Evaluation of Health Care Professionals’ Knowledge, Attitudes, and Practice to Prevent the Pandemic Spread of COVID-19: A Questionnaire-Based Cross-Sectional Study from Abha, Saudi Arabia

Background: Pharmacists and other healthcare professionals (HCPs) are at risk of transmitting the lethal COVID-19 virus globally and increasing its prevalence. Aim: The aim of this study was to assess knowledge, attitudes, and practices (KAP) about coronavirus disease 2019 (COVID-19) among HCPs in the Asir region for the first time. Methodology: A cross-sectional analysis with 491 healthcare professionals was tested using a pre-tested questionnaire in a tertiary care facility. The association between research variables and questions was determined using Chi-square tests and Kruskal–Wallis tests. Results: Pharmacists and other HCPs exhibited good knowledge, a positive attitude, and a negative practice pattern regarding COVID-19. There was a strong association between knowledge and attitude (correlation coefficient: 0.17; p < 0.001). However, healthcare practitioners had a suboptimal practice score of 2.09 ± 0.62 regarding COVID-19. Conclusion: This study discovered that despite relatively insufficient practices for adherence to recommended techniques regarding COVID-19 prevention during the outbreak, pharmacists and other healthcare professionals have a high level of awareness and a positive attitude towards COVID-19 as a medical condition. There is a need for more involved HCPs, improved COVID-19 management training, and approaches to make healthcare providers feel less anxious.


Introduction
Coronaviruses, which are transmitted through the air, produce infections ranging from the common cold to severe acute respiratory syndrome, and they impact people from all walks of life. Birds and animals have been observed to spread the virus in the past, with humans being particularly vulnerable to virus infection and transmission [1,2]. The novel coronavirus disease (COVID- 19), which originated in China, has easily crossed borders, infecting people worldwide [3,4]. COVID-19 is caused by a virus known as 2019-nCoV, which was later renamed coronavirus 2 syndrome by the ICTV (International Committee on Taxonomy of Viruses) (SARS-CoV-2) [5,6].
SARS-CoV-2 appears to have originated in bats, and the first cases were reported in Wuhan, Hubei Province, China, indicating an animal-to-human transmission from a live animal market. The virus then expanded outside of Wuhan and ultimately to the COVID-19. Some research [26][27][28] has shown that HCPs follow safer infection, prevention, and control methods if recommended by international and local health authorities. On the other side, a study in Ethiopia found that HCPs had poor COVID-19 prevention practices, while a study in Nepal found that nearly half of HCPs had unfavorable views on COVID-19. Saudi Arabian healthcare professionals in a prior study on KAP were shown to have a solid comprehension of COVID-19. However, nurses who worked in critical care units made up the majority of the study's participants (75%). Therefore, general healthcare workers still need to be familiar with the appropriate KAP. Additionally, it is crucial to comprehend the specialization of various classes of healthcare providers and pinpoint the variables influencing their attitudes and practices in order to promote proper practices and protection [29][30][31].
Therefore, the objective of this study was to assess the knowledge, attitudes, and practices of healthcare workers about COVID-19 infections, which could benefit containment efforts. The results of this study will assist us in identifying potential problems and formulating corrective actions to prevent additional outbreaks in healthcare facilities and the general population.

Design of the Research
During the first week of November 2020, a prospective, web-based cross-sectional study was performed utilizing a survey questionnaire to acquire responses from healthcare practitioners.

Participants
The interviews were performed in Asir hospital in Saudi Arabia over the course of two months (November 2020-December 2020). The current study's targeted population included all healthcare personnel employed in an Asir region tertiary care institution. In this study, healthcare workers such as physicians, pharmacists, nurses, and other paramedical personnel were considered eligible. The objectives and outcomes of the study were explained to all participants, and those who consented to sign the consent form were enrolled. A total of 491 persons participated in the study.

