Perceptions of COVID-19 symptoms, prevention, and treatment strategies among people in seven Arab countries: A cross-sectional study

Backgroup the widespread COVID-19 infection worldwide has resulted in the inability of healthcare facilities to receive all infected patients; therefore, most are treated at home. In addition, factors such as high mortality, types and severity of symptoms, and the prevalence of unreliable information have prompted patients to resort to self-treatment. Objectives To assess prevention, treatment, degree of symptoms, and sources of information among patients with COVID-19 in Arab countries Method A cross-sectional study was conducted in seven Arab countries: Algeria, Egypt, Iraq, Lebanon, Libya, Tunisia, and the United Arab of Emirates. People who have recovered from COVID-19 completed the study questionnaire. Score of symptoms during and after COVID-19 infection has been calculated by giving the participants a list of 13 symptoms. Results A total of 3519 participants completed the survey. Mostly females (68.3%), and aged between 18 and 40 years old (59.4%). Prophylaxis treatments, including vaccines and antibiotics, have been used in around 40% of the participants. The total average score of symptoms during the infection period was found 7.31 ± 3.66 out of 13. However, the symptoms score upon recovery was low (0.48 ± 1.11 score). The significant associations with increased incidence of symptoms during infection were reported with older people, married, divorced or widowed, people with chronic diseases, and obese. Moreover, significant associations with decreased symptoms were reported with those who worked in the health sector, non- or ex-smokers, and vaccinated people. Conclusion The use of medication and other treatments to prevent infection with COVID-19 was common among the participants in the seven countries. Taking the vaccine was the only effect on the number of symptoms experienced by patients. Although nearly two years have passed since the onset of the disease, there is still a need to raise treatment awareness among patients at home.


Introduction
The World Health Organization (WHO) had declared COVID-19 as a pandemic disease in March 2020. Currently, the confirmed number of cases globally has reached up to 581 million and 6.4 million deaths [1]. The Eastern Mediterranean region had reported around 22.8 million confirmed cases and 345 thousand death cases in August 2022 [1].
The majority of those who recovered were treated at home with doctor-prescribed medication or medication self-treatment, primarily based on information from other infected people or social media [2,3]. Several drugs have proven clinical efficacy against COVID-19 infection, mainly in hospitals. In addition, most treatment guidelines are recommended prescribed medications based on the severity of symptoms and health status of patients [4]. Generally, the main recommendations for a patient at home are analgesic and rest [4]. For prevention, in late of 2020, the FDA approved the first vaccine to prevent COVID-19 infection [5]. Globally, the disease has caused widespread anxiety and fear among the population, mainly due to the increase in confirmed cases and the high death rate, which was exacerbated by the lack of an approved drug to treat it. In addition, the regulations of lockdown that have been issued and required for isolation when infected with the virus. These led billions of people to search in different sources of information for COVID-19 related topics online [6]. Where different information resources such as social media platforms contributed to distributing unproven medical information and increased selfmedication practices [3,7]. These sources make communication between infected people easier and then sharing information related to treatment that mostly with no evidence. Therefore, many people who feel unwell have resorted to consuming various substances, including traditional medicine, to treat or prevent COVID-19 infection, without considering the safety and efficacy of the substance for the human body [8,9].
Self-medication is defined as taking any type of treatment by individuals to treat an illness or symptoms without physician consultation [10]. Potential risks associated with self-medication might lead to make the condition difficult to treat, delay the diagnosis, increase prevalence of antimicrobial drug resistance, and cause adverse drug reactions due to incorrect doses and dosage forms, and use the medication for longer than its intended duration [11]. One reason to make medication self-treatment is ability to collect prescribed drugs from the pharmacy without prescription. This issue is highly practiced in many countries in the Middle East region, including some medications which are used to treat patients with COVID-19 infection in hospitals such as antibiotics, oral cortisone, antivirals, and anticoagulants [12,13].
There are many types of symptoms occurred among infected people, and the most common types of symptoms are fever, cough, headache and fatigue. In addition, there are atypical symptoms such as skin disorders and diarrhea [14]. In general, symptoms have been reported diversely in people between countries. In addition, many people have reported persistence of some symptoms weeks after recovery from the infection [15].
Due to the regulation of lockdown and fear among the population and required for isolation when infected with the virus, many people have gone to use different sources of information to get information related to treatment such as social media that makes communication between infected people easier and then sharing information related to treatment that mostly with no evidence.
The study aimed to assess the experiences of COVID-19 patients from seven Arab countries, including the prophylaxis treatment used, treatment during infection, score of symptoms, and the factors influencing them.

