Bird’s-eye View of Covid-19 Emergency Preparedness Among Emergency Physicians in the Kingdom of Bahrain


 Background: Coronavirus 2019 (COVID-19) has exemplified the crucial role played by emergency physicians on the frontlines, by triaging, quarantining and treating myriad patients in time. Despite this, there exists a dearth of literature comprehensively assessing the knowledge and awareness of these healthcare workers on the disease in the Kingdom of Bahrain. Objectives: This study was designed to evaluate the knowledge, attitude, and practice (KAP) of emergency physicians in the Kingdom of Bahrain towards COVID-19. Methods: This cross-sectional descriptive study included 142 emergency physicians of three major hospitals in Bahrain. A self-designed questionnaire divided into 4 parts which comprised of demographics, knowledge, attitude and practices towards COVID-19 were completed by the emergency physicians working in these hospitals. Analysis of variance (ANOVA), t-test, Chi-square test, and multiple linear regression were employed to evaluate KAP scores. Results: The mean COVID-19 knowledge and practice score was 26.29 for a maximum score of 32 suggesting an overall 82.15% correct rate on the knowledge and practice test. Multiple linear regression analysis highlighted age (p=0.038), genders (p=0.033), marital status (p=0.021), organization (p=0.032), having children (p=0.008), and continuing professional development (CPD) activity (p=0.0001) as significant predictors for knowledge and practice scores. The attitude towards the final success in controlling COVID-19 significantly differed across marital status (p=0.021), organization of participants (p=0.020) and position of participants (p=0.012) respectively.Conclusion: Good knowledge, positive attitude and sufficient safe practice towards COVID-19 were observed in majority of the participants. These findings can foster development of nuanced and salient health management strategies that augment KAP so that proper control and elimination of the disease can be achieved, while prioritizing patient health and satisfaction.


Introduction
Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) or novel coronavirus is the latest subset of RNA viruses that has crescendoed into a pandemic crisis. Moreover, it has simultaneously brought to fore a plethora of chinks in healthcare systems as well as the indomitable spirit of physicians worldwide.
This emerging respiratory infection was rst discovered in December 2019, in Wuhan city, Hubei, China and was declared as a global pandemic by World Health Organization (WHO) on 12th March 2020. 1,2 Coronaviruses constitute a large and ambiguous family of viruses that elicit a broad spectrum of symptoms and infections such as common cold, to more serious diseases, such as Middle East Respiratory Syndrome (MERS-CoV) and SARS-CoV. 3 COVID-19 is characterized by rapid transmission of the virus, and occurs through close contact with an infected person. [6][7][8][9] Disease progression revolves around respiratory illness (like u) with main clinical symptoms such as fever, dry cough and dyspnea. 4,5 This new outbreak has begotten undue hysteria partly due to misinformation and falsi ed news. The data surrounding the biology, epidemiology, and clinical characteristics however are evolving, thus making this a moving target.
Asymptomatic people can be contagious as the virus is mainly transmitted via respiratory droplets and has been detected in the respiratory secretions of such patients. 10 Recent epidemiological and experimental evidences implicates airborne transmission of Covid-19 virus via aerosols as a potential route for spreading the disease depending upon the viral load. [11][12][13] Reverse transcription polymerase chain reaction (RT-PCR) from a nasopharyngeal swab is the standard method of diagnosis. At present there is no speci c antiviral treatment or vaccine for COVID-19. Management includes supportive care, treatment of symptoms, isolation, and experimental measures.
The epidemics of COVID-19 has been recorded over in 216 countries, territories, and areas with more than 12 million con rmed cases and 5,68,573 deaths reported globally. 14 Following the WHO declaration, countries around the globe including Kingdom of Bahrain have been relying on various strategies to combat and contain this pandemic. Following the con rmation of its rst case of COVID-19 on 21 Feb 2020, the Bahrain government has been watchful in monitoring the situation and adopting speci c measures that were in line with the WHO guidelines in dealing with the outbreak. The cause of the infection is novel, and the extent of the disease is unknown.
The battle against COVID-19 is an ongoing one, across the world. As emergency services are lifelines of healthcare in times of a pandemic disaster, the responsibility of emergency staff has increased tremendously. A burgeoning patient pool and failure of health care system to retort to the increasing need of the patients during these testing times has led to an upsurge of negative emotions among emergency physicians. Physicians themselves are required to constantly update their knowledge on COVID-19 to assuage patient concerns. However, this knowledge must be supplemented with well-planned communication and management strategies to ensure the best outcome possible for each patient. Some hospitals have reportedly adopted an array of capacity building avenues including TV, videos, podcasts, online seminars and social media for all categories of healthcare personnel . 15 Although, several studies have been conducted in Asian countries indicating high levels of COVID-19 knowledge among the general population, there is very scarce literature available examining the knowledge and awareness in regard to COVID-19 among emergency physicians in different regions of the world especially Kingdom of Bahrain. Therefore, this study was designed to investigate the KAP of emergency physicians towards COVID-19 in the Kingdom of Bahrain so as to improve awareness and attitudes among emergency physicians in recommending any remedial measures and additional interventions.

Study design
This cross-sectional descriptive study was conducted in the months of May and June 2020 at three selected hospitals in the Kingdom of Bahrain among 142 emergency physicians after obtaining a written informed consent. The study was done after obtaining approval from the National COVID-19 Committee and from Research & Research Ethical Committee at the BDF Hospital. The minimum sample size representing the population which should be reached was calculated to be 140 with a prevalence of 90%. The power of 80% with a con dence interval of 95% and precision of 5% with an error set at 95% was considered.

Patient and Public Involvement
Patients or the public were not involved in the design, or conduct, or reporting, or dissemination plans of our research.

