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Table of Contents
Year : 2021  |  Volume : 4  |  Issue : 4  |  Page : 317-323

Assessment of knowledge, attitudes, practices, and vaccine acceptance for coronavirus disease 2019 among the public in a MERS-CoV-endemic country

Department of Internal Medicine, Infectious Disease Unit, College of Medicine, King Saud University, Riyadh, Saudi Arabia

Date of Submission07-May-2021
Date of Decision20-Jun-2021
Date of Acceptance29-Jul-2021
Date of Web Publication06-Oct-2021

Correspondence Address:
Mazin Adnan Barry
Department of Internal Medicine, Infectious Disease Unit, College of Medicine, King Saud University, P.O. Box 2925, Riyadh 1145
Saudi Arabia
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jnsm.jnsm_51_21

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Objective: The objective of the study is to identify associations between the sociodemographic characteristics and the level of knowledge, scope of attitudes, and self-reported practices among adults during the coronavirus disease 2019 (COVID-19) pandemic in Riyadh. Methods: A quantitative, cross-sectional study of adults was conducted using a multistage participatory approach between May 31 and June 7, 2020, in Riyadh, Saudi Arabia. Results: Of 1364 study participants, 73.9% knew the descriptive type of COVID-19. Females showed a statistically significant higher knowledge composite (P < 0.0001), and the majority had higher sufficient knowledge scores than males. Only 24.9% agreed that individuals could be tested positive for influenza and COVID-19 at the same time. Negative attitudes were highly prevalent among younger, unmarried, non-Saudi, male participants (P < 0.05). 72.9% reported placing masks on infants or children under 2 years. Similarly, older age groups and Saudi females were better at practicing risk-based preventive controls for COVID-19 than younger age groups and non-Saudi males (P < 0.0001). 60% expressed that if a vaccine would be available this year, they would feel it was rushed, while 56% would consider receiving it but would wait to see what happens to others. Conclusion: These findings could be helpful in guiding machine learning models in groups more affected by knowledge insufficiency, gaps in attitudes, and behavioral compliance.

Keywords: Adults, attitudes, coronavirus disease 2019, knowledge, practices, vaccine

How to cite this article:
Barry MA, Zawawi BA, AlGhusoon MK, AlArifi AS, AlHothaly SK, Fatani OA. Assessment of knowledge, attitudes, practices, and vaccine acceptance for coronavirus disease 2019 among the public in a MERS-CoV-endemic country. J Nat Sci Med 2021;4:317-23

How to cite this URL:
Barry MA, Zawawi BA, AlGhusoon MK, AlArifi AS, AlHothaly SK, Fatani OA. Assessment of knowledge, attitudes, practices, and vaccine acceptance for coronavirus disease 2019 among the public in a MERS-CoV-endemic country. J Nat Sci Med [serial online] 2021 [cited 2022 Sep 25];4:317-23. Available from: https://www.jnsmonline.org/text.asp?2021/4/4/317/327600

  Introduction Top

Coronavirus disease 2019 (COVID-19) is caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), a highly pathogenic virus that was first discovered in Wuhan, Hubei Province, China.[1] The World Health Organization has recognized COVID-19 as an ongoing pandemic that affects world security and causes economic instability.[2] As infected persons traveled, many cases were contact-traced and emerged as a cluster of acute respiratory illnesses in China and other parts of the world. Coronaviruses spread from person to person through respiratory droplets.[3] Bodily fluids, such as sputum and saliva, carry substantial amounts of virus in infected people.[4] Researchers estimate that 44% of COVID-19 transmissions occur before people develop symptoms.[5] The potential for viral transmission peaks 5–8 h before any symptoms develop. Moreover, infected people become rapidly less infectious within a week, although the virus likely remains in the body for up to 6 weeks.[6] This indicates that it may be infectious presymptomatically for up to 2 days before the onset of symptoms and remain infectious for 7–12 days in moderate cases and an average of 2 weeks in some severe cases.[7] The most common symptoms of COVID-19 include fever, dry cough, and general fatigue.[8]

