Knowledge, Perception, Attitude, Practice, and Barriers towards COVID-19 Infection among Saudi Residents in the Period of Rapid Outbreak of the Disease: A Cross Sectional Survey

The adherences to protective actions are subjective to knowledge, perception, attitude, practice and barriers towards COVID-19 by Saudi residents. The self-design questionnaires were used as a cross-sectional online survey for assessed their social and behavioral parameters during the agonizing time. The cross-sectional study used data collected via an online self-reported questionnaire from 2216 Saudi residents. SPSS software and chi-square test were applied to analyze and categorize significant differences among sectional variables of the parameters. More than 95% of responders were well aware about the main clinical symptoms of COVID-19 infection and had sufficient knowledge about the protocols of five steps to stop the spread of coronavirus. Apositive perception towards COVID-19 was observed, about 55% participants strongly agreed that Original Research Article Ansari and Al-Shaibani; JPRI, 33(19B): 7-21, 2021; Article no.JPRI.64129 8 the coronavirus outbreak could impact the global economy and infection could be successfully controlled by imposing lockdown and by staying at home. The majority of respondents had good practices regarding COVID-19 infection. A high percentage of participants favored wearing masks, cleaning hands and frequently using hand sanitizer. A large number of participant (83.2%; n=1844) agreed that misinformation and rumors are spreading more quickly than the current outbreak of the new coronavirus. The findings suggested that Saudi residents are possessed good knowledge, optimistic attitudes, and appropriate practices towards COVID-19 during the rapid rise of the COVID-19 outbreak. Hopefully, under the combined efforts of WHO, Ministry of Health, Saudi Arabia, all Saudi residents surely will win the battle against COVID-19 very soon.


INTRODUCTION
The current epidemic of the coronavirus disease 2019 (COVID-19) is a contagious disease caused by severe acute respiratory syndrome coronavirus (SARS-CoVs). Coronaviruses (CoVs) are positive-single stranded RNA viruses with a crown-like exterior, which is shown in an electron microscope because of the existence of spike glycoproteins on the covering. The subfamily Orthocoronavirinae of the Coronaviridae family (order Nidovirales) classified into four genera of CoVs: alpha coronavirus (alpha CoV), beta coronavirus (beta CoV), delta coronavirus (delta CoV), and gamma coronavirus (gamma CoV).Genomic description has revealed that perhaps bats or rodents are the natural sources of alpha and beta CoVs [1]. However, avian species are considered the gene sources of delta and gamma CoVs [2]. Furthermore, reports reveal that 2% of the human populations are healthy carriers of CoVs and these viruses are liable for about 5% to 10% of acute respiratory infections [3].
The World Health Organization (WHO) described this novel coronavirus as the causative agent of the recent disease and named COVID-19. The enormity of the cases of COVID 19 and quick spread of the disease all over the world forced WHO to declare it a pandemic on 11 th of March 2020 [4].
Saudi Arabia was one of the leading countries that had taken active measures to minimize the spread of the infections. The COVID-19 diagnoses of all those patients were carried out to all those people who had fever, cough, sore throat, myalgia, and fatigue. The country put 24 hour restrictions with limited access to movement of people and only in a dire situation people are allowed to move out to their houses.
Collaborative efforts to manage the COVID-19 pandemic are needed which includes scientific, evidence-based and multi factorial approaches. The first step forward to manage COVID 19 is to stop or limit person-to-person contact not only in the community people but also amongst healthcare workers [5]. The exit and entry of the people from and to the country should also be limited to the extent that only thoroughly medically examined people can have access to this facility.
The second step is to incorporate a robust testing policy so that the COVID 19 patients to be identified, isolated, and provided the home or hospital quarantine facility [6]. Subsequently, there is an urgent need to find the animal source from whom the virus jumped to human. However it is not yet clear that the virus jumped from snake source or bat source [7][8][9][10]. The other animal which is doubted to be the source is pangolins [11]. In general people working in wild animal facility must be tested routinely for the COVID 19 infection.
Once the COVID 19 individual is identified it is imperative to focus on treatment options. The severity of the disease will decide the course of action as there is no any specific drug identified so far, for the treatment of the COVID 19 infection. As time passes, there is anxiety among the population for complete disruption of their social and economic condition. How long the social distancing to be maintained in the event viral infection does not disappear, this question strikes every individual's mind.
The purpose of this study was to analyze the different social and behavioral parameters of Saudi population during the outbreak of SARS-COV-2 infection. The online survey assessed their knowledge, awareness, perception, attitude and practice during this agonizing time. The study also evaluated the social and economic barriers they faced complying with the guidelines of the health ministry of Saudi Arabia.