Study design
A cross-sectional study was conducted using a self-administered questionnaire. The survey was used to collect information among people who have recovered from COVID-19 including sociodemographic data, prophylaxis treatment used, drug treatment during infection, and types of symptoms.
The study was conducted in seven Arab countries: Algeria, Egypt, Iraq, Lebanon, Libya, Tunisia, and the United Arab of Emirates (UAE). People from both sexes aged ≥ 18 years from participating countries were invited to participate in the study. Exclusion criteria were: (a) people who did not contract COVID-19 and (b) people who were admitted to hospital due to COVID-19.
The questionnaire was distributed electronically, through Google Forms. The link to the survey preceded by introductory section about the study was sent via two social media platforms: Facebook and Instagram. The survey distribution period from June to August 2021. The cover section described the aim and objectives of the study and the voluntary nature of participation with a consent statement, that no written consent was needed, and that consent was assumed if recipients agreed to participate and completed the questionnaire. The questionnaire was terminated automatically if participants declined to take part. The participants were requested to complete the survey without consulting people, materials, textbooks or internet web pages.

Study instruments
The questionnaire was developed by the authors after an extensive review of the literature [9,16]. The final version of the questionnaire was composed of four sections. The first section designed to collect general sociodemographic and health data about the participants such as age, sex, occupation, level of education, health status, weight and height, and smoking and alcohol status. The second section included questions related to types of medications used as prophylaxis and during infections period. The third section was related to types, period and severity of symptoms of people who were infected with COVID-19. The fourth section included the sources of information about COVID-19 among the participants.
Score of reported symptoms during and after (more than 2 weeks) of COVID-19 infection has been calculated by giving the participants a list of 13 credential symptoms (fever, cough, loss of smell and taste, headache, tiredness, nose decongestion and sneezing, pain in the throat, pain in muscles and joints, diarrhea, abdominal pain, shortness of breath, problem with sleep, skin problem). The score of symptoms has been adapted and modified according to published literature [17,18]. Each symptom had two response choices, either yes/present or no/absent. Each symptom was scored based on whether it was present (score of 1) or absent (score of 0); thus, the overall symptoms' score ranges between (0 and 13). There were no cut-off scores implemented, that is, a higher score in each category represents a higher symptom in the same category. The questionnaire was in the Arabic language and reviewed by the authors and five academic members then subjected to a pilot testing by 10 people from different Arab countries to ensure clarity of the questions. Then, the questions were modified based on their feedback.

Sample size calculation
The target sample size was estimated for each included country using Raosoft® software sample size calculator for the minimal sample size needed for unlimited population size using a confidence interval of 95%, a standard deviation of 0.5, a margin of error of 5%, the required sample size was 384 participants from each study population (country) [19].

Data analysis
Study data were analyzed using the 24th version of the statistical package for the social science (SPSS®). The mean ± standard deviation (SD) and frequency (or percentages) were used for continuous Table 1 Sociodemographic characteristics of study participants (n = 3519).  and categorical variables respectively. The Chi-square test was used to identify significant difference in sociodemographic variables between countries, and for the frequencies < 5 Fisher's exact test was used. Binary logistic regression analyses were undertaken using the incidence of symptoms during COVID-19 infection (yes/no) as the outcome. Univariable and multivariable logistic regression were used to test the predictors for symptoms during COVID-19 infection. Variables that were found to be significant on a single predictor level (P < 0.25), using univariable logistic regression analysis, were entered into multivariable logistic regression analyses. Variables were selected after checking their independence, where Pearson's correlation coefficient (r) less than 0.9 indicates the absence of multicollinearity between the independent variables in regression analysis. In the logistic regression analysis, variables that were independently associated with score of symptoms during COVID-19 were identified. Statistical significance was considered at P ≤ 0.05.