COVID-19 has caused an unprecedented health crisis worldwide. Saudi Arabia has been profoundly impacted by overwhelming hospitalizations. Riyadh, in particular, has been experiencing large outbreaks, among the largest in the region.[9] By October 19, 2020, Saudi Arabia had 343,373 confirmed cases, including 8423 active cases receiving necessary medical care, 329,715 recoveries, and 5217 deaths. Riyadh has had 57,096 confirmed cases, including 55,108 recoveries and 1199 deaths.[10] Total lockdowns were implemented in Riyadh and other affected cities, with movement restricted to essential travel with permits between 6 a.m. and 3 p.m. to enact mitigation measures and review hospital preparedness.[11] Major shopping areas in major cities play a central role in building a sustainable and resilient COVID-19 reporting system. Shortly before the COVID-19 pandemic, one of the studies carried out at the five largest shopping malls in Riyadh found that less than a quarter of visitors would avoid crowded places and less than a tenth would wear a mask in the event of an outbreak of acute respiratory tract infections.[12] Contextualized geospatial data even revealed a positive association between higher per-capita income and COVID-19 diagnoses, and severe acute respiratory infections were associated with lower per-capita income.[13] It is therefore essential for adults to be educated about the nuances of acute respiratory tract infections. This study aimed to identify associations between sociodemographic characteristics and recent trends or gaps in proper physical distancing and other risk-based prevention methods, knowledge of transmission dynamics, and attitudes toward recommended behaviors during the COVID-19 pandemic in Riyadh.

  Materials and Methods Top

This quantitative, cross-sectional study was conducted in six regionally distributed shopping areas in Riyadh, Saudi Arabia. The areas were Al Nakheel mall in the northwest district, Panorama mall in the west-central district, Riyadh Gallery Mall in the north-central district, Granada Mall in the east district, Al-Othaim Mall in the southwest district, and Al-Qasr Mall in the southeast district. These sprawling shopping areas attract millions of visitors per year and thousands daily. In fact, Riyadh's share of retail sales and market visitors remains the largest in the Gulf region.[14] A total of 1364 Saudi and non-Saudi adults aged 18 and older were interviewed between May 31 and June 7, 2020. The study was performed on both males and females for sociodemographic variables (e.g. age, marital status, education, and income). No participant was excluded on the grounds of gender or nationality. The electronic questionnaire developed for the interviews was guided by validated reviews from the Centers for Disease Control and Prevention (CDC).[15],[16],[17] The questionnaire, which included 29 items, contained three parts: sociodemographic data (8 items), in which participants were assessed for knowledge about COVID-19 and the mechanism of transmission (4 items); depth of attitudes toward COVID-19 (5 items); and physical distancing practices and other risk-based preventive controls during the COVID-19 pandemic (12 items). The reliability of the questionnaire was validated, resulting in a Cronbach's alpha value of 9. A pilot study with 30 people was conducted to test the questionnaire and estimate the time frame needed for the main study. All participants were provided with informed consent for participation in the study. The identity, affiliation, and contact information of the researchers and interviewers were revealed to participants before the interviews. The participants were able to review the contents of the survey and could withdraw from the interview with no penalty.

Data were analyzed using IBM SPSS 24. IBM® SPSS® Statistics, Chicago, Illinois, United States. Frequency counts and percentages were used to summarize sociodemographic variables into descriptive statistics. Each participant was scored on their level of knowledge using a scale from 0 to 4, with 1–2 deemed insufficient knowledge and 3–4 deemed sufficient knowledge. The median score obtained was 2. Similarly, participants' scopes of attitude toward COVID-19 were scored with 5 for a positive attitude and 1 for a negative attitude. The median score was 4. The median total score from assessments of self-reported practices was 10 (11–12 denoted good practices, whereas ≤10 denoted poor practices). Associations between sociodemographic variables and level of knowledge, scope of attitude, and self-reported practices were tested using the Chi-square test. A P < 0.05 was established as an indicator of a statistically significant difference, and continuous variables were summarized as mean ± standard deviation. The study was approved by the Institutional Review Board Committee in King Saud University College of Medicine Board Research on research project on 14.05.2020 with Ref. No. 20/0508/IRB.

