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Table of Contents
Year : 2021  |  Volume : 4  |  Issue : 1  |  Page : 25-32

Knowledge, attitude, and practice study of laboratory staff toward Middle East respiratory syndrome Coronavirus

1 Department of Emergency Medicine, College of Medicine, King Saud University, Riyadh, Saudi Arabia
2 Department of Medical Education, Medical Informatics and E-Learning Unit, College of Medicine, King Saud University, Riyadh, Saudi Arabia; National Advanced IPv6 Centre (NAv6), Universiti Sains Malaysia, Pulau Penang, Malaysia

Date of Submission07-May-2020
Date of Decision08-Jun-2020
Date of Acceptance21-Jul-2020
Date of Web Publication18-Dec-2020

Correspondence Address:
Samina A Khan
Department of Medical Education, Medical Informatics and E-Learning Unit, College of Medicine, King Saud University, Riyadh, Saudi Arabia; National Advanced IPv6 Centre (NAv6), Universiti Sains Malaysia, Pulau Penang

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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/JNSM.JNSM_41_20

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Background: The Middle East respiratory syndrome coronavirus (MERS-CoV) is one of the most commonly prevalent and a highly pathogenic human coronavirus. The infection may lead to severe acute respiratory illness in a large proportion of affected individuals, with a high mortality rate. The processes and procedures involved in the management of patients could significantly improve the disease outcome. The purpose of the study was multifold: (1) to assess the actual knowledge, attitudes, and practices (KAP) toward MERS-CoV infection and (2) to determine the factors affecting KAP among the medical laboratory staff in Riyadh, Saudi Arabia. Both the aims would collectively help in designing effective policies in our fight against the evolving coronavirus disease. Materials and Methods: A cross-sectional anonymous survey was conducted among medical laboratory staff associated with tertiary health-care hospitals between October and December 2018. The participants were invited to complete a self-administered questionnaire about MERS-CoV infection. The association between KAP score and potential dependent variables was computed using multivariable linear regression model. Results: A total of 180 participants (57.8%) completed the survey. Our univariate analysis demonstrated that experience and education of an individual played a significant role in determining knowledge and attitude scores, respectively. On the other hand, practice score of an individual was shaped by age, profession, and department. Finally, our multivariate analysis regression analysis showed that staff with a bachelor's degree and those with a minimum laboratory experience of 15–20 years scored significantly higher KAP scores with respect to other individuals (P = 0.019 and P = 0.026). Conclusion: Our study identified alarming gaps in KAP toward MERS-CoV among different individuals. Furthermore, data collected in the present study might help to define strategies required to establish professional education programs for training medical laboratory staff.

Keywords: Knowledge, attitudes, and practices, laboratory, Middle East respiratory syndrome coronavirus, Riyadh

How to cite this article:
Al-Motiri NM, Khan SA, Khan AA. Knowledge, attitude, and practice study of laboratory staff toward Middle East respiratory syndrome Coronavirus. J Nat Sci Med 2021;4:25-32

How to cite this URL:
Al-Motiri NM, Khan SA, Khan AA. Knowledge, attitude, and practice study of laboratory staff toward Middle East respiratory syndrome Coronavirus. J Nat Sci Med [serial online] 2021 [cited 2023 Jan 28];4:25-32. Available from: https://www.jnsmonline.org/text.asp?2021/4/1/25/306261

  Introduction Top

The Middle East respiratory syndrome coronavirus (MERS-CoV), a new pathogenic virus, is known to cause severe acute respiratory illness in humans.[1] MERS-CoV belongs to a family of single-stranded RNA virus coronaviruses that caused outbreaks of severe acute respiratory syndrome in 2003 and novel coronavirus in 2019, both of which have been believed to emerge in China.[2],[3] On the other hand, MERS-CoV was first reported in Saudi Arabia in 2012. Since the notification of its first case, the latest global update by the WHO till November 30, 2019, shows a total of 2,494 laboratory-confirmed cases from 27 countries, 84% of whom belong to the Kingdom of Saudi Arabia.[4] Among the reported cases, 791 individuals died with a crude case fatality rate of 35.5%. The epidemiology, transmission patterns, clinical presentation of MERS-infected patients, viral characteristics, and laboratory parameters required for MERS diagnostic testing are well documented.[5] While MERS-CoV is known to enter the human population with direct or indirect contacts with camels, limited and nonsustained human-to-human transmission in clinical settings continues to be reported from the Arabian Peninsula. However, being a relatively rare disease, medical staff, including those employed by medical laboratories, have limited awareness for MERS. Furthermore, several reports in the past have highlighted a critical role of health-care workers (HCWs) in the spread of infection. Oboho et al. 2015, in their recent report on 255 patients with laboratory-confirmed MERS-CoV infection from Jeddah, Saudi Arabia, showed that a large proportion of symptomatic patients were either health-care personnel (HCP) or came in contact with a HCP.[6] Medical laboratories are staffed with individuals with diverse expertise, who play an essential role in the early detection and identification of the etiology of potential infectious disease. Besides, reports on the rate of infection at an early stage generated by the staff could help in planning strategies for the prevention of further disease spread. Several studies have further highlighted the existence of advanced diagnostic capabilities along with trained medical laboratory staff in responding to any future outbreaks.[7],[8],[9] Although a significant improvement in surveillance for MERS in the Middle East in recent years, limited knowledge, and misperceptions of medical staff in the mid-evolving infectious outbreak continue. In preparation for future emergencies, infections continue to be of significant concern.

