Introduction

Coronavirus disease 2019 (COVID-19) is a highly contagious disease caused by a novel strain of outbreak-related coronavirus, which emerged in Wuhan, China, in December 2019.1,2 It has since been recognized as a zoonotic coronavirus, “severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2)” and was also referred to as “2019-nCoV”. Most uncomplicated cases with COVID −19 have mild symptoms such as fever, cough, sore throat, nasal congestion, headache, fatigue, and myalgia, and some patients develop severe symptoms such as acute respiratory distress that need hospitalization.3,4 In Saudi Arabia, the first COVID-19 case was confirmed on 2nd March 2020 (a female case in the Qatif region in the eastern area of Saudi Arabia had a history of returning from Iraq) to be followed by the announcement of the Ministry of Health for disaster declaration on 4th March in line with the WHO guidelines to promote significant concerns about the healthcare awareness, public mass gatherings, and preventive measurements such as “Umrah suspension, tourism, suspension to several countries, suspension of domestic/international flights, partial curfew for 21 days, Madinah and Makkah lockdown”.5 After a while, these instructions followed by the closure of educational institutes, the non-essential business and “stay at home” call.6,7 Despite these restrictions, Saudi Arabia had the highest number of COVID-19 cases compared with the other Gulf countries.8

At present, managing the epidemics is not depending only on the announced and/or applied restriction rules, however; it also depends largely on individual’s adherence to recommended healthcare measurements which are highly influenced by the people’s awareness and good practice.9

In this sense, this review was conducted to summarize the articles that explore and/or evaluate the healthcare awareness of COVID-19 among the Saudi population during the COVID-19 outbreak. This literature review is expected to give deeper insights into the existing healthcare awareness identified by the published work in this region, thereby helping to identify attributes that influence this awareness and highlight misperceptions/malpractices related to preventive measurements for future analysis, prevention of new airborne disease outbreaks, and mitigations implementation.

The Searched Outcomes

The outcomes evaluated by the original investigators, such as sufficient knowledge, positive feelings, worrying about the COVID-19 pandemic and following the good practice such as wearing a mask, handwashing, and social distancing, were searched. The included studies were summarized in Table 1, and the overlay visualization map of the related terminology in the enrolled studies is presented in Figure 1. The column titles of the table included the name of the first author/month/year of publication, study title, sample size, data collection protocol, and the study’s primary outcome. Significant growth in literature was observed from the beginning of May 2020 to Feb 2022. A total of 116 studies were enrolled in this review.9–124

Figure 1 The overlay visualization map of the included studies in this review. Each circle represents an item (term) mentioned in the included literature. Curved lines that link (connect or relate) two items indicate co-occurrence of the items in the enrolled studies. There are 13 items in this map arranged into two clusters and linked by 64 lines with a total link strength of 872. The color bar indicates the year of publication in which the item is mentioned in the included literature. The VOSviewer tool version 1.6.15 was applied to generate, visualize, and explore this map after importing the bibliographic citation list in an endnote file.

COVID-19 is a Public Health Emergency

Saudi Arabia has 750,179 cases, with 732,939 recoveries and 9036 deaths on 25th March 2022 (Figure 2) and (Supplementary File 1: the full dataset used in generating Figure 2).125 It employed policies of “availability of personal protective equipment, stay-at-home, social distancing, and quality hospital care to the people”.126 The Saudi Arabian Ministry of Health (MOH) has performed an exhaustive awareness campaign communicated via its website (https://www.moh.gov.sa/en/awarenessplateform/) or direct public awareness sessions, national television programs, several platforms of social media, and mobile phone SMS messages.91 In collaboration with the “Saudi Center for Disease Control”, the MOH has launched a COVID-19-related guide and health education in more than ten languages to provide all citizens, Saudi and non-Saudi ones, with scientific facts and preventive measurements. This early engagement of the public in prevention/control measures, and the efforts paid to combat claims/misinformation, have been greatly extended.8 Various community-based measurements, including

the provision of facemasks, hand gloves, and hand sanitizers in all workplaces/markets, cleaning and disinfecting public places, community surveillance to prevent the movement and gathering of people, closure of masjids/community halls, and hefty fines for those who did not comply with wearing facemasks and social distancing

Figure 2 Cumulative confirmed COVID-19 cases (A) and deaths (B) in Saudi Arabia. Adapted from Ritchie H, Mathieu E, Rodés-Guirao L, et al. Coronavirus pandemic (COVID-19). Our world in data; 2020.125

were implemented.51 Additionally, the impact of the incidence and fatality ratio-related reports shown on electronic/social media 24 hrs. for seven days on an individual’s psychosocial responses also was acknowledged by Al-Shammary et al.51

