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Table of Contents
Year : 2022  |  Volume : 5  |  Issue : 3  |  Page : 230-238

Knowledge, attitude, and practice of family medicine residents toward COVID-19 in Riyadh, Saudi Arabia

1 Department of Family Medicine, King Saud Medical City, Riyadh, Saudi Arabia
2 Department of Hepatobiliary Sciences and Organ Transplant Center, Hepatology Division, King Abdulaziz Medical City, King Saud Bin Abdulaziz University for Health Sciences, Ministry of National Guard Health Affairs, Riyadh, Saudi Arabia

Date of Submission13-Sep-2021
Date of Decision08-Oct-2021
Date of Acceptance24-Nov-2021
Date of Web Publication08-Jul-2022

Correspondence Address:
Sara I Altraif
King Khalid University Hospital, Riyadh
Saudi Arabia
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jnsm.jnsm_120_21

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Objectives: The aim is to evaluate the knowledge, attitude, and practice (KAP) regarding prevention, diagnosis, and management of COVID-19 in family medicine residents in Riyadh, Saudi Arabia and also to examine the association of the residents' demographic variables with their COVID-19 KAP level. Methods: A cross-sectional survey conducted during July to August 2020 that targeted all family medicine residents who were enrolled in the Saudi board training programs in Riyadh. An online version of a specifically designed questionnaire was distributed to determine the residents' KAP toward COVID-19. Results: A total of 97 of 170 residents responded for a response rate of 57%. The most important results noted from this study are that participants had satisfactory knowledge of COVID-19; but, it was not associated with their demographic characteristics. Most participants demonstrated positive attitudes toward persons having risk factors for COVID-19 and who disclose their exposure (n = 82, 85%). Most participants exhibited good practices except participating in training programs concerning COVID-19 infection prevention and control (n = 46, 47%). Total knowledge scores were significantly affected by feeling tired, lack of confidence in defeating the virus, and persons with risk of COVID-19 infection. There was no significant association between the knowledge and practice. Conclusion: The results demonstrated that family medicine residents in Riyadh overall had good KAP on COVID-19 disease in Riyadh, Saudi Arabia. Such good KAP could help limit viral spread.

Keywords: COVID-19, family medicine residents, knowledge, attitude, and practice, Riyadh, Saudi Arabia

How to cite this article:
Altraif SI, Almezaini LI, Alsaif HK, Altraif IH. Knowledge, attitude, and practice of family medicine residents toward COVID-19 in Riyadh, Saudi Arabia. J Nat Sci Med 2022;5:230-8

How to cite this URL:
Altraif SI, Almezaini LI, Alsaif HK, Altraif IH. Knowledge, attitude, and practice of family medicine residents toward COVID-19 in Riyadh, Saudi Arabia. J Nat Sci Med [serial online] 2022 [cited 2022 Nov 30];5:230-8. Available from: https://www.jnsmonline.org/text.asp?2022/5/3/230/350292

  Introduction Top

COVID-19 first appeared in China and has spread rapidly worldwide. It was declared a “Public Health Emergency of International Concern” in January 2020, by the WHO and upgraded to a pandemic in March 2020.[1],[2],[3] On 29 March 2020, the WHO reported that the main form of transmission of this virus through respiratory tract droplets based on coughing, sneezing, or other contact routes. According to the WHO, close contact between individuals may transmit the disease leading to the probability of airborne transmission; thus, airborne precautions are recommended.[4],[5] The presentation ranges from being asymptomatic to manifesting clear clinical conditions with varying severities. Most reported cases are mild and classically present as “mild fever, dry cough, sore throat, nasal congestion, malaise, headache,” with or without muscle pain. Severe presentations include pneumonia, acute respiratory distress syndrome, and sepsis.[6] Other systems may be involved in addition to the respiratory tract system such as gastrointestinal system (diarrhea, nausea, or vomiting) and neurologic system (headache or confusion).[7]

In this current critical health situation, health-care workers, including family physicians, are at risk of getting infected with this disease. According to the WHO Case Report Forms onJanuary 31, 2021, about 1.29 million health-care workers became infected (8% of all infected populations worldwide).[8] Health-care workers in Saudi Arabia became infected as well.[9] Family physicians are expected to constitute a sizable proportion of HCWs affected by the pandemic: they are frontline workers who detect, assess, manage, and prevent cases of COVID-19, thus helping to control the outbreak. Their input in this pandemic is of great significance for better outcomes.