  Results Top

Most study participants knew the descriptive type of the novel coronavirus causing COVID-19, but only around half of them knew the most common symptoms of the disease. About half knew how the disease spreads, and about half knew that older adults and persons of any age with underlying medical conditions are at higher risk [Figure 1].
Figure 1: Responses to questions on knowledge of coronavirus disease 2019 (N = 1364)

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Scores for knowledge about COVID-19 as a function of demographic variables were highly statistically significant overall. More than half of the study participants were female, and they showed a statistically significant higher knowledge composite than males (P < 0.0001). In fact, 70.7% of females had more sufficient knowledge than males (21.3%). In terms of participants' residential status, only 23.9% of non-Saudi nationals showed sufficient knowledge, compared to 52.7% of Saudi nationals. The study revealed that the highest scores of sufficient knowledge about COVID-19 were recorded among participants between 36 and 50 years (66.4%) and those older than 50 (75.3%) years of age, versus those aged 18–25 (23.7%) and 26–35 (26.7%) years of age groups. Sufficient knowledge seemed to improve with higher education and income. It was highest among postgraduates (78.2%) and those with high income (defined as more than 15,000 Saudi Riyal, equivalent to USD 4000 per month) (80.8%). Most participants (87.1%) who had tested negative for COVID-19 had significantly higher rates of insufficient knowledge (P < 0.0001), whereas those who had not been tested scored higher on sufficient knowledge (58.0%) [Table 1].
Table 1: Distribution of scores on knowledge of coronavirus disease 2019 (n=1364)

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Participants were assessed for their attitudes toward the COVID-19 pandemic. Almost half of the participants agreed that every person should be tested for COVID-19, and more than one-third disagreed on whether warm weather helps stop viral transmission. Less than a quarter of the participants agreed on whether a person could test positive for influenza and COVID-19 at the same time. The majority agreed that there is a risk associated with being in the same room as the body of someone who has recently died of COVID-19, even without touching them, and that COVID-19 can be transmitted through food, including restaurant take-out [Figure 2].
Figure 2: Responses to statements on attitude toward the coronavirus disease 2019 pandemic (N = 1364)

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Participants were almost equally distributed among four age groups (18–25, 26–35, 36–50, and over 50 years). Negative attitudes toward the COVID-19 pandemic were highly prevalent among young, non-Saudi, and unmarried male participants (63%, 61.7%, 61.8%, and 61.7%, respectively). Similarly, lower education (60.7%) and lower monthly income (61.4%) were associated with negative attitudes toward the COVID-19 pandemic. Although those groups achieved statistically significant P values (P < 0.05), participants who tested negative for COVID-19 had a statistically insignificant (P = 0.105) higher negative attitude toward the disease (59.9%) compared to those who stated that they had not been tested (54.6%) [Table 2].
Table 2: Distribution of scores on attitudes toward the coronavirus disease 2019 pandemic (n=1364)

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With respect to risk-based preventive controls to prevent COVID-19, fewer than two-thirds of all participants reported washing their hands after sneezing or coughing. More than three-quarters reported wearing a mask when experiencing flu-like symptoms. Fewer than two-thirds reported wearing gloves and carrying sanitizer or disinfectant. Most participants kept a distance of two arm-lengths and used a form of contactless payment when shopping. Most skipped work whenever they had a fever, cough, or shortness of breath. Two-thirds reported putting masks on infants or children under 2 years old [Figure 3].
Figure 3: Responses to questions on practice of risk-based preventive controls for coronavirus disease 2019 (N = 1364)