Sociodemographic characteristics
A total of 3519 participants completed the survey from the seven Arab countries. Most participants were aged 18-40 years old (59.4%), married (77.7%) and 68.3% were females. More than half of the respondents were bachelor's degree holders (58.7%) and almost half (46.3%) were employed in non-health sectors. Most of participants were non-smokers (67.1%) and above the normal weight (70.3%). The most common chronic diseases among participants were cardiovascular diseases (20.2%), and diabetes mellitus (7.0%). Table 1 shows sociodemographic characteristics and health status of participants.
Regarding prophylaxis used among participants before infection with COVID-19, 39.9% of the participants used at least one therapy. Most participants who used prophylaxis therapy were from the UAE and Iraq with 49.1% and 45.0%, respectively. Main types of prophylaxis therapy were vitamins and dietary supplements, including vitamin C and zinc. The use of herbal products as prophylaxis against the COVID-19 infection was most commonly reported by participants from Algeria at 31.8%. Antibiotics were used by more than 5% of participants in most countries, the highest being in Algeria with 10.4%. The used of vaccine among participants' prior the COVID-19 infection was recorded more than 20% in three countries: Tunisia, the UAE, and Libya with 37.7%, 29.8%, and 21.8%, respectively. Fig. 1 shows prophylaxis therapy used among participants in the seven countries. Fig. 2 represents the types of treatment \ used among study participants during COVID-19 infection. Vitamins and dietary supplements were the most commonly used treatment in almost all countries: lowest in Egypt at 19.7% and the highest in the UAE at 27.1%, followed by antibiotics and herbs products. In addition, antiviral, corticosteroids, bronchodilator (inhaler), and anticoagulants were used among the participants in the study.
The symptoms of COVID-19 infection during infection (for two weeks) and upon recovery for at least 2 weeks were measured and given number of symptoms out of 13 scores. The total average score from all countries for symptoms during COVID-19 infection among participants was found (7.31 ± 3.66 scores), while after the infection was (0.48 ± 1.11 scores) as represented in Table 2. The highest score of symptoms during COVID-19 infection was reported among Algerian participants (7.69 ± 3.15 scores) and the lowest was reported among Lebanese participants (6.81 ± 3.96 scores). With regard to scores after COVID-19 infection, the highest was found among UAE participants (0.59 ± 1.37 scores) while the lowest was among Tunisians (0.23 ± 0.70 scores).
Regarding the reported symptoms during COVID-19 infection, more than half of the participants from all countries reported fever, cough, fatigue, nasal congestion and sneezing, sore throat, muscles and joints pain, diarrhea and abdominal pain. Followed by shortness of breath and sleeping problems. Minority reported skin related problems as represented in Fig. 3. Following COVID-19 infection (more than 2 weeks) the most reported symptoms among study participants from different countries included nasal decongestion and sneezing, headache, cough, diarrhea, and sleeping problems. Followed by sleeping problems, fatigue and the loss of smell and taste as represented in Fig. 4.
Logistic regression model of association between sociodemographic characteristics and score of symptoms during COVID-19 infection among the study participants is represented in Table 3. A significant positive correlation was found between score of   On the other hand, a significant negative correlation was found between score of symptoms and smoking status (non-smoker (p = 0.028), and former smoker (p = 0.016).