Data Collection
The respondents were recruited on ease of accessibility based on the convenience sampling approach. A comprehensive questionnaire was carefully developed based on veri ed literature with suitable modi cations and additions. Following which, it was scrutinized in terms of its integrity, simplicity and overall content, by three consultants hailing from the Emergency Medicine specialization. A pilot study on a small sample (n = 5) of emergency physicians was undertaken to assess the intelligibility and reliability of the questionnaire. Subsequently, the questionnaire as a research instrument for this study was further validated by an expert in the eld of infectious diseases who was also a member of the Bahrain National COVID-19 committee. After thorough deliberation, the expert's suggestions were incorporated and this self-administrable questionnaire was distributed to the participants by email for data collection. The cover page of the questionnaire included a short introduction regarding the objectives, procedures, the voluntary nature of participation, declarations of con dentiality and anonymity. The structured questionnaire was categorized into four parts. The rst part consisted of respondent's demographic information. The second part classi ed the respondents' knowledge on COVID-19 transmission source, etiology, incubation period, symptoms, risk group, and consequences by the use of dichotomous questions with Yes or No as options. The third part evaluated the healthcare worker's attitude towards COVID-19 in which their response was assessed through 5-point Likert scale of agreement wherein, the responders specify their level of agreement to a statement typically in ve points: (1) strongly disagree; (2) disagree; (3) Neither agree nor disagree; (4) agree and (5) strongly agree. 16 The last part depicted the practice statement of respondents regarding COVID-19 using a series of 11 Yes/ No questions.

Statistical Analysis
Data was analyzed using SPSS software. Percentage mean and standard deviation (SD) were used to present data to evaluate the demographic variables. KAP scores of participants according to demographic characteristics were analyzed using t-test, Chi-square test and analysis of variance (ANOVA). Multivariable linear regression analysis was conducted to identify factors associated with knowledge. P-value of < 0.05 was considered as signi cant.

Results
The distribution of participants based on their demographic characteristics is depicted in Table 1. Majority of the subjects were in the age range of 35-44 years (38.7%). A male predominance was noted (66.2%). With respect to the experience, most of them had > 5 years of experience in Emergency medicine and 59.9% of them participated in continuing professional development (CPD) activity about COVID-19. Organization circulars/Guidelines were found to be the main source of knowledge on COVID-19 (90.8%) ( Fig. 1). With respect to attitude statements about COVID-19, majority of the participants (73%) agreed that this disease could be successfully controlled. In addition, majority of participants (72%) agreed to provide care for COVID-19 patients. Furthermore, most of the participants were in inclined towards working in COVID-19 treatment/isolation center. In terms of practice statements about COVID-19, more than 90% of the participants were aware of the local guidelines, use of sanitizer and use of personal protective equipment (PPE). In addition, most of the participants were also aware of the standard precautions to be applied while dealing with COVID-19 patients and also were aware of the order of put and take off PPEs after use.
Various demographic characteristics were considered, with respect to the distribution of participants in terms of knowledge, attitude, and practice statements about COVID-19. Participants in the age group of 35-44 had higher scores as compared to other age groups with regard to practice statements (p = 0.021) as depicted by Fig. 2.
Regarding the marital status, married participants had higher knowledge scores (p = 0.016), attitude scores (p = 0.0087) and practice scores (p = 0.013) as compared to divorced, single and widow (Fig. 2). With respect to organization, participants from King Hamad University Hospital (KHUH) had highly signi cant knowledge score (p = 0.026) and attitude scores (p = 0.007) as compared to other organizations. In terms of position, consultant in emergency medicine and others which included registrar and senior resident had high practice scores (p = 0.045) compared to other positions. Based on emergency medicine experience, participants with > 5 years of experience had signi cantly higher practice scores (p = 0.014). Emergency physicians who attended CPD activity had signi cantly higher knowledge scores (p < 0.001) and practice scores (p = 0.000024) compared to those who did not attend any CPD activity ( Table 2, Fig. 2). and those who attended CPD activity about COVID-19 (p = 0.0001) were signi cantly associated with higher knowledge and practice score. Overall, these variables were observed to be signi cant predictors for knowledge and practice scores (Table 3).  The attitude towards the nal success in controlling COVID-19 signi cantly differed across marital status (p = 0.021), organization of participants (p = 0.020) and position of participants (p = 0.012). Participants who reported "Disagree" and "Neither agree nor disagree" had signi cantly lower attitude scores than those reporting "Agree" and "strongly agree".

Discussion
COVID-19 pandemic, an infectious disease poses a signi cant threat to public health has brought the entire world to a standstill. Researchers all over the world are working extensively on the therapies and vaccines against the virus. KAP of the public is crucial towards the containment of this disease and in implementing directives such as social distancing, isolation, maintaining personal and community hygiene to ght against COVID-19. Accordingly, this study was designed to gauge the KAP of Bahraini emergency physicians through a questionnaire survey. The study had some limitations such as the sample sizes being restricted to emergency physicians and hence the results cannot be applied in general to physicians. Another limitation of the study could be the misinterpretation of information and chances of errors due to the self-answered questionnaire by the participants. Therefore, more studies are warranted in future among all frontline healthcare workers to investigate KAP towards COVID-19 rather than considering only a section of healthcare professionals for better understanding of the arising pandemic.

Conclusion
The present ndings suggest that emergency physicians demonstrated good knowledge, positive attitude and reasonable practice skills to combat COVID-19. Furthermore, based on the signi cant positive association between knowledge, attitude, and practice scores in our study, health education programs, particularly targeting lower knowledge individuals regarding COVID-19, is essential for encouraging positive attitude and safe practices. Hopefully, by increasing knowledge among the public health policymakers, and the general population, optimistic control and elimination of the disease can be anticipated.

Declarations
Availability of data and materials The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.