Various studies worldwide have shown that “knowledge, attitudes, and practices (KAP) of health-care workers” are associated with better control and management of the pandemic.[10],[11],[12],[13],[14],[15],[16],[17],[18],[19],[20],[21],[22] For instance, a study in China reported that 89% of subjects had sufficient knowledge to directly affect their attitudes; those with sufficient knowledge had a more positive attitude toward defeating the virus. As for practice, 89.7% were maintaining quarantine with family, removing PPE correctly, frequently washing their hands, and participating in training.[10] Similar results were also found in various other studies.[14],[16] A similar study in Pakistan among primary care physicians showed that knowledge and positive attitudes were associated with good practices, but some gaps were noted regarding knowledge and practice.[12] Another study in Uganda indicated sufficient knowledge and practice, but a negative attitude toward COVID-19 was noted.[15]

Only three studies on this topic have been published on a Saudi cohort; none of these focus on knowledge, attitudes, and practices of Family Medicine Residents. A cross-sectional study showed that most health-care workers in radiology departments had good COVID-19 knowledge and infection control practices.[23] Another study by Abolfotouh et al. reported moderate concerns toward COVID-19 (e.g., perception and attitudes) among health-care workers in Saudi Arabia.[24] An additional study was conducted in Saudi Arabia assessed the KAP of health-care workers and showed that health-care workers who experienced MERS-CoV had “increased knowledge, adherence to protective hygienic practices, and a reduction in anxiety toward the COVID-19 pandemic.”[25]

No studies have been published that have assessed the KAP of family physicians toward COVID-19. Although it is expected that they may have insufficient KAP toward the COVID-19 pandemic as compared to those in MERS-CoV. Alsahafi and Cheng have indicated that health-care workers, including medical professionals, had low knowledge levels about MERS-CoV infection control.[26] Similar studies showed that health-care workers had low levels of KAP toward MERS-CoV infection.[27],[28] Nevertheless, none of these studies have focused on family medicine physicians.

COVID-19 is encountered in primary care settings. Thus, assessing the KAP of family medicine residents, understanding what factors may be affecting their KAP levels at this stage of the pandemic, and promptly acting upon the identified gaps (e.g., through proper implementation of further training, applying for policies and health education programs) would have a great impact on the residents and their performance regarding COVID-19 containment. Thus, KAP should be promptly addressed if family medicine physician health-care workers are to effectively perform their role in containing the pandemic. The main aim was to investigate KAP levels toward COVID-19 among family medicine residents in Riyadh, Saudi Arabia. The secondary aim was to examine the factors that affect their KAP levels.

  Methods Top

This cross-sectional survey was conducted between July 2020 and August 2020. The study was carried out across all Saudi board training programs of Family Medicine in Riyadh city, Saudi Arabia. The target population of this study is all family medicine residents who were enrolled in Saudi board training in all public sites in Riyadh, Saudi Arabia. All Saudi and non-Saudi family medicine residents who were enrolled in the Saudi Board training program in all sites in Riyadh and involved directly or indirectly in the care of COVID-19 cases were eligible to participate in this study. However, we excluded family medicine residents who were not enrolled in the Saudi board training and nonresident family physicians (fellows, interns, consultants, etc.) as well as other health-care workers (nurses, paramedics, clinicians, etc.). This is because our aim was to target family medicine residents only.

This study applied simple random sampling on the target population of 450 family medicine residents under the Saudi board training program in Riyadh. The required sample size was calculated to be 170 at the 95% confidence level with a margin of error of 7.5%, assuming the outcome response to be 50%.