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Most participants were Saudi nationals, were married with children, and had a university-level education. Like the results obtained for knowledge and attitudes, female (71.4%), older (71.4%), and Saudi (50.5%) adult participants practiced better risk-based preventive controls for COVID-19 than male (15.1%), younger (22.3%), and non-Saudi (19.8%) participants. High education and monthly income levels were significantly associated with compliance with appropriate practices (P < 0.0001), since the highest prevalence of appropriate practices was recorded among postgraduates (59.7%) and people with a high income (65.8%). Nonetheless, having a history of being tested for COVID-19 was associated with highly significant poor practices of risk-based preventive controls (89.4%) [Table 3]. When asked if a vaccine for COVID-19 was announced this year in 2020, what would be your first thought be: 60% thought it was probably rushed without enough testing, while 40% thought it would be a scientific achievement to find a vaccine that fast. When asked if they would receive it, 22% said they would get one as soon as possible, 56% would consider it but wait to see what happened to others, and 22% said they would never get one.
Table 3: Distribution of responses about practice of risk-based preventive controls for coronavirus disease 2019 (n=1364)

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  Discussion Top

Ongoing efforts to educate the public about SARS-CoV-2 are a major aspect of curbing the transmission of COVID-19. A recent influx of data in the literature on population awareness, attitudes, and practices toward COVID-19 in various regions that were most impacted, including Saudi Arabia, has been recorded.[18] Our study builds on similar merits and sheds light on the importance of knowledge, attitudes, and practices of the population of Riyadh.

There is a strong need to implement periodic education about the COVID-19 outbreak in Riyadh. Past SARS coronavirus outbreaks have demonstrated that knowledge about highly infectious diseases is associated with public misconceptions of appropriate behaviors, which can further complicate attempts to prevent the spread of those diseases.[19] In this study, some demographic variables of the population were explored to obtain a baseline for COVID-19 knowledge that could be used to strengthen the efforts of COVID-19 awareness. Shortfalls in knowledge about a respiratory disease can lead to underutilization of public health services, delay in seeking diagnosis, and poor treatment adherence.[20] The findings of the study suggest a spectrum of people with an overall unsatisfying level of knowledge about COVID-19. We recorded higher scores for knowledge among Saudi female participants and those above the age of 50 years from both genders. This finding is consistent with a similar study conducted across Saudi Arabia, which found highly educated older females to be more knowledgeable about this same emerging communicable disease.[21] Our findings also revealed a positive uphill correlation between education level and monthly income and knowledge about COVID-19. In China, people with a higher level of education and income were more likely to correctly identify whether asymptomatic patients can transmit SARS-CoV-2.[22] However, though many participants correctly answered the question on virus type, almost half answered the subsequent three questions incorrectly. This indicates that a significant portion of respondents in our study was not sufficiently knowledgeable about COVID-19. In areas such as Bangladesh, inadequate knowledge of COVID-19 differed significantly across ages, genders, education levels, residences, income groups, and marital statuses.[23]