COVID-19 Awareness Among the Health-Related Professions

Well-informed health care professionals on COVID-19 may not only be an essential source to disseminate sound knowledge but also to create a safe environment for coworkers and patients. As health-related professions are invariably at a higher risk of developing COVID-19, several recent studies worldwide unraveled the knowledge and/or good practice on COVID-19 among these professions.127–130

Quadri et al found that knowledge was related to the qualification level “interns vs auxiliaries vs specialists” of the study participants regardless of the source of OVID-19-related information. In addition, the overall mean knowledge score and the number of enrolled individuals with correct responses had significantly increased after the intervention.13 Similarly, Al-Khalifa et al showed that dental consultants/specialists with prolonged experience had higher awareness of the latest news of the COVID-19 pandemic.16 Although Tripathi et al found that age, sex, and regional area were insignificant COVID-19 awareness predictors among healthcare workers, their findings confirm that residents who are less educated and “non-healthcare professionals” had less knowledge of COVID-19 and preventive measurements than their counterparts. Meanwhile, significant percentages of participants in their study showed substantial knowledge of the COVID-19 and good preparedness for the prevention/control of the disease.15 By applying 32 concern statements in five different domains-related scales about COVID-19 severity, governmental efforts to contain it, and disease outcomes for HCWs, Abolfotouh et al identified moderate level of concern with Saudi nationality, younger age, undergraduate education, living with others, working in the western region, and direct contact with patients, were identified as “predictors of high concern scores”. They recommended that measures are required to improve the protection of the HCWs and reduce the psychological effect of the perceived risk of infection.20 Also, Alduraywish et al determined a relatively good level of knowledge over the attitude of HCPs regarding COVID-19, and this trend was similar across all regions of Saudi Arabia. They recommended “continuing education programs” to fill the potential gap in knowledge for HCPs in higher-risk groups.23 Interestingly, Temsah et al found that previous experience in their study of healthcare workers with “MERS (Middle East respiratory syndrome-related coronavirus)” was associated with increased knowledge/adherence to protective practices and reduced anxiety towards COVID-19. Similarly, Al-Dossary et al confirmed this issue, stating that “lessons learned treating these previous infections may strengthen nurses’ ability to prepare, adapt, and effectively respond to any disease outbreak”.26

Taken together, increasing the accessibility to materials provided by health care authorities, intensive training programs for all categories of the healthcare workers, rigorous attentive protocols, and a commitment to change behavior/practice, will significantly benefit the spread of the outbreaks.24,31,32,37,40–45,47,48,60,78,84,131 Mushi et al suggested that “risk communication as an effective strategy to improve the attitude and practice of HCWs towards COVID-19 in Saudi Arabia”.89 Measures to enhance protection for HCPs and minimize psychological consequences/potential social stigmatization should be recognized in the planning stage before any pandemic.49,54,102 Also, it is essential that healthcare facilities provide more emotional/psychological support for all HCWs.68

COVID-19-Related KAP Among Patients Residents in Saudi Arabia

Assessment of KAP related to COVID-19 among populations at high risk of acquiring SARS-CoV-2 infection and to whom the COVID-19 course would be worrisome, such as patients with different diseases play an essential role in the control of the impact of the COVID-19 pandemic.25

For example, Alnajashi and Jabbad identified that out of 176 patients with multiple sclerosis, 95.5% realized the COVID-19 symptoms, 90% followed preventive measures introduced by the MOH, and 83% were complying with quarantine guidelines. These findings indicate a high level of knowledge/practice of preventive measures among these patients, although still some anxiety has been identified. Also, about 32% of the patients missed their hospital appointments, and another 15% had a relapse. In this sense, the investigators recommended that actions to relieve the impact of COVID-19 on healthcare service delivery to patients, such as telemedicine, should be encouraged.25 Similarly, Hassen et al found that “fear of disease deterioration if contracting the infection correlated with the rheumatic patients’ levels of knowledge and patients’ perceptions of worsened disease activity were correlated with unplanned healthcare visits, non-adherence to medication, and difficulty accessing medication”.28 Effective positive psychological interventions/support strategies also are required to be immediately implemented to increase psychological resilience and improve the mental health of patients, in particular, immunocompromised and those with chronic diseases,64 as well as who have a history of mental illness.83

Discussion

The compliance of the general public in following preventive measures plays a critical factor in reducing the widespread transmission of COVID-19. Therefore, the public’s awareness and good practice are fundamental elements in the overall public health response to the COVID-19 pandemic.132

It was evident that Saudi Arabia took extreme measures, including the awareness campaigns to respond to COVID-19, which contributed to limiting the spread and the burden of the disease.133 This action is unsurprising as Saudi Arabia has a unique experience dealing with two previous virus family-related outbreaks.134–137 This unique history assessed the government in considering the rapid response and precautionary measurements against COVID-19 to control its spread.10