Study Tool
A standardized, self-administered questionnaire was used to collect data. This poll was created using a validated concern scale previously used in a study evaluating HCPs' concerns about COVID-19. In addition, the WHO course materials on emerging respiratory viruses, including COVID-19, were used to create a 25-item survey instrument [32][33][34], which addressed the domains of HCP characteristics, awareness, information sources, knowledge, and perception linked to COVID-19.
There were four sections to the standardized, self-administered questionnaire. The first section contained demographic data about the respondents-age, gender, and occupation (3 items). The second section determined where respondents got their COVID-19 knowledge (media, webinars, journals, internet, family and friends-5 statements/5-point Likert scale). The next section tested healthcare workers' understandings of COVID-19 by asking them to answer "Yes" or "No" to each set of questions. The final section examined respondents' attitudes toward COVID-19, with their responses rated on a five-point Likert scale of agreement/disagreement. The survey instrument took about 3 min to complete on average. Respondents were given enough time overall to read, comprehend, and answer all of the questions.
The survey instrument used in this study tested HCPs' knowledge of COVID-19's nature, etiology, symptoms, risk group, consequences, and source of transmission, as well as its prevention and treatment. Knowledge scores varied from 0 to 12, with 8 as the cutoff for low versus good knowledge. Attitude was evaluated using an 8-item questionnaire with responses recorded on a 5-point Likert scale. Strongly agree received a score of 1, agree received a score of 2, undecided received a score of 3, disagree received a score of 4, and strongly disagree received a score of 5. A good attitude was defined as a mean score of 2, whereas a negative attitude was described as a score more than 2 and less than or equal to 5.
Practices of respondents towards COVID-19 was used to collect data on methods of prevention and control of COVID-19. Seven questions measured practices of HCPs towards COVID-19. The average score was measured and used as a cutoff for good, average, and insufficient practice on the practice questionnaire. A mean score of ≤2 was considered good practice, while a score of 2-3 was regarded as insufficient practice, and a score of 3-5 was considered poor practice.

Statistics
Data were coded, validated, and analyzed using the Statistical Package for the Social Sciences (SPSS), version 21. Descriptive analysis was applied to calculate the frequencies and proportions. The Pearson Chi-square test was used to check whether the respondents' answers deviated from the expected correct answer. A p-value greater than 0.05 signaled no statistically significant departure from the correct answer. It was also used to assess differences (e.g., between males and females) in their responses concerning particular practices. To identify the association between demographic characteristics and knowledge, attitude, and practice of COVID-19, the Kruskal-Wallis test was applied. A p-value less than 0.05 indicated a significant difference between groups with respect to their responses to these variables.

Ethical Approval
The study was approved by research committee ECM#2020-239-HAPO-06-B-001 and conducted in a tertiary care hospital. Furthermore, written consent was obtained from the respondents prior to participation in the study.

Socio-Demographic Characteristics
About 491 healthcare workers responded to the questionnaire, yielding a response rate of 95.71%. The majority was male (55.6%) and belonged to major healthcare professions, with physicians and pharmacists comprising the most respondents (49.3% and 28.9%, respectively). Most of them (n = 396) were less than 30 years and had just started their job with minimum experience, with about 75% having less than three years of experience. More than one-third of the participants were categorized as frontline healthcare professionals. Respondents' characteristics are shown in Table 1. The main source of information reported by participants was the Internet, as shown in Figure 1. In addition, the participants' occupational distribution is shown in Figure 2. Table 2 describes the status of COVID-19 knowledge among HCPs. About 412 (84%) of respondents showed good knowledge, while 79 (16%) of patients had poor knowledge of COVID-19. Respondent awareness of COVID's origin, since the Chi-square value was 0.059, indicated departure from the expected correct answer, namely, that it originated in bats. The study showed that average knowledge was more apparent in response to questions regarding the transmission, treatment, availability of critical care, and the consequences of COVID-19 in children, with the rate of correct responses being 71.89%, 72.3%, and 70.3%, respectively. The mean knowledge score of healthcare workers was 9.17 ± 1.48.   Table 2 describes the status of COVID-19 knowledge among HCPs. About 412 (84%) of respondents showed good knowledge, while 79 (16%) of patients had poor knowledge of COVID-19. Respondent awareness of COVID's origin, since the Chi-square value was 0.059, indicated departure from the expected correct answer, namely, that it originated in bats. The study showed that average knowledge was more apparent in response to questions regarding the transmission, treatment, availability of critical care, and the consequences of COVID-19 in children, with the rate of correct responses being 71.89%, 72.3%, and 70.3%, respectively. The mean knowledge score of healthcare workers was 9.17 ± 1.48.