Source of Information
With regards to participants' source of information about COVID-19, the majority of participants from all countries reported the physician as their main source. Social media was the second most commonly reported by Algerian, Libyan, and Tunisian participants, while pharmacists were the second most commonly reported source in Iraq, Lebanon and UAE followed by social media and family. On the other hand, participants from Egypt reported infected or recovered people as their second source of information after physician followed by pharmacist, social media, and friends. The sources of information about COVID-19 infection are reported in Fig. 5. Table 2 Score of symptoms during and after (more than 2 weeks) COVID-19 infection.

Country
Score of symptoms out of 13

Discussion
The study included data from recovered COVID-19 patients (n = 3519) who were treated at home from seven Arab countries, describing the use of preventive treatment before infection with the Corona virus, the practice of self-treatment during infection, and the occurrence of symptoms among participants during infection and after recovery. Female and adult participants aged 18-41 years were the highest in all countries. Several prescription and nonprescription drugs, with no evidence of some of them treating or preventing infection or symptoms, were used among the participants. The physicians and social media were the most common sources of information among the participants in all countries. Our findings found association between demographic characteristics and health status of several participants and the incidence of symptoms of COVID-19 infection among study participants such as elderly patients (> 65 years old), smoker, obese people, patients with chronic disease, and vaccinated people which is similar with published studies in many communities around the world [20][21][22]. In addition, there are other uncommon factors that have association with severity of symptoms such as being single and working in the health sector.
The COVID-19 pandemic has posed detrimental health, social and psychological challenges on public's wellbeing [23]. Such consequences accompanied with the lack of effective treatments provoked people's precautionary measures to use prophylaxis therapies including the use of antiviral, antibacterial and other therapeutics already in use for other diseases in addition to the use of vitamins and dietary supplements [13,24]. Vitamins (including vitamin C and D) as well as zinc and selenium, were emphasized as potentially beneficial for individuals with respiratory viral infections [25], based on a theory that these substances might play a role in stimulating the immune system that could be used to treat/ prevent COVID-19; however, dietary supplementation and vitamins intake was not linked to prevent or treat COVID-19 [26]. Nevertheless, the consumption of these supplements was significantly increased with the emergence of this pandemic hoping to provide some protection or reduction of disease severity [27,28]. Similarly, our study findings reported that almost half of the participants were using vitamins and dietary supplements as prophylactic therapy before COVID-19 infection. The use of these vitamins and supplements were reported in many published studies during COVID-19 pandemic. More than half of the participants (56.0%) were reported in two studies: in Pakistan among medical students (n = 489) [29], and in the UAE among general population (n = 2060) [30]. Another study included three countries, UK, USA, and Sweden (n = 445,850), more than half of people used at least one vitamin and/or dietary supplement during COVID-19 pandemic [31]. Also these materials were highly used among patients in many other countries with various ratios such as in Poland [32], Bangladesh [33], and Togo [34]. In addition, the use of dietary supplement was increased many folds during COVID-19 as reported in a study from Lebanon [35].
In the current study, taking the vaccine was only the prophylactic factor that has significant association with severity of symptoms during COVID-19 infection among the participants. Although COVID-19 remains with no cure up till this day, developed vaccines remain a safe and highly effective solutions to reduce the risk and severity of the disease [36]. A high rate of COVID-19 vaccine hesitancy among Middle Eastern Arabs was reported, affecting people's likelihood to receive the COVID-19 vaccine [36,37]. According to our study findings, UAE and Tunisia participants were more approving on receiving the vaccine compared to other participants in other countries specially Algeria and Egypt, in compliance with what was reported in earlier studies [38]. Also, the recorded symptoms scores were generally lower in the high vaccinated countries compared with other countries, either during the infection period or after the recovery. This variation in vaccination hesitancy among participants from different countries could be due to different economic, social and political conditions, in addition to public's trust in their national health agencies [37]. As well as education and national awareness, combined with other factors such as the prevalence and mortality rates of COVID-19 among these countries plays a crucial role in deciding peoples' approaches to protect and treat themselves before and during the COVID-19 infection [38]. Several common symptoms