Previously, various cross-sectional studies have investigated knowledge, attitudes, and practices (KAP) toward MERS-CoV infection among HCWs in Saudi Arabia, the majority of them being physicians, nurses, and medical students.[10],[11],[12],[13],[14],[15] While the studies showed considerable heterogeneity among the results, which could be attributed to diverse educational background and social class of the study participants, a consistent poor attitude with limited virological knowledge of MERS-CoV was observed.

However, to date, reports specifically assessing the KAP toward MERS-CoV, specifically individuals employed in laboratories, are lacking. We hypothesized that there are gaps in KAP toward MERS-CoV among medical laboratory staff in Riyadh. In light of laboratory staff members as one of the most high-risk individuals who help us in combating this deadly infection and rapidly changing demographics of coronavirus infection, we aim to evaluate KAP toward MERS-CoV among medical laboratory staff in Riyadh, Saudi Arabia. We further aim to determine the factors affecting KAP among the study participants.

  Materials and Methods Top

Study design

This cross-sectional, self-administered, anonymous survey was conducted on the medical laboratory staff of three hospitals: (1) Prince Mohammed Bin Abdulaziz Hospital, (2) Yamama Hospital, and (3) Dr. Sulaiman Al Habib Hospital, all in Riyadh city, Saudi Arabia, from October to December 2018. The target population specifically included medical laboratory staff with a minimum clinical experience of 1 year. The study was conducted in accordance with the Strengthening the Reporting of Observational Studies in Epidemiology guidelines.[16] The sample size required for the study was estimated to be 170, based on an average conservative estimate of 55% of perfect KAP score with a margin of error for 2.5% and a 95% confidence interval.

Data collection

The data were collected through an electronically administered, using social media platform, Twitter, a structured and validated questionnaire in the English language, based on the Centers for Disease Control and Prevention guidelines.[17] The questionnaire was designed and validated by a team of experts belonging to various fields of specializations, namely epidemiology, biostatistics, and infectious disease. The researcher went to the targeted three hospitals with approved Institutional Review Board (IRB) form from the institution and talked to the laboratory supervisors. They discussed the aim of the research, and the researcher was taken to the laboratory to meet and explain the purpose and importance of the study to the laboratory staff members. The study was conducted in accordance with the Declaration of Helsinki. The staff was requested to take the survey by going to the researcher's Twitter account. Social media is a potential alternative to traditional surveying methods, because of its virtual interaction features, that allows for the creation, sharing, and exchange of information.[18],[19],[20] And therefore, to reach a large audience, Twitter approach was used.[21] The questionnaire and the study protocol were further approved by the IRB at King Saud University Medical City. All the study participants gave their informed consent for participation in the study at the beginning of the survey. The questionnaire comprised six main sections: sociodemographic, knowledge, attitude, practice, training and learning preference, and barrier prevention. In the sociodemographic section, information about the study participants was collected and included information on variables such as age, gender, profession, education, and experience. The knowledge section comprised a set of 10 questions related to signs and symptoms in infected individuals, mode of transmission of virus, diagnosis, and prevention and treatment of infection. The attitude section comprised a set of 13 questions related to behavioral perceptions toward active participation and measures required to prevent the transmission of MERS-CoV infections. The practice section comprised a set of 12 questions used to evaluate the compliance of recommendation laid down by the public health institutes to prevent the spread of infection. The training and learning preference section comprised questions related to previous training and learning preferences of the study participants, if they were to be involved in receiving training on the MERS-CoV issues. The last section included questions about the barriers to infection control practices as addressed by medical laboratory staff.