Public attitude is crucial when evaluating clinical readiness for combating outbreaks of highly pathogenic viruses. In the US, misconceptions about seasonal influenza vaccination have contributed to low vaccination rates, even among healthcare workers.[24] Several studies have reported the impact of a community's attitude on reducing transmission rates during pandemics.[25] The findings of this study revealed that the majority of male participants who were particularly young held negative attitudes toward COVID-19. Our attitude assessment covered some items that have been vigorously shared in the local media and public domain. Participants agreed that not everyone needs to be tested for COVID-19. They were then asked if warm weather would stop the spread and slow the transmission of the virus. The results showed disparities in responses. The CDC states that weather and warm temperature have no known effect on the spread of COVID-19.[14] Similarly, only a quarter of participants knew that a person could be tested positive for influenza and COVID-19 concurrently. According to the CDC, patients can be tested positive for influenza and other respiratory infections, such as COVID-19, at the same time.[15] The remaining investigations revealed that the majority of participants believed that there is risk associated with being in the same room with someone who recently died of COVID-19. The CDC clarifies that no risk is known to be associated with being in the same room at a funeral or visitation service with the body of someone who died of COVID-19. Nonetheless, it may be possible that a person may be infected with COVID-19 by touching their own mouth, nose, or eyes after touching an item belonging to a deceased person that harbors the virus. The CDC stressed that this is not the scientific means by which the virus spreads.[16] Further, most participants incorrectly thought that COVID-19 can be transmitted through food, including restaurant take-out. No evidence indicates that people can contract COVID-19 from food items or food packaging; SARS-CoV-2 is a respiratory, not a gastrointestinal, virus. The primary transmission route is person-to-person contact or direct contact with respiratory droplets generated when an infected person coughs or sneezes.[26] In Greece, the knowledge score was significantly associated with the attitude score across many socioeconomic variants, demonstrating a more positive perception of preventive measures.[27] However, our results do not reinforce conclusions from previous studies associating higher levels of knowledge about COVID-19 with positive attitudes about the COVID-19 pandemic.[28]

The ongoing spread of COVID-19 around the globe requires collaborative efforts to change behaviors and ensure that individuals follow the preventive measures shared by local health officials.[29] This study suggests that it will be important to be selective in increasing public awareness of certain effective behaviors among the public. In fact, the Ministry of Health previously engaged the public on preventive measures during the outbreak of Middle East respiratory syndrome-related coronavirus.[30] In this study, most participants who wore masks and frequently washed their hands after sneezing, coughing, shaking hands, and even removing their masks were females. This is supported by another study that indicated that, in response to COVID-19, males were significantly less likely to take preventive and protective measures than females.[19] Females would wear masks and gloves if they developed flu-like symptoms, as well as carry sanitizer or disinfectant, but most participants would skip work if they developed a fever, cough, or shortness of breath, as well as keep a distance of two arm-lengths and use contactless payment methods. One study in the US reported better COVID-19 awareness among females than males, particularly in self-reported behaviors among minority communities, males, and younger people.[31] Several studies have consistently confirmed the role of gender in response to respiratory disease pandemics.[32] However, regardless of gender, the majority of the study participants would place a mask on an infant or child under the age of 2 years. The CDC recommends that masks or any face coverings should not be placed on infants or children younger than 2 years because of danger of suffocation. It states further that children younger than 2 years, as well as anyone who has trouble breathing or is unconscious, incapacitated, or otherwise unable to remove a face covering without assistance, are exempted.[17] Overall, our results were supported by a study that reported that knowledge was positively correlated with attitude and practices.[33]

Finally, our findings were obtained in the early postpandemic phase in Saudi Arabia. This means that the participants in the study may not have been representative of the Saudi and non-Saudi populations in Riyadh. We recommend further studies with a larger group of adults in larger geographical areas. These studies may attempt to investigate more variables on health behavior and motivation analysis.

  Conclusion Top

The significance of assessing knowledge, attitudes, and practices regarding COVID-19 could be positive or negative. The findings ascertain that public health education improved the knowledge and practices of participants during the COVID-19 pandemic. However, awareness and educational campaigns targeting younger age groups, non-Saudi nationals, and low-income groups are needed to increase positive attitudes toward COVID-19. This lower level of knowledge, negative attitudes, and inappropriate practices among these groups toward COVID-19 may necessitate the adoption of more effective health messages and strategies to strengthen current COVID-19 reporting and preventive protocols – although to a lesser extent than expected. Regular interactions between healthcare providers and the public through various mediums are recommended to continue to help dispel misconceptions about this virus, and with recent advances in vaccine development, public education of a clinically tested vaccine should be emphasized as well.

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Conflicts of interest

There are no conflicts of interest.

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  [Table 1], [Table 2], [Table 3]


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