have been associated with COVID-19 infection among the participants such as fever, cough, fatigue, muscle or body ache, diarrhea and headache [39]. The severity of COVID − 19 infection varies among individuals from mild to highly severe symptoms. According to our study findings a significant positive correlation was found between score of symptoms and several factors such as age > 65 years, employment in health-related sector, marital status (divorced or widowed), chronic disease and obesity. Similar to our findings factors, the findings of two systemic reviews and meta-analysis included of hundreds studies around the world that factors: increasing age, the presence of chronic diseases and the presence of obesity increased the risk of severe illness [28,29]. In another studies, married, divorced and widowed participants recorded higher symptoms scores than single people. However, some studies reported that married people have better quality of life which is coming from family support for the patients and lower stress level and anxiety among the married people [40][41][42]. In addition, there was no association reported between marital status and symptoms in another study [43]. In our study, people who are working in health-sector stated lower symptoms scores compare with employed in non-health sector. This result is controversial with a study conducted in UK [44].
As well as several studies have examined the impact of COVID-19 and the lasting symptoms on patients after several months (including fatigue, muscle aches and sleep difficulties) [45]. The findings of this study indicated that many participants from all countries severed from symptoms that persisted after recovered from the infection. However, these symptoms are much less than symptoms during the period of infection. It is reported that 10-70% of individuals who were previously infected suffered from various physical and neuropsychiatric symptoms that persisted for several months after recovery of the infection which is described as "long COVID-19″ [15,46]. Long-term COVID-19 symptoms is a term used to describe a group of miscellaneous symptoms in people who have recovered but reporting lasting symptoms of the infection that are distinct from those of patients recovering from severe COVID-19 or have had the usual symptoms for a longer period than usual (including fatigue, muscle pain, headache, sleep difficulties, and cognitive dysfunction) [15,46]. However, risk factors for developing long COVID are not known yet as there is no reported association between the severity of COVID-19 infection during the acute illness phase and the likelihood of developing symptom burden at follow-up leading to long-COVID syndrome [46].
Regarding participants' sources of information about COVID-19 infection, similar to previous studies, the results reported that physicians were the main source of information sought in all countries. This highlights the crucial role of health care providers in delivering accurate and reliable information regarding the COVID-19. Expectedly, social media came in second place, following physicians in most countries considered an important source of information [47]. However, the easiness and accessibility of social media can lead to incomplete and misleading information about the virus [48]. Thus, providing trusted sources that assure clarity and reliability among populations regarding COVID-19 information is vital to fight misconceptions and false information speculating around.
There are some limitations in the study. The cross-sectional design of the study is not without limitations as causality cannot be established. Furthermore, issues related to the questionnaire such as the difficulty of distributing the survey, and the level of understanding of the questions among the participants; however, the understanding of the questions was evaluated among the Arab peoples. Also, participants may not feel comfortable giving answers that present themselves unfavorably, which creates a source of bias. Finally, social media can only be used to distribute the survey to people who are literate and have internet access and a social media account.
Future researches are needed to evaluate the reasons for using drugs (self-treatment) and other substances to prevent and treat COVID-19 infection in people. In addition, there are some socioeconomic factors that need more focus for evaluation such as marital status and work in the health sector, which may have an impact on people dealing with COVID-19 infection. Finally, there is a need for more research in the future that focus on the long-term effect of COVID-19 infection on people in the region.

Conclusion
The study indicated the use of several drugs and treatments to prevent infection with the COVID-19 virus and treat patients at home. However, several symptoms were also observed among patients; some persisted even two weeks after recovery. In addition, specific demographic characteristics and treatments influenced the severity of symptoms, such as vaccination, obesity, non-smoking, and older age. The primary sources of information among participants were health care providers and social media, but the choice of treatment was often inconsistent with health organizations' recommendations.
There is a need for more awareness and attention to treatment among patients being treated at home to avoid unnecessary treatment and adverse effects of medication.