Responders
This cross-sectional survey was conducted from March 28 to April 11, just one week after the curfew was imposed as a potential measure to curb the spread of SARS-COV-2 infection in Saudi Arabia. Since it was not practical to conduct a community-based and countrywide survey, during this exceptional time, therefore, the data was collected through online google form. Posting the link to the responders among Saudi residents throughout the kingdom, a brief description about background, objectives, methodology, and consent of responder, confidentiality and notes for filling the questionnaire were posted on the various social platforms and also to the individual's contact addresses.
Individuals who were residing in Saudi Arabia irrespective of nationality, gender, age group and medical conditions were included for the study by clicking the link in English as well as national language Arabic. The study participants had to answer in "yes", "no" or "can't say" and also by clicking "strongly disagree", "disagree", "neutral", "agree" and "strongly agree" for the respective questions to after showing their keenness to participate voluntarily in the survey.

Procedures
The questionnaires were prepared in six sections: the demographic profile, knowledge, awareness, perceptions, attitudes, practice, and barrier.The demographic profile included age group, gender, type of family, marital status, education, occupation, crowding, living area, health insurance and food habits.
According to guidelines for COVID-19 clinical and community management by the Saudi center for disease prevention and control, ministry of health, Saudi Arabia, 30 questions were designed on COVID-19 knowledge, awareness, perceptions, attitudes, practice and barrier for prevention and stop the spread of infections. The questions were grouped in 6 sections, each consisted 5 questions to determine the outcomes of the imposed curfew and its impact on prevention of COVID-19 infections during period of cases outbreak.

Statistical Analysis
Recorded data were analyzed using SPSS software. Demographic statistics were performed in terms of means and frequencies and also the variables data were noted when it was required. The differences in the sections of responded questionnaires across the study variables for demographic profile, knowledge, awareness, perceptions, attitude, practice and barriers were analyzed. The chi-square test for sectional variables was applied to categorize significant differences among the parameters (significance level set at p < 0.05).

Knowledge of Saudi Residents
Regarding COVID-19 The responses obtained under "knowledge" categories of questionnaires were mixed and contained five knowledge based questions. Most of the respondents correctly answered that the coronaviruses are from the family of RNA viruses that cause illnesses ranging from the common cold to more severe diseases same as Middle East Respiratory Syndrome (MERS) and Severe Acute Respiratory Syndrome (SARS). Almost half of the responders, 48.6% (n=1077) were aware that the corona viruses are airborne and spread through droplets from one person to another person. More than 95% of responders were well aware about the main clinical symptoms of COVID-19 infection and had sufficient knowledge about the protocols of five steps to stop the spread of coronavirus. And also, it was observed that most of the responders were having incredible knowledge about treatment and management of COVID-19 even though there is no specific treatment and vaccine available for COVID-2019 infection, but early symptomatic treatment can help patients to recover from the disease.

Awareness of Saudi Residents Regarding COVID-19
The response of questionnaires regarding awareness included five questions and was mixed. Almost 96.8% (n=2145) respondents marked yes answer for the COVID-19 transmission pathways, respiratory droplets, contact with contaminated surfaces and direct contact with infected person. The 79.3% (n=1757) of the responders were aware about that the symptoms of COVID-19 similar to pneumonia. More than 95% (n= 2110) of responders were well aware of the COVID-19 infection that can be prevented by washing hands with soaps and water, covering mouth and nose when coughing and sneezing, and avoid close contact of people who have symptoms of a respiratory problem such as breathlessness or difficulty in breathing. A similar type of awareness response was observed regarding

Fig. 1. Knowledge of Saudi residents regarding COVID-19
the instructions, for example, wash hands before, during and after preparing food, before eating, after coughing and sneezing, before and after taking care of an infected person, after using the toilet, after changing diapers, after touching the animals and after touching the trash. Furthermore, it was observed that most of the responders had correct awareness about the belief that sneezing etiquettes helped reduce COVID-19 infection.

Perception of Saudi Residents towards COVID-19
All the participants responded to all five questions related to their perception of COVID-19. Their answers demonstrated a positive perception towards COVID-19.About 54.50% (n=208) individuals strongly agreed that the coronavirus outbreak could impact the global economy. A low percentage (13.6%; n= 301) of participants showed strong agreement about their hospital where they have enough infection control staff and they were satisfied. Similarly, a very low percentage (3.3%; n=72) had strongly agreed that coronavirus was due to the ingestion of unprocessed food whereas, 3.4% (n=66) had strongly agreed for the perception that eating or contacting with wild animals only cause COVID-19 infection. A miniscule percentage (2.5%; n=55) of the respondents had strong belief that general masks used by residents was enough to prevent the spread ofCOVID-19 infection. The coronavirus is airborne and spread through droplets mainly from personto-person?
Coronaviruses are a family of RNA viruses that cause illnesses ranging from the common cold to severe diseases such as MERS-CoV and SARS-CoV

Knowledge of Saudi residents regarding COVID-19
Yes No Can't say General masks used by residents is enough to prevent the infection by the COVID-19 Eating or contacting with wild animals only cause of the COVID-19 infection.
Coronavirus is due to the ingestion of unprocessed food.
In our hospital we have enough infection control staff so no need to worry.
Coronavirus outbreak can impact the global economy.