A self-administered questionnaire was used which comprised two sections. The first section contained the personal details such as age, gender, marital status, whether they have children or not, residency year, training program, COVID-19 diagnosis, and source of transmission if infected. The second section of the instrument measured the KAP dimensions and was divided into three parts that were utilized from a previously published article by Zhang et al. after getting approval from the authors with some modifications.[10] The first part comprised eight items for the knowledge regarding COVID-19 infection. The responses were on a five-point Likert scale (“1” not understanding and “5” master). The range of score for knowledge was from minimum of 8 points to a maximum of 40 points. The knowledge score was obtained by summing the scores of all knowledge items. Higher scores indicate that respondents have good knowledge and lower scores indicate poor knowledge. Specifically, we used the overall median score as a cutoff point to indicate whether respondents had good or poor knowledge scores. Accordingly, respondents who scored higher than the total median knowledge score were categorized as good knowledge while those who scored lower than the overall median score were categorized as poor knowledge. The second part contained four items regarding the respondents' attitudes and the last part contained six items related to the participants' practice.

The questionnaire was piloted among ten participants and the Cronbach's alpha was 0.78 for the modified questionnaire. The Cronbach's alpha for the KAP questions ranged from 0.76 to 0.79. The questionnaire was available through Google forms for data collection, and the link was sent to potential participants through WhatsApp and E-mail. A brief introduction along with aims of the study, ethical consideration, consent, and instructions was provided at the beginning of the questionnaire.

Responses were recorded through excel and imported into SPSS 24.0 software for analysis. Descriptive statistics of continuous variables were provided as mean (standard deviation; SD) or median (interquartile range [IQR]) as appropriate. Categorical variables were presented as frequencies and percentages. Mann–Whitney and Kruskal–Wallis tests were used to test for possible differences in median total knowledge scores by respondents' characteristics. A Spearman correlation coefficient was used to measure the correlation between total knowledge score and age. Furthermore, multivariate binary logistic regressions were performed to measure the factors associated with attitudes and practices. The dependent variables were dichotomized into “Yes = 1” (e.g., always, most of the time) and “No = 0” (e.g., sometimes, occasionally, rarely). Significant statistical significance was considered at a P < 0.05.

An electronic informed consent was obtained before completing the questionnaire. All information was kept confidential and was published upon subject approval. The respondents were instructed to respond honestly to all the questions. Their participation was completely voluntary.

  Results Top

There were 97 respondents, and the response rate was 57% (97/170). The average age was 27.5 + 1.7 years (range = 25–32 years). A little more than one-half of them were male (n = 50, 52%); most of the residents were not married (n = 64, 66%). Thirteen married participants had children (13/33; 39%). One-third of the participants were in their 1st year of residency (n = 34, 35%) and most were from King Saud University Medical City (n = 41, 42%). The majority had not been infected with COVID-19 (n = 74, 76%). Ten participants had been infected with COVID-19 (10%), and 13 (13%) of respondents stated that one of their family members was infected with COVID-19. Of those ten who got infected with COVID-19, six participants did not know the source of transmission [Table 1].
Table 1: Characteristics of the family medicine residents (n=97)

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[Table 2] gives the summary of the descriptive statistics of knowledge scores. The greatest proportion of respondents who reported their knowledge as master/familiar about COVID-19 was for the following: “A health-care worker should wear a medical mask when entering a room of patients with suspected or confirmed COVID-19 cases or use a particulate respirator at least as protective as N95 (European Union Standard FFP2, or equivalent) when performing procedures likely to generate aerosols” (n = 80, 82%; K2). The lowest reported proportion for Master/Familiar knowledge was “suspected and confirmed COVID-19 patients should be isolated in single rooms. Patients with suspected COVID-19 infection may have other respiratory illnesses; hence, they must be housed separately from patients with COVID-19” (n = 47, 48.5%; K1). The median knowledge score of COVID-19 disease was 32 (IQR = 9.0) points. There were 53 (55%) respondents who had good knowledge and 44 (45%) had poor knowledge.
Table 2: Knowledge scores of family medicine residents regarding COVID-19* (n=97)

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The results also indicate that the differences in median knowledge scores were not statistically significant by gender, marital status, married with children, residency year, training program, and whether the participant was infected or not with COVID-19 (P > 0.05). There was also no significant association between total knowledge scores and age (P > 0.05) [Table 3].
Table 3: Association of knowledge scores of family medicine residents by their demographic characteristics

