing with AHPs has been discussed and compared in the present study.

The AHPs in the current study demonstrated a moderate knowledge (52.8%) and good attitude (80%) towards the COVID-19. An interesting finding in the present study is that the AHPs rely more on the MOH website (80.5%) compared to other sources such as social media. It is contrary to the findings of studies done with Vietnam and Pakistan HCPs [25, 29] where social media was the most preferred source of information. Although social media helps in fast propagation of information but it has a potential to spread news which is otherwise not correct [30]. Hence, a closed watch with logic is must to follow the norms propagated with social media. In our study majority of the respondent referred MOH website for information which shows a unanimous spread of information throughout the country. This dissemination of information by MOH was not only restricted to the HCWs, but also the general public was being constantly informed through the website and awareness campaigns [31].

In the knowledge domain, pertaining to the questions related to nomenclature and origin of the disease, respondent have correctly answered the que-stion in majority of the cases. Incorrect responses were received for question related to the virus and disease identification pertaining to SARS CoV-2 and COVID-19 respectively. The probable reason could be the constant update in the taxonomy based on the evidences gathered by researches in this field. On January 12 2020 WHO named the virus novel coronavirus 2019 (2019-nCoV) [9]. Later, the name of the virus was renamed to severe acute respiratory syndrome coronavirus 2 (SARS CoV-2) in a consen-sus statement of the International Committee on Taxonomy of Viruses [32]. On February 11 2020, to avoid any inaccuracy and stigma, the disease was named coronavirus disease 2019 (COVID-19) [9]. Therefore, it seems logical that the AHPs might have been confused with the nomenclature and have responded incorrectly. Questions pertaining route of transmission were correctly answered by most of the respondents. The main route of disease transmission is supposed to be through respiratory droplets via direct or contact transmission [12], although with emerging evidences fecal-oral, saliva, aerosols as well as airborne and fomite transmissions are gaining attention [12, 13]. The aerosols measuring <5 microns remain disseminated especially in the closed environment with improper ventilation for a longer period of time, hence are supposed to be more infectious in the medical setup [11]. The knowledge of AHPs about the route of transmission for COVID-19 was consistent with other studies [26–28, 33]. Questions about the symptoms and recognizing patients at higher risk, has shown excellent correct response rate of 99%. Another study carried out with Egyptian population had a response rate of 95%, which is comparable [28]. This is considerably important for AHPs to be updated with the knowledge about this aspect as it will help them to screen the patients as well as plan the treatment accordingly. The common symptoms associated with COVID-19 include fever, cough, shortness of breath, myalgia, headache, vomiting and diarrhoea [9, 10]. It has been reported that elder age group and patients with systemic illness are more prone for COVID-19 [10, 34]. In a study done on Saudi Arabian population, it was found that the patient affected by COVID-19 has shown clinical manifestation of fever (85.6%), cough (89.4%), and sore throat (81.6%). The other symptoms were runny nose (72%), myalgia (28.6%), headache (27.3%), and gastrointestinal symptoms (14.3%) [35]. In the same study 20.1% of the patient who had co-morbidity were affected by COVID-19 [35]. As far as questions related to prognosis and treatment were concerned, the case fatality rate of COVID-19 is lower than SARS and MERS [15] and it was correctly answered by majority of the respondents. Regarding the antibiotics been the first line of treatment, was answered correctly. As a matter of fact, it is a viral infection and antibiotics can play a role only to prevent bacterial superinfections. Presently, many antiviral drugs, plasma therapy, and corticosteroids are given as symptomatic treatment [36]. Knowing the causative agent as virus, many antiviral drug therapies have been proposed but to conclude affirmatively as a curative agent, none of them have claimed as the prophylactic/curative antiviral drug [37]. The AHPs have responded correctly to the availability of the vaccines. Vaccines for COVID-19 are currently not available on the market, although in many countries vaccines are under the phase III trial, i.e. human trial are ongoing, whereas in Russia the vaccine has been registered although the trial is still ongoing [38]. For the prevention of disease transmission, WHO and centre of disease control (CDC) guidelines have identified the practice of hand hygiene of outmost importance [39, 40]. The knowledge of AHPs regarding the question about duration of performing hand hygiene is not adequate. According to WHO, it should be at done for least 40 second with soap and water when the hands are visibly soiled. The technique adopted for this is equally important as it includes five specific movements ensuring that every aspect of hand is disinfected [39–41]. When visible dirt is not seen, the hand rub technique can be followed for 20 seconds with 60% –80% alcohol-based hand sanitizer [39, 40]. Thus, the time duration needs to be emphasized to the AHPs. An important finding for this present study is that none of the independent variables such as age, gender, region, education, educational level and years of experience have affected the knowledge outcome. The knowledge level of AHPs about COVID 19 was similar all around KSA.