HCPs' Attitudes towards COVID-19
About 369 (75.15 percent) of 491 respondents displayed a positive attitude to COVID-19, while 122 (24.85 percent) respondents showed a negative attitude to COVID-19. On average, respondents displayed negative attitudes towards the condition and actions that might be taken when asked about intensive care to be given to diagnosed patients (2.26 ± 1.17), and there was also less COVID-19 anxiety (2.28 ± 0.99). Conversely, when asked about the use of gowns, gloves, and other safety measures when working with COVID-19 patients, most participants replied positively (1.44 ± 0.79). In addition, different groups of professionals and those with different levels of experience diverged in their level of agreement on three of the questions (2, 3, and 8). Table 3 summarizes the findings.

Mean Score of Knowledge, Attitude, and Practice (KAP)
The association of demographic characteristics with mean knowledge and attitude questions is expressed in Table 4. Among the demographic variables, profession and category of respondents were significantly associated with mean knowledge and attitude scores. Level of experience just missed statistical significance. These results align with those of Table 3 on attitude. Frontline healthcare professionals showed more knowledge (9.28 vs. 8.98, p = 0.05) and positive attitudes (1.68 vs. 1.99, p = 0.005) towards COVID-19 compared to their non-frontline counterparts. Similarly, it was also revealed that doctors have more knowledge and a positive attitude compared to those who are less involved in the field. A Spearman correlation test revealed a significant positive relationship between knowledge and attitude of healthcare workers regarding COVID-19 (r = 0.17, p < 0.001).

HCPs' Practices towards COVID-19
On average, for COVID-19, there was an inadequate practice score of 2.09 ± 0.62 among healthcare practitioners. Approximately 245 (49.89 percent) of 491 respondents showed good practices towards COVID-19, while 246 (50.1 percent) respondents were shown to be inadequate towards COVID-19. Inadequate practices were observed when HCPs were asked about diagnostic centers (2.17 ± 0.9) and five steps (2.36 ± 1.07) of the hand washing technique. In addition, insufficient practices were observed for adherence to recommended techniques such as nasopharyngeal swabbing (2.41 ± 1.19) and procedures (2.03 ± 1.03) for hand washing. The categories of professionals and males versus females were noted to differ in these two areas. Conversely, most participants displayed good experience (1.92 ± 0.98) when asked about safety precautions such as quarantine with the family when dealing with COVID-19 patients. Table 5 summarizes the findings.