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[Table 4] shows the attitudes and practices of the family medicine residents for the COVID-19 statements. Participants exhibited the highest attitudes toward visitors “who should disclose exposure as a significant risk factor for COVID-19” (n = 82, 85%; A4), while the least attitude was toward the level of fear of being infected with COVID-19 (n = 33, 34%; A1). The most frequent practice recognized by the study respondents was putting on a face mask to keep them safe from getting the infection when they leave the house (n = 95, 98%; P2). The least common practice was participation in training regarding COVID-19 (n = 46, 47%; P3). Most respondents practiced and maintained quarantine with their family, covered their nose with proper precautions when coughing or sneezing, they also followed the standardized protocols for PPEs and hand hygiene.
Table 4: Attitudes and practices among family medicine residents* (n=97)

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[Table 5] shows the multivariate binary logistic regression analysis as odds ratios and 95% confidence intervals. The results indicate that the level of feeling tired was directly associated with knowledge score (odds ratio [OR] = 1.10, [1.04, 1.81]). Confidence in defeating the virus was directly associated with knowledge score (OR = 1.28, [1.08, 2.42]). Those who think that visitors with significant risk factors should disclose their exposure had higher knowledge scores than those who did not (OR = 1.19, [1.10, 3.28]).
Table 5: Multivariate logistic regression analysis for attitudes and practices of family medicine residents concerning possible risk factors

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The males' confidence in defeating the virus was 10.23 (8.6, 13.2) higher than their female counterparts. Participants in 2nd year of residency had 0.16 (0.06, 0.58) less confidence than those in the 1st year. Married participants had lower attitudes toward visitors with significant risk factors for COVID-19 who should disclose their exposure than those who were not married (single or divorced) counterparts (OR = 0.20, [0.08, 0.86]). There were no factors related to the level of fear of COVID-19 [Table 5].

Married participants practiced training regarding COVID-19 disease more than those who were single (OR = 3.04, [2.28, 6.25]). Moreover, the frequency of applying WHO's five moments for hand hygiene was inversely associated with age (OR = 0.61, [0.17, 0.86]). That is, older participants were less likely to be following hand washing protocols. There was no association of age on maintaining quarantine with family, covering nose and mouth properly, and removing and replacing PPE according to protocol.

  Discussion Top

This study assessed the KAP of COVID-19 in family medicine residents in Riyadh, Saudi Arabia. It revealed that most respondents scored higher than the median knowledge score which indicates good knowledge levels in regards to COVID-19 among family medicine residents in Riyadh. The level of knowledge among the participants of this study is lower than in previous studies.[10],[11],[12],[13],[14],[15],[16],[18] For example, Zhang et al. reported that almost 90% of health-care workers had good knowledge scores in China.[10] Some studies indicated that about 86% to 97% of health-care workers had good levels of knowledge in Pakistan.[12],[13] The results of this study indicate that the knowledge of family medicine residents was not affected by age, gender, marital status, having children, residency year, training program, and whether they got infected with COVID-19 disease or not. These findings are consistent with some previous findings[18],[13] but contradict other research.[10],[13],[15],[22],[24] Hussain et al. indicated that knowledge among health-care workers in Pakistan was significantly different by age (range 22–33 years), profession, hospital, and residence but did not vary significantly by marital status or educational level.[13] Olum et al. found that knowledge among health-care personnel in Uganda significantly differed by age and news media access but was not significant by gender and education.[15]