Most enrolled studies indicate the significant impact of age, sex, educational level, and income on the knowledge domain of assessed KAP, in which elders, females, more educated participants, and those with relatively higher income levels showed higher scores and/or mean of knowledge levels (Table 1). This finding is consistent with similarly assessed domains in other nations like the Chinese population.128 Previously, females were reported to show more concern/positivity toward their families and society concerning any infectious pandemic.39,138,139 Education and marriage modify individual responses resulting in KAP improvement and overall positiveness.140 These observations could be helpful for future handling of similar epidemics to emphasize the mass media’s role in running targeted awareness-raising intervention programs, particularly for young men, lower-income, and less educated subgroups.

Regarding attitudes, most studies showed a positive/optimistic attitude toward COVID-19 among citizens/residents or health workers during curfew/country closures and/or movement restrictions.10,44,57 This positive attitude was sometimes correlated to the educational level19 or related to some myths.39 Large percentage of study participants realized that the virus could be successfully controlled, and they were confident in the Saudi government’s precautionary measures toward the pandemic (detailed in the previous sections).62 This attitude is in line with findings from other countries worldwide, where most contributors were convinced that COVID-19 is treatable, several governmental authorities have a social responsibility to implement safety/preventive measures to control the spread of this infection, and that their country will be able to control the disease.128,141,142

Regards the practice domain of KAP, most studies, in general, found good practices, and these findings are similar to other studies worldwide.143,144 Being male and having a divorced status were correlated to low practice scores, and older participants, students, and private-sector jobs were associated with high practice scores (Table 1). These findings are similar, more or less, to other reports.128,142,145,146 Implementing strict curfew/lockdown across the country could contribute, in part, to this good practice, as individuals were not allowed to navigate the neighboring areas and other cities during lockdown breaks. All mass media platforms have been full of COVID-19 news, and the short message services have also been swiftly disseminating information. Thus, the KAP domains were relatively good in a positive direction among most of the included studies (Figure 3).

Figure 3 A summary of the main determinants of knowledge, attitude, practice (KAP), and healthcare awareness in the current review. The KAP domains were relatively good in a positive direction among most of the included studies. The two-directional arrows indicate that significant mutual relations between knowledge/attitude and attitude/practice were found. SMPs: social media platforms.

Limitations

Although this review covered many studies conducted during 2020–2022 throughout a broad range of Saudi Arabia regions, one of the limitations of this work is that data used in the analysis of included studies were self-reported, which could have some reporting bias. Also, most studies’ design was cross-sectional and hence, cannot be used to infer causality because a temporal sequence cannot be established. Nevertheless, this study design is used to “generate descriptive statistics regarding the disease/outcome burden in a population or determine background exposure rates”,147 which can be very useful, especially during pandemics.

Conclusion and Future Perspective

The findings of this review indicate that residents of Saudi Arabia have basic knowledge, awareness, and relatively good practice about the way of SARS-CoV-2 transmission, how to protect themselves from the virus, and the highly susceptible age groups at risk of COVID-19. More specifically, most included studies indicate the significant impact of age, sex, educational level, and income on the knowledge domain of assessed KAP, in which elders, females, more educated participants, and those with relatively higher income levels showed higher scores and/or mean level of knowledge. Furthermore, most studies showed a positive attitude toward COVID-19 among citizens/residents or healthcare workers during curfew/country closures and/or movement restrictions. Meanwhile, older participants, students, and private-sector jobs were associated with high practice scores (Figure 3). Collectively, the KAP domains reviewed in this work were relatively good in a positive direction among most of the included studies.

Most concerted efforts organized by the MOH were efficient/effective, with an observable influence on public education towards preventive measurements through multiple media platforms. Based on these findings, Alanezi et al proposed an interesting conceptual framework for augmenting public awareness with elements, including “information sources, types of information, communication channels, and the outcomes” formulated according to the Saudi Arabian lifestyle.18 The yielded observations can provide baselines to the Saudi government(s) and other health associations for keeping the strict measures during the handling of similar epidemics, updating public awareness creation strategies, including the “targeted awareness-raising intervention programs”, expanding targeted populations’ attitudes toward the pandemic, and planning preventive measures during the lockdown periods in case of future outbreaks.

Acknowledgments

We would like to thank all the authors of the original articles enrolled in this study. This work was supported by funding from the Deanship of Scientific Research (grant no. 2222-MED-2019-1-10-F), Northern Border University (NBU), Arar, Saudi Arabia.

Disclosure

The authors report no conflicts of interest in this work.

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