Data analysis

For the knowledge section, the correct responses were given a 1 score and incorrect answers were given a 0 score. The expected maximum total knowledge score was 10. For the attitude section, 9 of 13 questions were available with the options: strongly agree, agree, uncertain, disagree, and strongly disagree and were scored 5, 4, 3, 2, and 1, respectively. The remaining four questions were given a score of 1 for a positive attitude and 0 for a negative attitude. The expected maximum total attitude score was 49. For the practice section, the correct responses were given a 1 score and incorrect answers were given a 0 score. The expected maximum total practice score was 12. The KAP scores of each study participant were further pooled to give a cumulative KAP score, which had a maximum expected score of 71. Data entry, coding, cleaning, and data analysis were performed using the Statistical Package for Social Sciences (SPSS) version 24.0 (SPSS, Inc., Chicago, IL, USA) and R software (version 3.2.4; R Foundation for Statistical Computing, Vienna, Austria). Normal distribution of knowledge, attitude, practice, and KAP scores was assessed using the Kolmogorov–Smirnov test. Furthermore, normally distributed continuous variables were expressed as arithmetic means with standard deviations and nonnormally distributed continuous variables were expressed as medians and ranges. Similarly, distribution of categorical variables was expressed as frequencies and percentages. Normally and nonnormally distributed continuous variables were compared using ANOVA and Kruskal–Wallis test, and categorical variables were compared using χ2 test. P < 0.05 using a two-tailed test was considered as significant for all the statistical analyses. Multivariable linear regression models were used to judge the association between knowledge, attitude, practice, and KAP scores and potential dependent variables. We further used multiple imputation based approach to impute missing data if missing information for any of the variables was <10%.

  Results Top

Demographic characteristics

A total of 180 laboratory staff who filled the survey completely and were eligible were included in the study. The demographic characteristics of the study participants are further shown in [Table 1]. Females were more prevalent in our study sample as compared to males (58.3%). The majority of the study participants were of Saudi ethnicity (61.7%) and were <36 years of age (52.8%). A large proportion of our participants were laboratory specialists (45.0%), followed by laboratory technicians (17.8%), and most of the respondents had a bachelor's degree or above (79.4%). The participants belonged to various departments, mostly working under the government (75.6%). Furthermore, finally, we observed a fairly constant representation of participants for differences in laboratory experience, with only a small proportion of participants with more than 15 years of experience (14.5%).
Table 1: Demographic characteristics of the study participants (n=180)

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Correlation among knowledge, attitude, and practice scores

The median and range of KAP scores and the correlation among all the scores are shown in [Table 2]. We observed a strong and positive correlation between knowledge and attitude scores (r = 0.204, P = 0.006). On the other hand, a strong and negative correlation was observed between knowledge and practice scores (r = −0.217, P = 0.003).
Table 2: A correlation matrix exploring the relationship between knowledge, attitude, and practice among the study participants (n=180)

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Descriptive analysis of knowledge, attitude, and practice scores

The survey showed that most of the participants had the knowledge of MERS-CoV, as summarized in [Table 3]. The participants knew that HCP must wear gowns, surgical masks (or N95), face shields, and gloves when dealing with suspected or confirmed cases of MERS-CoV infection. Surprisingly, only one of every three respondents knew that MERS-CoV spreads through close contact only. Furthermore, a large proportion of the participants had a false belief that antibiotics are the first line of treatment of choice (59.9%).
Table 3: Knowledge about the transmission of Middle East respiratory syndrome coronavirus among the study participants (n=180)

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The majority of the participants had an acceptable attitude toward treating MERS-CoV as a dangerous infection (93.9%) in [Table 4]. Furthermore, the majority of them felt disturbed when directly dealing with patient's samples or hearing-related news (67.8%). Surprisingly, only one in every two participants believed that protective measures available at hospitals are sufficient for prevention. However, regarding attitudes toward prevention and staying up to date with the latest information on infection, most of the participants showed a positive attitude. On the contrary, approximately half of the participants expressed a lack of confidence in procedures and policies when directly dealing with sample patients.
Table 4: Attitudes toward Middle East respiratory syndrome coronavirus among the study participants (n=180)

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In contrast to knowledge and attitude of the study participants toward MERS-CoV infection, all the participants performed extremely well when answering questions related to best practices when dealing with MERS-CoV infection in the laboratory [Table 5]. However, a large proportion of participants had never attended a workshop or training course, suggesting the possible reason for participants scoring poorly in some of the knowledge questions with poor attitude (65.6%).
Table 5: Practices related to the handling of Middle East respiratory syndrome coronavirus infection cases among the study participants (n=180)

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Simple inferential statistics

The distribution of KAP scores among the study participants stratified by different demographic characteristics is shown in [Table 6]. While education levels (P = 0.021) and laboratory experience (P = 0.016) were moderately associated with knowledge scores (P = 0.021 and P = 0.016), the profession was shown to strongly influence the knowledge scores, with clinical pathologists being the best performers with a median score of 8 out of 10 (P = 0.007). On the contrary, the education level of an individual was observed to be the only factor associated with attitude scores with those having completed a master's degree or equivalent, showing a median attitude score of 36 out of 49. Practice scores, on the other hand, were also profoundly influenced by the department in addition to age, profession, and education levels, all of which had a substantial impact on shaping the best laboratory practices. Interestingly, education and laboratory experience were shown to be moderately associated when cumulative KAP scores were compared among different demographic variables.
Table 6: Distribution of knowledge, attitude, and practice scores among the study participants (n=180)