Perception of Saudi residents towards COVID-19
Strongly disagree Disagree Neutral Agree Strongly agree

Barriers among Saudi Residents towards COVID-19
Mixed COVID-19 will develop to more serious in those who are elderly, have chronic illnesses.
The Ministry of Health Saudi Arabia provided enough information about how to win the battle against the COVID-19 infection.
COVID-19 infection will be successfully controlled by making lockdown and stay at home.

Attitude of Saudi residents towards COVID-19
Strongly disagree Disagree Neutral Agree Strongly agree essential barriers in the prevention of COVID-19.The majority of the individuals (83.2%; n=1844) agreed that misinformation and rumors are spreading more quickly than the current outbreak of the new coronavirus (COVID-19).On the other hand, 35.8% (n=793) participants believed that global collaborative efforts had not been taken to prevent COVID-19 cases.

DISCUSSION
This study may be the first among all that has thoroughly assessed the knowledge, awareness, perception, attitude, practice, and barrier towards COVID-19 among the Saudi population. The study has highlighted the possible methodologies and healthy practices to prevent the spread of COVID-19. For individuals, better knowledge, positive sense of awareness, accurate or right perception, affirmative attitude, healthy practices, and least social barriers are fundamental in the effective dealing of COVID-19 pandemic with minimum risks. Furthermore, coronavirus disease's ongoing pandemic nature made it necessary for all individuals to increase their precautionary measures and to put efforts by achieving standards of hygienic and healthy conditions. Findings of this survey demonstrated that demographic responders were in the age group 31-45 years, male, living in the nuclear type of family, married, education gained up to bachelor level or above, professional, living in a crowd of 5-10 persons in a flat, urban dweller, majority of them did not have health insurance,  To prevent the spread of COVID-19 infection do you participate in social gathering or function with your family, friend and relatives?
The incubation period of virus is 14days, therefore, if any one gets in direct contact with COVID-19 infected person should stay quarantine for 14 days.
Wear mask, clean hands with soap in every 2 hour, and use hand sanitizer frequently as COVID-19 spreads via respiratory droplets of infected individuals.

Practices of Saudi residents regarding COVID-19
Yes No Can't say and their food habit was mixed. The finding of the study is in agreement with the previously studied report [11].

Barrier in Saudi residents towads COVID-19
Yes No Can't say was mixed with global economic impact, local infection control and treatment, food habit concerning COVID-19, and wearing gloves and masks to prevent the infection. A Similar study was conducted by Jordanian team among health care professional and found almost same outcomes [12]. In this study, participants showed a positive general attitude towards measures that can be followed to prevent the transmission of the disease. More than two-thirds of participants agreed that COVID-19 infection could be successfully controlled by imposing lockdown and stay at home policy, a measure taken by the ministry of health, Saudi Arabia. Older people having chronic diseases are more prone to COVID-19 infection.
The practices to control the spread of COVID-19 showed positive results; most residents generally used masks, cleaned hands with soap every 2 hours, and frequently used hand sanitizer. The incubation period of the virus is 14 days; therefore, if anyone gets in direct contact with COVID-19 infected person, stay quarantined for 14 days. Avoid social gathering or function with family, friend, and relatives and ask the query, doubt, questions to the toll-free number, hashtag and email provided by the ministry of health Saudi Arabia related to prevention of COVID-19 [11]. The findings demonstrated that majority of participants perceived that no clear cut information about what to do or what not to do in regard to the prevention of COVID-19 transmission, social stigma about COVID-19 infection and willing to disclose their symptoms in early stage, misinformation and rumors are spreading more quickly than the current outbreak and Global collaborative efforts have not been taken efficiently to prevent COVID-19 case [13].

CONCLUSIONS
In summary, the findings suggested that Saudi residents of a relatively high socioeconomic status possessed good knowledge, optimistic attitudes, and appropriate practices towards COVID-19 during the rapid rise of the COVID-19 outbreak. Besides, good COVID-19 related knowledge instilling optimistic attitudes and encouraging healthy practices towards COVID-19 are suggested. Health education programs aimed at improving COVID-19 knowledge help encourage optimistic attitudes and maintain safe practices. Hopefully, under the combined efforts of WHO, Ministry of Health, Saudi Arabia, all Saudi residents surely will win the battle against COVID-19 very soon.

CONSENT
As per international standard or university standard, respondents' written consent has been collected and preserved by the authors.

ETHICAL APPROVAL
The research and ethics committee of College of Pharmacy, Shaqra University approved this study protocol and methodology of survey.