Summary and Comparisons
COVID-19 is presently a global topic of discussion among the media and the public, and especially HCPs and patients. This pervasiveness raises a significant recurring concern about how we handle knowledge to assist frontline healthcare workers in times of public health crisis. The transition towards a COVID-19 environment raises pressure on all, including health officials and the health system. For this reason, during a global outbreak, we examined the awareness and attitudes of HCPs towards the prevention and control of COVID-19.
The participants in this study exhibited good awareness and a positive attitude towards the novel coronavirus . This overall assessment is similar to that of a study conducted by Kara et al., which indicated that healthcare workers with good knowledge regarding COVID-19 also showed good attitudes and engaged in good practices. Most of our respondents in the study were aware of the coronavirus from news, media, and Internet sources. This detail was confirmed by a study that showed technologies are a critical source of awareness of such viruses by the participants [32]. Healthcare workers are now more reliant than ever on Internet technologies to gain knowledge of novel diseases such as SARS-CoV-2 [35]. Most of the educational materials on COVID-19 are posted online by the Ministry of Health, which may have urged the HCPs to use Internet technology to access those documents. A key factor in HCWs' preparedness and response is trust that transparent knowledge about the emerging COVID-19 infection derives from authentic sources. Therefore, healthcare professionals should place the focus on skills for the retrieval of information on the Internet and its assessment.
Moreover, knowledge regarding COVID-19 symptoms, incubation period, treatment, and preventing the spread of the disease was assessed. The observed results may be due to health authorities' focus on these issues in their training programs. The current findings are consistent with other studies showing HCPs' positive responses to prevention of disease when dealing with SARS-CoV-2 [12,36,37].
In terms of awareness of symptoms, however, the outcome of the current study is not in line with one conducted by Bhagavathula et al. in 2020 [34] to assess healthcare workers' knowledge of COVID-19. Respondents in that study displayed poor knowledge when questioned about disease prevention and symptoms. One explanation for the disparity in findings can be due to educational campaigns in Saudi Arabia having concentrated more on the signs and symptoms of COVID-19, which might be strengthening people's awareness in this area.
Approximately one-third (29.7%) of healthcare professionals were not well aware of COVID-19 preventive strategies for younger adults and children. About 27.6 percent of respondents answered incorrectly about the supportive care and specific treatment for COVID-19 available in their zone. In contrast to less experienced peers, experienced staff correctly answered this question. Therefore, this aspect of COVID-19 must be emphasized so that HCPs can play their part by educating individuals to address the threat to global public health of such a novel virus.
The current study observed that the mean attitude score was in the positive range. The healthcare workers' most optimistic approach was to use protective equipment when interacting with COVID-19 patients (1.44 ± 0.79). This result is in line with another study showing healthcare workers' positive reactions to wearing goggles and gloves while coping with healthcare-related infections [38]. Our study also observed that relative to non-frontline HCPs, frontline healthcare professionals replied positively to most of the attitude-related questions (p < 0.05). A different attitude was found when respondents reacted negatively to the prioritization of intensive care and emergency treatment. This outcome is consistent with another study conducted by Huynh et al. noting the positive attitude of healthcare staff towards active involvement in the hospital control program [20]. No significant attitudinal variations between male and female healthcare professionals in our study were identified. For example, the pandemic's emergency centeredness, the actual medical system, and the paucity of resources compelled medical practitioners to make pragmatic, sometimes ethically changing decisions out of necessity [11].
The findings align with other studies that have reported positive physician attitudes among all health workers [39,40]. The statistically significant correlation between healthcare workers' awareness and attitudes reaffirms the positive relationship between COVID-19 knowledge and attitude. Thus, HCPs with a more optimistic attitude toward COVID-19 are encouraged to seek more information about the disease and improve their knowledge base. Nevertheless, future research must be undertaken to fully understand the pattern of information flow and HCPs' expressed attitudes. Our study additionally shows that professional category and level of experience are significant factors in readiness to participate in hospital infection control and information sharing with peers.
Conversely, there was an inadequate practice score of 2.09 ± 0.62 among healthcare practitioners towards COVID-19. The practice of hand hygiene is essential. It is very beneficial for infection prevention, and adequate hand hygiene practice is also encouraged by governments and many other stakeholders. Tamang et al. also stated that one of the critical barriers to disease transmission is hand washing [41]. We asked participants in this survey if they believed in taking all five WHO-recommended hand washing steps; about 57 percent of the HCPs either strongly agreed or agreed. Seventy percent of the participants responded positively when asked whether they had attended hand hygiene training, but the remaining participants reported that they were neutral, disagreed, or strongly disagreed. These findings indicate that the majority of our participants find hand hygiene procedures warranted. However, we still think that hand hygiene is the most overlooked operation, and HCPs do not typically follow all the moments and steps. Of note, we found a statistically significant difference between respondents from different professions on hand washing, a finding worth exploring.

Study Limitations
A web-based survey was conducted to identify the knowledge, attitudes, and practices (KAP) of healthcare professionals operating in the nation's numerous hospitals where they have full Internet service access. A physical assessment at these facilities was not possible. Furthermore, as our research was performed primarily via an online self-administered questionnaire, we could not observe the pattern of personal protective equipment (PPE) use and had to rely on self-reported evaluation for that. Another limitation was that our study did not include laboratory technicians and pharmaceutical employees. Despite all these constraints, the KAP survey on COVID-19 among HCPs in the Asir area maintained representativeness for the professionals we assessed.

Implications of Research
Healthcare professionals' awareness plays a vital role in reducing morbidity and mortality, as they are directly exposed to patients and causative agents. Comprehensive knowledge encourages a positive approach and constructive activities at work, which reduces the risk of COVID-19 infection. The study recommends implementing educational and professional campaigns to increase healthcare professionals' awareness, which would also positively affect their COVID-19 work practices.

Conclusions
Healthcare professionals in the Asir region of Saudi Arabia showed adequate knowledge and positive attitudes towards COVID-19 and mitigation steps. Still, there is a need for development in certain areas, such as effective treatment of such pandemic diseases. We found a significant correlation between COVID-19 awareness and positive attitudes among healthcare professionals. The attitudes of healthcare professionals are directly linked to their expertise. Thus, despite improved awareness and attitudes, more deliberate practice efforts are required. Training in preventive and safety measures is also necessary to encourage best working practices during the pandemic response to COVID-19. Our study recommends further implementation of educational and professional campaigns to increase HCP awareness, which would also have a positive impact on their COVID-19 working practices.  Informed Consent Statement: Informed consent was obtained from all subjects involved in the study.

Data Availability Statement:
The datat used in the current study will be made available on request from Rajalakshimi Vasudevan; raja@kku.edu.sa.