This study found that 34% of family medicine residents demonstrated fear of being infected with COVID-19. However, this fear was not associated with any factor including knowledge. This finding is congruent with some previous findings.[10],[12],[15],[16] For instance, in a study by Zhang et al., knowledge was not significantly associated with attitudes toward the fear of COVID-19 but these attitudes were significantly associated with paramedics versus doctors and nurses.[10] However, the results were not consistent with other studies.[18] For example, in a study by Limbu et al., 53% of health-care personnel exhibited positive attitudes. These positive attitudes were found to be significantly related with higher knowledge.[18] Furthermore, 43% of the participants demonstrated attitudes toward feeling tired, which was affected by their level of knowledge, but not by their age, gender, marital status, residency year, or training program. A greater level of knowledge correlated to feeling tired. These findings are similar to other studies.[10],[13],[29] Males exhibited higher attitudes toward defeating the virus than their female counterparts, which is similar to the results of Sulaiman et al.[16] but different from other studies.[10],[12],[13],[15],[24] Hussain et al. indicated that the attitudes of health-care workers in Pakistan were significantly associated with “age, marital status, educational level, profession, hospital, and residence”.[13]

Although only 47.4% of family medicine residents were engaged in training programs toward infection, prevention, and control measures and the proper use of PPE, most of them exhibited good practice toward COVID-19. Most of the participants had good practices toward maintaining quarantine, using face masks in public places, and ensuring droplet precautions as seen in [Table 4]. These practices might be the effects of the Saudi ministry of health and Weqaya mandatory protocols and guidelines during this pandemic.[30] These results were not associated with knowledge scores, age, gender, marital status, married with children, and training program. However, married family physicians exhibited higher practices of quarantine with their families versus those who are not married. In addition, applying WHO's five moments of hand hygiene did not improve with participant age. The findings are partially contradicted by previous research.[10],[13],[15] Zhang et al. indicated that the frequency of hand-washing was not impacted by knowledge, gender, education, or overwork.[10] However, this study finds comparable results with Limbu et al. who indicated that knowledge, gender, education, marital status, and designation were not significantly associated with practice.[18]

This study contributes to current knowledge in various ways. First, this is the first survey in Saudi Arabia on family medicine residents. Second, it sheds light on the deep understanding of the level of KAP among family physicians that are necessary to be adequate or have high levels to help stop viral spread. Finally, the results are important for policy implications. Training and educational programs should be made available for family medicine residents for improving the knowledge, attitude, and practice during future pandemics for stopping the virus transmission. It will also help to shed light on the need to improve required resources particularly training in the care and treatment protocols for COVID-19 patients. Furthermore, appropriate prevention and control measures are needed to make the environment safer for health-care providers.[16],[31]

Limitations of the study

The limitations of the study may have some effect on the generalization of the results. First, the low response rate might be influenced by the online nature of collecting the data from respondents. This could be resolved by distributing the questionnaires manually. Second, the study was conducted in Riyadh city and thus may not reflect the actual levels of KAP among total family physicians in Saudi Arabia and thus could limit the generalizability of the results. Further research is needed to overcome this low response rate. A national study is needed to understand the impact of contributing factors such as stress and anxiety during such a pandemic on KAP levels among family physicians in Saudi Arabia. Third, there is no international and validated instrument of measuring the KAP whereby every study has a distinct tool; this may make these instruments imprecise due to the variations in items or a limited number of items. Furthermore, selection bias must be considered because the questionnaire was sent through social media platforms. Hence, further study is needed to provide an adequate measurement of KAP. Finally, the cross-sectional design limits attempts to demonstrate any causality among outcome and explanatory variables.

  Conclusion Top

This study demonstrated that family medicine residents in Riyadh have overall good knowledge, attitudes, and practice related to COVID-19. This study may provide a baseline for studies of KAP and its associated factors that may enhance the level of KAP among family physicians and health-care workers in Saudi Arabia. Given the importance of KAP, family medicine residents, as well as all health-care workers, should have an effective part in preventing and controlling COVID-19 and therefore in reducing viral spread.


First and foremost, praises and thanks to the God, the Almighty, for His showers of blessings throughout our research work to complete the research successfully.

We would like to express our deep and sincere gratitude to our research supervisor, Prof. Lubna Alansari., Ph.D., Family physician at King Saud Medical City, for giving us the opportunity to doresearch and providing invaluable guidance throughoutthis research. Her dynamism, vision, sincerity and motivation have deeply inspired us. She has taught us the methodology to carry out the research and to present the research works as clearly as possible. It was a great privilege and honor to work and study under her guidance. We are extremely grateful for what she has offered us.

Financial support and sponsorship


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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