The AHPs have attained a good (80%) attitude scores towards COVID-19 which portrays that they are fighting the disease with a positive attitude. Display of such attitude is must to overcome any disease. It has been reported that person with positive attitude and positive behaviors have a better tendency for coping strategies [42]. Attitude score of the present study were similar to few [28] and less compared with the study done on Nepalese HCPs [27].

It is noteworthy that AHPs are well aware that they should attain knowledge about the COVID-19 and disseminate among peers so that they should remain updated with the current norms. It shows zeal among them to combat the disease with updated knowledge. The AHPs are well aware about the protocol of travel restriction and large gathering. As per the WHO, the patients are supposed to be in quarantine for about 14 days if they had travelled internationally or locally or they have come in close contact to the COVID-19 positive patient [43]. As far as the large gathering is concerned, the protocol of safe distancing is compromised leading to spread of the disease. Hence, recommendations and advisory were published not to gather in a crowded area [43, 44]. Interestingly, the AHPs have shown a good attitude towards the infection control protocol. The results were similar with other countries [25] and better than few others [27]. Few questions related to infection control has been overestimated and overrated by the AHPs such as the usage of N95 respirators by undiagnosed patients of COVID-19. Over usage of respirators or other personal protective equipment (PPEs) can lead to shortage and hence it cannot be provided to the needy [45]. Hence, judicious usage of mask is a crucial. Although, as per the new evidence of airborne transmission, WHO advised to wear a mask, perform social distancing and follow hand hygiene measure to curb the disease spread [46]. The AHPs are well aware that they have to follow the infection control protocol and guidelines issued by WHO, CDC as well as local body i.e. MOH. Strict compliance with the measures will help in complete rehabilitation of the patient and lessen the chance of AHPs from getting infected. As reported in a study in Saudi Arabia, 12.5% of COVID-19 patients were working in a health care facility [35]. Hence, it is important to understand that the HCPs along with AHPs are at higher risk of getting this disease. Any disparity to follow infection control protocol can lead to grave consequences for the health care machinery. Regarding treatment, the AHPs are well-aware about the criteria for a patient to be advised for isolation or admit in intensive care unit. This shows a positive attitude and correct approach for the treatment. An important point to be addressed is the attitude of AHPs working in a private setup, as they were shown to have 2.8 times risk for possessing a moderate/poor attitude in comparison to AHPs working in a governmental setup. However, the level of knowledge of AHPs working in both the sets up was similar. In a study done on Saudi Arabian hospitals, it was found that there is a significant association between attitudes towards healthcare service quality and hospital performance [47].

The present study has a few limitations. Since the study was conducted online in a period where the country was facing lockdown, a face-to-face survey would have excluded the potential bias of misinformation. In the background of the current survey results, continuing professional development program (CPD) can be conducted to bridge the gap between existing and the required knowledge. Based on these findings, a recommendation can be made which would be helpful for the AHPs to work with a scientific background by protecting the patients as well as themselves.

5.Conclusions

The allied healthcare professionals have shown moderate knowledge and good attitude towards COVID-19. The knowledge of the AHPs can be enh-anced by conducting continuing professional development program. Furthermore, strategic planning should be implemented for the private hospitals to enhance the attitude of AHPs.

Author contributions

Conceptualization, D.S., A.A.A, K.C.S. and M.G.S; methodology, D.S., A.A.A, K.C.S. and M.G.S; software, K.C.S. and A.F.S.; validation, K.C.S., D.S. and A.F.S.; M.K.A formal analysis, K.C.S.; investigation, K.C.S., K.A and A.F.S.; resources, A.A.A, K.C.S. and M.G.S; data curation, D.S; K.C.S. and M.G.S; writing—original draft preparation, D.S. and K.C.S.; writing—review and editing, D.S., A.A.A, K.C.S., A.F.S., K.A., M.G.S;M.K.A visualization, K.C.S., A.A.A, and M.G.S; supervision, K.C.S; project administration, M.G.S;M.K.A funding acquisition, A.A.A. All authors have read and agreed to the publish the final version of the manuscript.

Conflict of interest

The authors declare no conflict of interest.

Funding

This research received no external funding.