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Multiple linear regression

We further carried forward the variables shown to be associated with univariate analysis to check for potential confounding. Our multiple linear regression showed that both education and experience of the study participants were retained as significant and independent predictors of KAP scores, explaining 7.58% of the variance in the distribution of KAP scores (P = 0.0042). Our model further identified that individuals with bachelor's degrees and those with 16–20 years of laboratory experience performed the best in our MERS-CoV KAP survey (P = 0.0194 and P = 0.026).

  Discussion Top

To the best of our knowledge, this is the first study on the KAP toward MERS-CoV among medical laboratory staff only. Although most of the participants reported that they were aware of MERS-CoV, they had insufficient knowledge about the spread of infection and treatment. Surprisingly, despite having a positive attitude and adoption of best practices, the majority of the participants expressed lack of confidence in dealing with an outbreak. We further observed that education level played a predominant role in shaping the knowledge, attitude, and adoption of best practices by an individual. Although age and department of an individual played an important role in the following of best practices, education level and experience were observed to be the independent significant factors in determining the overall KAP score. Our data, therefore, provide ground realities and challenges that may be encountered during an infection outbreak and suggest the need for designing strategies to fill the knowledge and attitude gap among various medical laboratory staff members and thereby ensure better preparedness in the future.

To date, several studies have investigated KAP toward MERS-CoV in Saudi Arabia.[10],[13],[22],[23],[24] Interestingly, the majority of the studies employed HCWs as study participants. Furthermore, most of the studies focused primarily on students and nurses. We further identified only a handful of studies using study participants from Central Saudi Arabia.[22],[23],[24] While a recent study by Albarrak et al. 2019 reported data collected from 391 HCWs based in Riyadh, comprising mostly physicians and nurses (74.4%), a study by Hazmi et al. 2016, although had a larger sample size of 1109, had only university and school students.[22],[24] Our study with 180 medical laboratory staff thereby represents an extremely unique cohort and adds critical information to the missing literature.

Although the nature and difficulty levels of questions asked by different studies were highly variable, we did observe that our results showing high overall good knowledge score were in consent with previously reported findings among HCWs. Similar to significant influence of an individual's profession on knowledge scores reported by Albarrak et al. 2019 with physicians performing better than laboratory technicians, we observed clinical pathologists scoring high compared to laboratory technicians.[22] On the contrary, almost half of our study showed poor attitude with lack of awareness of handling of samples and policies that need to be implemented during an outbreak of MERS-CoV infection. Our study participants, however, performed better than a previous study on 1216 HCWs from Western Saudi Arabia, which reported lack of awareness of guidelines or protocols for the care of patients with MERS-CoV infection in almost two-third of the respondents.[10] Nevertheless, similar to our study, a large majority of HCWs showed eagerness to apply infection control measures in the same study. Our study participants also performed well on most of the practice questions. However, one-third had never attended a workshop or training course on MERS-CoV. Furthermore, our results show that accessibility to such workshops was influenced by an individual's age, profession, and education level, highlighting the need of restructuring the existing policies of the Ministry of Health when imparting training to medical laboratory staff.

Our study had several strengths and limitations. The strength of this study is that it addresses a major public health concern specifically in light of recent outbreak of COVID-19 pandemic.[25] Our study specifically highlights the prevalence of KAP among the laboratory staff, whose role often goes unnoticed compared to other frontline workers such as physicians and nurses. Another strength of our study could be that we had a good representation of Saudis and non-Saudi population, both males and females, and different age groups. Moreover, collection of information from various hospitals increases the generalizability of our results and findings. However, the questionnaire-based method to collect data may be subject to recall bias and misclassification. Furthermore, variable response rate across different hospitals and potential participant clustering cannot be ruled out, which could not be assessed due to anonymous nature of the questionnaire. Nevertheless, our study highlights the need for including an under-represented population of medical laboratories in assessing the preparedness toward future outbreaks of infectious diseases.

  Conclusion Top

The gap in knowledge, attitude, and awareness identified in the present study could serve as baseline data for the Ministry of Health to design effective interventions including the conduct of comprehensive training programs targeting medical laboratory workers irrespective of their education levels or experience. Our study further necessitates the conduct of large-scale studies from various Saudi regions to explore knowledge, awareness, and attitude among medical laboratory staff at the national level.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

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  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]


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